Elevate Care Des Plaines

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Failure to provide safe and appropriate respiratory care occurred when the facility did not follow its Respiratory Care Equipment and Supplies policy for changing ventilator circuits and filters. A male resident with intact cognition, admitted with tracheostomy, ventilator dependence, and neuromuscular dysfunction of the bladder, was observed in bed with a ventilator/tracheostomy setup and cough assistance, using a visibly dirty ventilator circuit and a filter labeled with a change date of 2/20. During observation, the resident and his spouse reported that the facility was not changing the ventilator circuit every month and stated that the last change was on February 20th, which they believed was overdue. The respiratory therapist acknowledged that the resident’s ventilator circuit and filters were due to be changed every 30 days per policy and admitted waiting until the first of the next month instead of following the 30‑day schedule. The DON also confirmed that the ventilator circuit and filter should be changed according to the facility’s policy, which specifies that ventilator circuits and air intake filters must be cleaned and replaced every 30 days, indicating that this schedule was not followed for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that its emergency generator functioned during a widespread power outage and to document required weekly and monthly testing of the generator. On the evening of 09/20/25, the primary utility power failed, and the facility’s emergency generator did not engage as designed. The Administrator reported arriving to find the building dark, with the Maintenance Director already on-site attempting to troubleshoot the generator and having contacted the generator contractor. The Administrator stated that the root cause, as relayed by the generator service company, was that condensation in the gasoline tank may have caused water and gas to mix, which then burned out the generator wiring that activates the unit. Review of maintenance records revealed no evidence of weekly generator inspections or monthly load-bank testing for the three months preceding the outage. During the outage, all areas of the facility lost electrical power, including power to mechanical ventilators, tube feeding pumps, air mattresses, mechanical lifts, and other electrically powered equipment. Fourteen ventilator-dependent residents were affected when the emergency generator failed to provide power to life-sustaining devices. The Maintenance Director confirmed that emergency outlets (red plugs) remained without power until a portable generator was obtained and connected at 12:41 AM the following morning. Staff attempted to plug ventilators and other equipment into the red emergency outlets, but nursing staff reported that there was no power to those outlets and that the unit was in total darkness. Nursing and respiratory staff actions during the outage did not follow the facility’s Emergency Operations Plan. The plan states that if a ventilator battery does not continue operating or power is lost, manual ventilation (Ambu-bagging) must be initiated immediately, and that nursing and respiratory staff will ensure medical equipment is energized via red emergency outlets and will continually or continuously assess residents. One RN reported working a double shift and remaining on duty into the early morning hours, stating that he did not initiate manual ventilation or conduct specialized respiratory monitoring for ventilator patients, explaining that he “didn’t do anything to the ventilator patient, it’s not my thing,” and that he focused primarily on one ventilated resident and did not monitor other residents. Another nurse confirmed that manual ventilation was not performed for any of the 14 ventilator-dependent residents during the outage and that she had to call the respiratory therapist when she noticed the ventilators were dark, after which she brought oxygen cylinders to several patients. Staff also demonstrated a lack of knowledge regarding backup ventilator batteries. Two nurses working on the ventilator floor stated they did not know where backup batteries for the ventilators were stored in case of power failure. Personnel file review showed that the RN who was on duty during the outage lacked documented competency evaluation for ventilator management or emergency respiratory procedures such as Ambu-bagging. The combination of the generator’s failure to activate, the absence of documented generator testing, the lack of power to emergency outlets, and the failure of nursing and respiratory staff to implement the facility’s emergency procedures for ventilator-dependent residents led to the cited deficiency and was determined to constitute Immediate Jeopardy to resident health and safety.

Removal Plan

• The facility has an emergency policy and procedure system in place on what to do if the facility's electrical system is affected.
• The emergency policy and procedure affecting the facility's electrical system is reviewed upon hire during orientation and educated on annually.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide specialized respiratory care and continuous clinical monitoring to ventilator‑dependent residents during a total facility power loss. An area‑wide electrical outage occurred, the facility’s emergency generator failed to activate, and all electrical power to the ventilator unit and other medical devices was lost for approximately 3 hours and 15 minutes. During this time, the facility’s Emergency Operations Plan for loss of electrical power, which required initiation of manual ventilation with Ambu‑bags and continuous assessment of residents by nursing and respiratory staff, was not effectively implemented. All ventilator‑dependent residents were ultimately evacuated to the hospital to maintain their health and safety. One resident, identified as having chronic respiratory failure and COPD and requiring full mechanical ventilation via tracheostomy, had no documented respiratory assessments, ventilator checks, or clinical monitoring in the EHR from the afternoon prior to the outage through shortly after midnight, encompassing the period of the power failure. The respiratory therapist on duty at the start of the outage did not document any respiratory assessments or monitoring for this resident, and the facility could not provide documentation that manual ventilation was initiated once staff realized the red emergency outlets were nonfunctional. Hospital admission records for this resident showed an elevated lactic acid level, which the report notes can be a marker of tissue hypoxia and metabolic stress during respiratory compromise. Staff interviews revealed additional gaps in care and monitoring during the outage. There was one respiratory therapist on site for 14 ventilator‑dependent and 6 tracheostomy residents, and the ventilator unit was staffed with two nurses and two aides. One RN reported working a double shift exceeding 14 hours and stated that he did not perform interventions on ventilator patients beyond checking if a resident was breathing or in distress, did not monitor other residents due to limited staffing, and did not document his actions because the computers had no power. Another nurse reported that the outage began around 9:00–9:30 PM, that ventilator power cords were moved to emergency outlets, and that oxygen cylinders were brought to some patients, but there was no documented evidence that the required manual ventilation and continuous respiratory assessments were carried out for the ventilator‑dependent residents during the generator failure.

