Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elevate Care Abington during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and intact cognition reported that a CNA entered his room while he was yelling for assistance, told him to be quiet, and kicked his leg twice while he lay in bed, then left without helping him. A caretaker later stated the CNA admitted attempting to kick the bed in frustration but instead kicking the resident’s leg, and the resident’s family member reported the resident had repeatedly described being kicked by this CNA. The CNA denied recalling the event but acknowledged it was possible he had run into the bed, and key facility staff reported they had not spoken with the caretaker about the allegation, despite an abuse prevention policy affirming residents’ right to be free from abuse and mistreatment.
Failure to follow transmission-based precautions occurred when an RN entered a resident’s room on contact isolation for MRSA without hand hygiene or required PPE and left with contaminated items on a disposable tray. A CNA also entered a semi-private room with two residents on contact precautions without PPE, handled a reusable water bottle, and could not explain the refill protocol. In another event, two CNAs transferred a resident with enhanced barrier precautions and touched the catheter without PPE. The same RN later left a COVID-positive resident’s room with accucheck supplies and stated the tray would be discarded in the med cart garbage and the equipment sanitized for reuse.
Medication carts and storage areas contained multiple unlabeled or undated meds, including insulin, eye drops, and Tubersol, along with controlled meds stored without proper security and some with no current orders. Surveyors also found a Risperidone tablet in a plastic bag with only a handwritten label, and a Lorazepam dose documented as given even though the medication was observed unopened in the cart. The DON stated that opened meds should be dated with an expiration date and that controlled meds require double-lock storage.
A resident with a suprapubic catheter was found sleeping with the catheter bag strapped to his leg instead of hanging below bladder level. The RN stated the bag should be at the bedside to reduce urine backflow, and the DON confirmed staff are expected to keep catheter bags below the bladder at all times. The resident’s care plan and facility policy both directed that the catheter and tubing be positioned to maintain downhill urine flow.
Staff failed to consistently follow infection prevention and control practices, including disinfecting medical equipment before use, performing hand hygiene after glove removal, donning appropriate PPE for residents on Enhanced Barrier Precautions, and properly storing nebulizer equipment. These lapses affected multiple residents, including those with urinary catheters, colostomies, and respiratory needs.
A resident with multiple chronic conditions was found to be self-administering several medications at her bedside without physician orders or proper labeling, and without an assessment by the IDT to determine her capability for self-administration. Facility staff were aware of the practice, but no care plan or authorization was in place, contrary to facility policy.
A resident with multiple comorbidities and a history of pressure ulcers developed a new stage 2 pressure ulcer that went unrecognized and unreported by staff. Facility staff failed to conduct ongoing skin assessments, did not notify the physician or update the care plan, and did not provide a specialty mattress as required by policy. The wound was only identified during a surveyor's visit, and there was a lack of documentation and communication among nursing staff regarding the resident's skin condition.
Three residents requiring oxygen therapy did not receive care according to physician orders and facility policy. A resident had an oxygen cannula improperly placed and an empty humidifier bottle that was not replaced promptly. Two other residents had issues with improper storage of oxygen equipment, overdue humidifier bottle changes, and incorrect oxygen flow rates. Facility procedures for equipment replacement and storage were not followed by staff, including an LPN and the DON.
Surveyors found that a medication refrigerator was left unlocked and that two residents' opened eye drop solutions on a medication cart were not dated as required. Both an RN and an LPN confirmed that these actions did not follow facility policy, which mandates locked storage and dating of opened medications.
A resident, requiring a two-person mechanical lift transfer, fell during a transfer due to improper assistance, resulting in multiple fractures. The resident's care plan specified the need for a full-body lift with two-person assistance, but a CNA and an untrained private caretaker conducted the transfer, leading to the incident.
A resident was found with multiple medications at her bedside without a physician's order or assessment for safe self-administration. The facility's policies on medication storage and self-administration were not followed, as there were no orders or assessments documented for the resident to self-administer and store medications in her room.
