Elevate Care Riverwoods

In the surveyor’s words

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

• Immediate jeopardy, patternF692Sep 5, 2023

  Based on interview and record review the facility failed to complete quarterly and significant change dietary assessments on residents. The facility failed to ensure dietary assessments were completed by the Registered Dietician. The facility failed to identify resident weight loss prior to the weight loss becoming significant. The facility failed to ensure weight loss treatment interventions were initiated in a timely manner, once resident weight loss was identified. These failures resulted in R37, R69, R144, R9, and R79 sustaining a significant weight loss. […]

• Immediate jeopardy, isolatedF760Sep 5, 2023

  Based on interview and record review the facility failed to ensure a residents medication was given as prescribed and failed to ensure medication orders were transcribed correctly to avoid a significant medication error. This failure resulted in six of R9's medications being mistakenly discontinued without a physicians order. As a result of this failure R9 developed worsening psychiatric symptoms (paranoia) and was sent to the emergency room for evaluation. This applies to 1 of 7 residents (R9) reviewed for physician orders in the sample of 31. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 8/1/23, when the facility discontinued R1's medications without a physician order. V1 (Administrator) was informed of the Immediate Jeopardy on 8/30/23 at 2:21 PM. […]

• Actual harm, isolatedF684Aug 1, 2026

  Based on interview and record review the facility failed to do a thorough assessment and send a resident to the hospital in a timely manner after a fall. This failure resulted in R1 remaining in the facility for 8 hours after a fall that resulted in a left femoral and elbow fracture. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 9. The findings include:R1's post fall observation form dated 7/23/26 shows, R1 had a fall in her room that was witnessed by V5 Certified Nursing Assistant (CNA). I knees buckled down and lost my balance. CNA help to ease down to the floor [SIC-statement is correct]. The form shows, R1 is alert and oriented to person, place, and time. She complained of pain to her left knee that was painful with range of motion. […]

• Actual harm, isolatedF790Aug 6, 2025

  Based on interview and record review, the facility failed to ensure 1 of 27 residents (R76) in the sample of 27 was evaluated by a dentist. This failure resulted in R76 developing a tooth infection and requiring antibiotic treatment.The findings include:On 8/4/25 at 10:04 AM, R76 said he has been waiting months to see the dentist. R76 said he has been telling the facility at his care plan meetings that he wants to see the dentist. R76 said he has been using Orajel (an over-the-counter numbing agent) for tooth pain and proceeded to take a tube of Orajel from a bag attached to his left side rail. R76 said he is now taking an antibiotic for his mouth infection and said his mouth is all swollen. […]

• Actual harm, isolatedF689Apr 30, 2025

  Based on observation, interview and record review the facility failed to ensure a resident was provided incontinence care in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 falling from the bed during care and sustaining bilateral toe fractures. The findings include: R1's Face Sheet shows that he admitted to the facility on [DATE] and has diagnoses of: morbid obesity, rheumatoid arthritis and history of falling. R1's Nursing Notes dated 4/21/25 at 2:20 PM shows that R1 is alert and oriented x 4, 2 assist with sit to stand and would be coming to facility after 2 PM. […]