Removal Plan

• Updated emergency power outage plan.
• Updated staffing plan for emergencies.
• Updated command list for key personnel outlining responsibilities of responsible individuals.
• Created plan to monitor and track maintenance of life maintaining equipment.
• Created QA tool to monitor compliance.
• Reviewed and updated staffing plan.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's protective measures and oversight.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when staff failed to follow physician orders for wound care for a resident with necrotizing fasciitis, sepsis, type II diabetes, polyneuropathy, and anxiety disorder. The resident was cognitively intact and had a physician order for negative pressure wound therapy (NPWT) to be applied to the right foot on specific days and as needed. On the day of the incident, the resident independently removed the NPWT device after showering and wrapped her foot in a towel due to a strong odor. She repeatedly requested assistance from various staff members, including a CNA, nurse, social service director, and front desk staff, to have the wound care nurse attend to her wound, but her requests were not acted upon or communicated effectively to the wound care nurse. Multiple staff members, including the CNA, nurse, social service director, and front desk staff, either assumed the wound care nurse would see the resident during rounds or did not follow up after initial attempts to contact the wound care nurse. The wound care nurse reported not receiving any requests or reports about the resident needing wound care after her initial morning encounter. The facility's protocol required staff to call the wound care nurse directly if a resident requested wound care, but this was not done. Documentation for the day showed no record of wound care being provided, and the only progress note indicated the resident was non-compliant with prescribed wound care, had removed her wound vac, and was upset, eventually insisting on hospital transfer. The resident waited approximately five hours without receiving wound care, ultimately calling 911 herself and being transported to the hospital. Upon EMS arrival, the resident and her husband reported that she had been requesting wound care and pain management for several hours without response. EMS documented a large, deep, weeping wound on the right foot, and hospital records confirmed the resident presented with pain, erythema, and exposed tendon, with no wound care provided that day. The facility's grievance and policy documents further confirmed the lack of adherence to physician orders and wound care protocols.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident, who was dependent on tube feeding for nutrition, received the recommended amount of fluids. This deficiency was identified for a resident who was hospitalized with dehydration, high blood sodium, and hypotension. The resident, a male with a complex medical history including brain damage, epilepsy, and acute kidney failure, was admitted to the facility and was receiving enteral nutrition via a feeding tube. The care plan for the resident included interventions for potential impaired nutrition and required the registered dietitian to assess fluid needs and report any signs of dehydration. The registered dietitian recommended an increase in the resident's enteral flush from 30ml to 200ml every four hours to provide adequate hydration. However, the facility continued to administer only 30ml flushes as per the existing physician order, which was not updated to reflect the dietitian's recommendation. The resident's progress notes did not document any communication with the physician regarding the recommended increase in fluids, and the resident was subsequently hospitalized with severe dehydration and related complications. The Director of Nursing reported that the registered dietitian's recommendation was not communicated effectively due to a transition in the electronic health record system. The recommendation was entered into an inactive system and was not transferred to the active system, resulting in the facility being unaware of the need to increase the resident's fluid intake. The failure to communicate and implement the dietitian's recommendation led to the resident not receiving the necessary amount of fluids, contributing to his hospitalization.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its housekeeping policy and procedure, resulting in unclean and unsanitary conditions in the rooms and medical equipment of residents who are entirely dependent on staff for care. This deficiency was observed in four residents, each with significant medical needs, including brain damage, epilepsy, pressure ulcers, and feeding tube use. The observations revealed multiple instances of visible dust, particles, and substances on medical equipment such as oxygen machines and feeding tube monitors, as well as on furniture and other surfaces within the residents' rooms. For one resident, the oxygen machine and respiratory equipment were found with visible dust, and a brown substance was observed on the feeding tube monitor and pole. Uncovered syringes were also noted on the dresser, and the refrigerator had visible dust and residue. Another resident's room had similar issues, with dust on the oxygen machine and respiratory equipment, stained mats, and uncovered syringes. The resident's care plan indicated complete dependence on enteral feeding due to conditions like dementia and renal disease. The facility's Director of Nursing and Registered Nurse confirmed the observations and acknowledged the responsibility of nursing and respiratory staff in maintaining the cleanliness of medical equipment. The Housekeeping Supervisor noted that housekeeping staff are responsible for cleaning the rooms daily, but a staff shortage due to illness had impacted this routine. Despite the collaborative effort required to maintain cleanliness, the deficiency persisted, affecting the residents' environment and potentially their care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to its policy and procedures for feeding tube care by not following physician orders for daily cleansing and dressing of feeding tube sites for residents dependent on enteral nutrition. This deficiency was observed in four residents, each with significant medical histories requiring enteral feeding. The facility's policy mandates daily gastrostomy tube care, which was not consistently performed, as evidenced by missing documentation and observations of improper site care. One resident, a male with a history of brain damage, epilepsy, and other severe conditions, was found with a feeding tube site that lacked a dressing and had a noticeable scab. The registered nurse acknowledged that the site should have been cleaned and dressed nightly, as per the physician's orders. Another resident, a female with partial paralysis and dysphagia, had a feeding tube site with an outdated dressing and visible staining, indicating that the site had not been properly cleaned and redressed as required. Additional observations included a female resident with Alzheimer's disease and dysphagia, whose feeding tube site was found without a dressing and with old drainage. The licensed practical nurse confirmed that the site should have been dressed nightly. Similarly, another female resident with a history of stroke and dysphagia had a feeding tube site with an undated dressing and signs of crust and dry drainage. The Director of Nursing confirmed that the night shift was responsible for changing the dressings, and missing entries in the Treatment Administration Record suggested that the required care was not administered.

