Elevate Care South Holland

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 12, 2024

  Deficiencies at this level require more than one Deficient Practice Statement. A. Based on interview and record review, the facility failed to follow their practice and provide a staff escort to an appointment for a resident R1 diagnosed with dementia, BIMS (Brief Interview for Mental Status) score of 5, identified not capable of unsupervised outside pass privileges. R1 was dropped off by transportation company on 5/8/24 at approximately 2:00pm, unknown drop off point. R1 was later found by family in streets trying to self-propel over a curb ramp approximately 3:30pm. This affects 1 of 1 resident (R1) reviewed for supervision. […]

• Immediate jeopardy, isolatedF684Sep 5, 2023

  Based on interview and record review, the facility failed to follow their Emergency Care policy and procedure by not immediately calling 911 for residents identified to be in need of emergency medical assistance. This failure applied to two (R9, R12) of two residents reviewed for emergency services, and resulted in R9 noted to be experiencing symptoms of a stroke for over an hour before being transferred to the hospital; R12 experienced acute respiratory distress for over 40 minutes before 911 was called. The Immediate Jeopardy began on 7/4/23 when the facility failed to immediately call 911 for R9, who was experiencing symptoms of a stroke. V1 (Administrator) was notified of the Immediate Jeopardy on 8/31/23 at 11:07AM. […]

• Actual harm, patternF689Sep 5, 2023

  Based on interview and record review, the facility failed to keep residents free from injury, who were assessed to be a fall risk and require staff assistance for ADLs (activities of daily living). These failures applied to four of four (R1, R3, R7, and R12) residents reviewed for falls and resulted in R1 sustaining a laceration to her forehead after a fall; R3 sustaining a subdural hematoma after a fall; R7 sustaining a left hip fracture which required surgical intervention after a fall; and R12 sustaining abrasions to the scalp and ear as a result of a fall. Findings include: 1. […]

• Actual harm, isolatedF689Aug 23, 2026

  Based on observation, interview and record review, the facility failed to provide adequate safety and supervision to prevent one resident (R1) from falling from the bed while receiving care and one resident (R2) from falling while attempting to independently retrieve ice in the dining room in a sample of three residents reviewed for falls with injury. These failures resulted in R1 and R2 sustaining left hip fractures requiring hospitalization and surgical intervention. Findings include: R1 is [AGE] years old and was originally admitted to the facility 8/2/2020 with diagnoses that included cerebral infarction, hemiplegia and hemiparesis affecting left side, hypertension, heart failure and weakness. […]

• Actual harm, isolatedF692Feb 7, 2026

  Based on observation, interview, and record review, the facility failed to follow their Weight Assessment and Interventions Policy and Unintentional Weight Loss Policy. Specifically, the facility did not report poor appetite and decreased oral intake to the physician and dietician and failed to develop interventions to prevent further weight loss. Additionally, the facility failed to ensure that one resident who was identified as at risk for malnutrition and dependent on enteral nutrition, received his enteral feeding as ordered. The facility also failed to implement dietician recommendations and to evaluate interventions to promote weight gain. […]