The facility failed to obtain a physician's order for the appropriate tracheostomy tube size and did not implement the prescribed oxygen therapy for a resident with a tracheostomy tube. The resident was observed receiving 40% FiO2 instead of the prescribed 35% FiO2, and the medical records lacked the necessary tracheostomy tube size information.
The facility failed to perform a complete assessment and notify the physician of a significant change in condition for a resident. The RN did not document a complete set of vital signs or call for a rapid response team during the emergency. The DON expects nurses to call a rapid response and inform the physician after addressing the emergency. The facility's policy requires informing the physician and family of significant changes, but relevant policies were not provided upon request.
A resident with severe cognitive impairment and high fall risk was left unattended in the bathroom by a CNA, resulting in a fall and head injury requiring staples. The facility's policy states that such residents should not be left alone, but this was not followed, leading to the incident.
Failure to Protect Resident From Physical Abuse and Follow Abuse Reporting Procedures
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to follow its own abuse prevention policy. An 87-year-old resident with a BIMS score of 14/15 and multiple medical diagnoses, including peripheral vascular disease, multiple sclerosis, hypertensive heart disease, atherosclerotic heart disease, trigeminal neuralgia, history of falls, and prior TIA and cerebral infarction without residual deficits, reported that approximately two months prior he had been yelling for assistance because he could not find his call light. He stated that a CNA entered his room, told him to stop yelling and be quiet, then kicked him twice on his leg while he was lying in bed, describing it as a kick to get his attention. The resident reported that he then thought he was not able to defend himself and that the CNA left without assisting him. A caretaker reported that on a later date the CNA told him he had kicked the resident while the resident was in bed, explaining that both were frustrated and that he had intended to kick the bed but instead kicked the resident’s leg. The caretaker stated he relayed this to an RN. The CNA, when interviewed, said he did not recall the incident but allowed it was possible he may have run into the bed inadvertently. The resident’s family member stated the resident had complained that one CNA was not as nice as the others and that the resident had told both the caretaker and her, more than once, that the CNA had kicked him. The administrator, social services director, and RN each stated they did not speak with the caretaker about the allegation. The facility’s Abuse and Retaliation Policy Prevention Program affirms residents’ right to be free from abuse and to have an environment that promotes resident security and prevention of mistreatment, which was not adhered to in this incident.
Failure to Follow Transmission-Based Precautions
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for residents on transmission-based precautions. On 3/9/2026, a registered nurse entered a resident’s room with a disposable tray containing a glucometer, test strips, alcohol wipes, cotton balls, and a syringe filled with insulin without performing hand hygiene or donning PPE according to the signage outside the room. The nurse then left the room carrying the disposable tray with the glucometer, test strips, and a used needle still in packaging. The resident was on contact isolation for MRSA in the blood per physician orders dated 3/1/2026. Also on 3/9/2026, a CNA entered a semi-private room where two residents were on contact precautions with an N95 mask indicated on the door signage, but no PPE was worn before entry. The CNA later exited the room with a reusable water bottle and took it into the nourishment room, then stated the facility does not typically use reusable water bottles but disposable cups and could not explain the proper protocol for refilling reusable water bottles when a resident is on isolation. Later that day, two CNAs were observed transferring a resident back to bed while the resident had an enhanced barrier precautions sign outside the door; no PPE was worn while transferring the resident and touching the catheter. On 3/11/2026, the same nurse was observed leaving another resident’s room with a disposable tray containing accucheck items and test strips after checking blood sugars; the nurse stated the tray would be thrown in the medication cart garbage and the equipment sanitized before reuse. That resident was on isolation for testing positive for COVID. The infection preventionist stated staff should wear gown, gloves, N95, and face shield for COVID-positive residents, gown and gloves for contact isolation, and gown and gloves for enhanced barrier precautions, and that disposable items should be discarded immediately and equipment sanitized when exiting these rooms.