Penalty

Inspection fine: $108,29020 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly transfer a resident, resulting in the resident being hospitalized with a neck fracture. The resident, an elderly female with multiple diagnoses including dementia and difficulty walking, was being transferred from a wheelchair to a shower chair by a Certified Nursing Assistant (CNA). During the transfer, the resident began to slide and was lowered to the floor. The resident was wearing slippers at the time, which were not appropriate for transfers, and a gait belt was not used despite the care plan indicating its necessity. The CNA involved in the transfer stated that the resident could transfer independently and did not require a gait belt, contrary to the care plan and Minimum Data Set (MDS) which indicated the need for maximum assistance and a gait belt during transfers. The Director of Nursing confirmed that the resident should have been wearing non-skid socks and a gait belt should have been used. The incident led to the resident sustaining an acute C7 spinous process fracture, as confirmed by hospital records.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely and appropriate care for residents with indwelling catheters, leading to severe health consequences. For one resident, the facility did not obtain a urine specimen from the catheter in a timely manner, failed to document catheter output, and did not provide necessary catheter care. This resident, who had a history of UTIs and other significant health issues, showed signs of increased confusion and distress, which were not adequately addressed by the staff. Despite orders for a urinalysis, the specimen was not collected promptly, and the resident was eventually hospitalized with a severe UTI and sepsis. The facility's documentation was incomplete and inconsistent, with missing entries for urine output and catheter care in the Medication Administration Record (MAR). The resident's care plan included monitoring for signs of UTI and providing catheter care, but these interventions were not effectively implemented. The staff failed to recognize and respond to the resident's symptoms, such as altered mental status and poor appetite, which were indicative of a UTI. The lack of timely intervention and communication with healthcare providers contributed to the resident's deterioration and subsequent hospitalization. Another resident also experienced issues with catheter care, as evidenced by the presence of sediment in the catheter tubing and missing documentation of urine output and catheter care. This resident had a history of frequent UTIs and was on antibiotic therapy for a positive urine culture. The facility's failure to adhere to its own policies and procedures for catheter care and monitoring contributed to the deficiencies observed by the surveyors.

