Elevate Care Northbrook

In the surveyor’s words

From the most serious findings on record at Elevate Care Northbrook, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 8, 2025

  Based on interviews and record reviews, the facility failed to develop and implement a care plan for a resident with documented history of dysphagia, despite recommendations from speech therapy that resident should have swallowing precautions in place; and failed to follow policy and guidelines in performing emergency procedures during life-threatening situations. These deficiencies affected one (R1) of four residents reviewed for accidents and supervision. As a result, R1 was allowed to eat independently, experienced a choking incident, and subsequently died in route to the hospital for emergency care. These failures resulted in an Immediate Jeopardy. […]

• Actual harm, isolatedF600Jun 23, 2026

  Based on observation, interview, and record review, the facility failed to comply with its Abuse and Retaliation Policy and Prevention Program by failing to protect a resident from staff abuse. This failure resulted in severe pain for 1 of 3 residents (R1) reviewed for abuse in a sample of 5.The findings include:R1 is a [AGE] year-old female admitted on [DATE], having moderate cognitive impairment as per the minimum data set (MDS) dated [DATE].On 6/16/26 at 9:45 AM, R1's door was closed, and a screaming sound was heard from R1's room. This surveyor knocked on the door and found that V7 (Certified Nursing Assistant /CNA) was providing care for R1. […]

• Actual harm, isolatedF689Jun 23, 2026

  Based on observation, interview, and record review, the facility failed to follow its Fall Prevention Program by failing to implement appropriate interventions to ensure the safety of fall-risk residents for 1 of 3 residents (R1) reviewed for falls. This failure has resulted in a fall with a right distal femur fracture. The facility also failed to follow its elopement policy by failing to monitor and prevent the departure of an elopement-risk resident for 1 of 3 residents (R7) reviewed for elopement. Findings include:1. R1 is a [AGE] year-old female admitted on [DATE], having moderate cognitive impairment as per the minimum data set (MDS) dated [DATE].On 6/16/26 at 10:15 AM, R1 was observed in her bed along with R1's nurse (V4). […]

• Actual harm, isolatedF658Sep 8, 2025

  Based on interview and record review, the facility failed to provide care in accordance with professional standards of quality by failing to develop and implement a care plan for a resident with documented history of dysphagia, despite recommendations from speech therapy that resident should have swallowing precautions in place; and by failing to follow policy and guidelines in performing emergency procedures during life-threatening situations. These deficiencies affected one (R1) of four residents reviewed for accidents and supervision and resulted in R1 experiencing a choking episode and subsequently died in route to the hospital for emergency care. […]

• Actual harm, isolatedF684Mar 29, 2025

  Based on interview and record review, the facility failed to manage a resident with an insulin overdose in accordance with the standards of care for 1 of 4 residents (R1) reviewed for quality of care in the sample of 4. This failure resulted in a delayed transfer to the hospital, R1's wife summoning EMS (emergency medical services) and R1 being admitted to the ICU (intensive care unit) with an insulin overdose and hypoglycemia. The findings include: On [DATE] at 1:02 PM, V4, Registered Nurse (RN), said he found R1 to be groggy and sleepy at the end of his (night) shift (on [DATE]). V4 said he checked R1's blood glucose (BG), all BG measurements in this citation are in milligrams/deciliter (mg/dl) and it was very low; in the 30s. […]