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that medications and biologicals were labeled, dated, and stored according to accepted practice and facility policy. During medication cart and storage observations, surveyors found house stock medications in the medication carts opened and undated, including Lispro insulin, Glargine insulin, Latanoprost eye drops, and Tubersol. An opened Lispro insulin multi-dose vial had no name, no date, and no box, and an opened Glargine insulin multi-dose vial for one resident was undated and had an expiration date on the vial. A Tubersol multi-dose vial in the medication storage room had no expiration date and an open date, and staff stated they were unaware of the policy for how long it could remain open. A Risperidone tablet was also found in a small plastic medication crusher bag with no name and only a handwritten label. Surveyors also found controlled and resident-specific medications stored improperly or without current orders. Two boxes of Lorazepam for one resident were found in the cart without current orders, and one unopened Lorazepam box for another resident was stored under an unlocked sink cabinet after that resident had already been discharged. A Lorazepam dose was documented as given even though the medication was observed unopened and sealed in the cart. The DON stated that controlled medications should be kept behind two locks and that refrigerated medications should be stored in the locked refrigerator, and the facility policy stated that medications are to remain in their original containers, discontinued or outdated medications are to be destroyed or returned to the pharmacy, and controlled drugs are to be stored under double-lock and key.
Suprapubic catheter bag was not maintained below bladder level
Penalty
Summary
The facility failed to ensure that a suprapubic urinary catheter was positioned to maintain a downhill flow of urine in accordance with facility policy. R141, an older male resident with diagnoses including retention of urine, unspecified obstructive and reflux uropathy, and benign prostatic hyperplasia without lower urinary tract symptoms, had physician orders for a suprapubic catheter with a diagnosis of neurogenic bladder/obstructive uropathy. During observation, the resident was found sleeping in his room with the head of bed slightly elevated and no visible catheter. When the surveyor asked the RN to help locate the catheter, the suprapubic catheter bag was found strapped to the resident’s right leg and contained bright red blood. The RN stated she believed the bag was supposed to be hanging at the bedside to reduce the risk of urine backflow, which could cause a UTI. The DON stated that staff are expected to keep the catheter bag hanging below bladder level whether the resident is in bed or in a chair, and that if a nurse found the bag not in the proper position, it should be changed and hung below bladder level at that time. The resident’s care plan also directed staff to position the catheter bag and tubing below the level of the bladder, and the facility policy stated catheters shall be positioned to maintain a downhill flow of urine to prevent backflow during transfer, ambulation, and body positioning.
Failure to Implement Infection Control Practices During Medication Administration and Resident Care
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices during medication administration and resident care. Observations included staff not disinfecting medical equipment, such as blood pressure cuffs, before use on different residents, and not following proper hand hygiene protocols after glove removal. In one instance, an LPN used a blood pressure machine on a resident without disinfecting it beforehand, despite acknowledging that equipment should be cleaned before and after use. Another staff member entered the room of a resident on Enhanced Barrier Precautions (EBP) without donning the required gown, only wearing gloves and a mask, and placed medical equipment on the bedside table before use. The same staff member only disinfected the equipment after use, not before, and did not adhere to the manufacturer’s recommended contact time for disinfectant wipes. Additional deficiencies were observed in the handling and storage of medical equipment and supplies. A urinary drainage bag with visible sediment was found hanging over a grab bar next to a dirty emesis basin in a resident's bathroom, contrary to facility policy. The emesis basin was visibly soiled with dried toothpaste. In another case, a nebulizer mask and tubing were left attached to the machine on a nightstand rather than being stored in a plastic bag as required. Staff interviews confirmed that nebulizer equipment should be rinsed, air-dried, and stored in a plastic bag when not in use, but this was not consistently practiced. The facility's own policies require the use of PPE, including gowns and gloves, for high-risk activities with residents on EBP, and mandate cleaning and disinfecting shared medical equipment between residents. Policies also specify that hand hygiene must be performed after glove removal and that nebulizer equipment should be properly cleaned and stored. Despite these policies, staff did not consistently follow these procedures, as evidenced by direct observation and staff interviews. Several residents, including those with complex medical needs such as urinary catheters, colostomies, and respiratory treatments, were affected by these lapses in infection control.