Penalty

Inspection fine: $45,120

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a recliner wheelchair to a resident, identified as R12, who expressed a desire to get out of bed and interact with the environment. R12, who is [AGE] years old, was admitted to the facility with diagnoses including multiple sclerosis, a sacral ulcer, chronic anemia, and protein energy undernutrition. The Minimum Data Set (MDS) indicated that R12 uses a wheelchair for mobility. However, during facility rounds, R12 was observed in bed and stated a desire to get out but was unable to do so due to the lack of a wheelchair. The resident mentioned not remembering the last time they got up and had asked nursing assistants for assistance but was told there was no chair available. The deficiency was further highlighted when a Certified Nursing Assistant (CNA) confirmed that R12 had been using a recliner wheelchair provided by hospice services, which was removed after hospice care was discontinued. The CNA admitted to not having gotten R12 out of bed since the hospice service ended. A Registered Nurse and the Assistant Director of Nursing were unaware of the lack of a recliner wheelchair for R12, despite the facility's policy stating that residents should have reasonable arrangements to meet their needs. The Director of Nursing expected all residents to have a wheelchair upon admission or as needed, but no wheelchair was available for R12 during the surveyor's checks.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the wheelchair locking mechanism was engaged and failed to supervise a high-risk resident, resulting in the resident falling out of an unlocked wheelchair in an unsupervised dining room. The resident sustained bruising to the left side of the face and a cut above the left eye, requiring hospital evaluation and four sutures. The incident occurred when the activity aide transported the resident to the dining room and did not lock both sides of the wheelchair. The resident was left unsupervised, and the fall occurred shortly after. The resident involved in the incident had a history of dementia with other behavioral disturbances, anemia, anxiety disorder, major depressive disorder, essential hypertension, heart failure, glaucoma, osteoarthritis, and vertigo. The resident was assessed as high risk for falls, with a care plan indicating the need for the wheelchair to be locked at all times and for the resident to be placed in supervised areas when out of bed. Despite these precautions, the resident was left unsupervised in the dining room, leading to the fall. Interviews with staff revealed that the activity aide was not adequately trained on the use of wheelchairs and the importance of locking both wheels. The aide admitted to locking only one side of the wheelchair and was unaware of the need for supervision in the dining room. The facility's policies on fall prevention and wheelchair safety were not effectively communicated or enforced, contributing to the incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to physician orders for transmission-based precautions for a resident diagnosed with multiple infections, including Klebsiella in the urine and MRSA in the nares. The resident was placed on contact and droplet isolation precautions due to their neutropenic status, as documented in their care plan. Despite clear signage indicating the need for PPE and isolation precautions, a CNA entered the resident's room without performing hand hygiene or donning any PPE, collected a meal tray, and continued to other rooms without following proper infection control protocols. The CNA admitted to not wearing PPE because they believed it was unnecessary if they did not touch the resident. This misunderstanding was corrected by the RN and the Infection Prevention Nurse, who both confirmed that PPE must be worn by anyone entering the room to prevent the spread of infection. The facility's infection control policy, revised in May 2024, outlines the necessity of PPE and hand hygiene to prevent the transmission of infectious agents, but these protocols were not followed in this instance, leading to a deficiency in infection control practices.

Penalty

Inspection fine: $89,88016 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident (R4) from abuse, resulting in R3 punching R4 in the face, causing discoloration to the right eye and bleeding from the nose and mouth. The incident occurred on 12/12/2023 when a Certified Nursing Assistant (CNA) found R4 bleeding and reported the situation to the nurse. R3 admitted to punching R4 because R4 was coughing and allegedly did so on purpose after R3 asked him to stop. R4's care plan indicated a risk for abuse due to dementia and behavioral disturbances, while R3's care plan noted a risk of abuse due to schizophrenia and a history of provoking others. Both residents were transferred to the hospital for further evaluation, and the police were notified, but no criminal charges were pursued due to the mental diagnoses of both residents. The facility's investigation confirmed that R3 hit R4, and R3 was subsequently discharged from the facility. The facility's abuse prevention policy affirms the right of residents to be free from abuse, neglect, and exploitation. The deficiency was corrected on 12/15/2023.

Penalty

Inspection fine: $89,88016 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately supervise a high-risk resident (R2) for falls, resulting in R2 falling out of his wheelchair and sustaining injuries. R2, who has a history of falls and multiple medical conditions including Orthostatic Hypotension, Major Depressive Disorder, and Mild Cognitive Disorder, was left unsupervised at the nurse's station. Despite being identified as a high fall risk, R2 was allowed to fall asleep in his wheelchair and subsequently fell forward onto the floor, causing a laceration on the bridge of his nose that required hospital evaluation and sutures. Interviews with staff revealed that R2 was being moved around by a CNA (V9) to prevent him from falling out of bed. However, R2 was left at the nurse's station while the CNA attended to another resident. The LPN (V10) at the nurse's station was not closely monitoring R2 at the time of the fall, as she was engaged in other tasks and conversations. Multiple staff members, including V8 and V17, confirmed that they did not witness the fall but heard a loud noise and found R2 on the floor. The Director of Nursing (V2) acknowledged that R2 had a history of falls and that the facility was aware of his high fall risk. Despite this, the facility did not have a specific policy on monitoring high fall risk residents, relying instead on general supervision practices. Observations by the surveyor also noted a lack of supervision in the dining room, where residents were left unattended, further highlighting the facility's inadequate supervision practices.