Failure to Assess and Authorize Resident Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were not kept at a resident's bedside without a physician's order and did not assess the resident for safe self-administration of medication. During medication administration, an LPN was observed with a resident who had several medications, including triamcinolone lotion, two nasal spray bottles, and caladryl lotion, on her bedside tray table. These medications were not labeled, and the resident reported self-administering them daily and as needed for rashes and itchiness. The resident was alert and oriented, able to verbalize her needs, and stated that the nursing staff were aware of her self-administration practices. Upon review, it was found that there were no physician orders for the nasal spray and caladryl lotion, nor was there an order allowing the resident to keep medications at her bedside. Additionally, no assessment had been completed by the interdisciplinary team to determine the resident's capability for self-administration, and there was no care plan in place for this. Facility policy requires a written physician order and an assessment for self-administration, as well as proper storage of bedside medications, none of which were followed in this case. The resident's medical history included acute and chronic respiratory failure, congestive heart failure, paraplegia, congenital deformity of the spine, spina bifida, and allergic rhinitis.
Failure to Identify, Report, and Treat New Pressure Ulcer in High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure ongoing assessment and monitoring for a resident with a history of pressure ulcers, resulting in a new, unreported stage 2 pressure ulcer on the sacral area. The wound was discovered during a surveyor's observation, not by facility staff, despite the resident being at high risk for skin impairment due to multiple medical conditions including chronic kidney disease, heart failure, Parkinson's disease, dementia, and incontinence. The wound care nurse and wound care coordinator were not aware of the new open wound, and there was no recent documentation of wound assessments in the resident's medical record since the previous year. The facility did not follow its own pressure ulcer prevention and skin assessment policies, which require daily skin inspections, prompt reporting of changes, and timely notification of the physician and family. The charge nurse and LPN were unaware of the new wound, and the certified nursing assistant (CNA) did not report the skin breakdown. The wound care coordinator and wound nurse continued to provide daily treatments to the sacral area without documenting weekly skin assessments or identifying the new pressure ulcer. Additionally, the facility failed to implement preventive measures as outlined in its policy, such as providing a specialty mattress for the resident, who was at high risk for pressure injuries. The specialty mattress was not provided until after the surveyor raised concerns. The physician was not notified in a timely manner for appropriate wound treatment orders, and the care plan was not updated to reflect the new pressure ulcer.
Failure to Provide Safe and Appropriate Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required oxygen therapy. Observations revealed that one resident had an oxygen nasal cannula improperly placed on her cheek instead of in her nostrils, and the oxygen concentrator's humidifier bottle was empty and not replaced in a timely manner, despite being brought to the attention of an LPN. The same resident was later observed with the humidifier bottle still empty. Physician orders indicated continuous oxygen at a specified flow rate, and the care plan required monitoring and timely replacement of oxygen equipment, which was not followed. Additional deficiencies were noted for two other residents. One resident's oxygen tubing and cannula were stored improperly in a nightstand drawer without a plastic bag, and the humidifier bottle was not changed as scheduled. Another resident was observed receiving oxygen at a higher flow rate than ordered, with a humidifier bottle that was nearly empty and past the scheduled replacement date. Facility policy required humidifier bottles to be changed every seven days and when water levels were low, and for oxygen appliances to be stored in plastic bags when not in use, but these procedures were not followed.
Failure to Secure Medication Storage and Properly Label Opened Medications
Penalty
Summary
Surveyors observed that the medication refrigerator in the second floor medication storage room was left unlocked during a walkthrough with an RN. The RN confirmed that the refrigerator should have been locked according to facility procedures. Additionally, during a review of a medication cart with an LPN, two separate eye drop solutions belonging to two residents were found to be opened but not dated. The LPN acknowledged that medications should be dated when opened. The Director of Nursing was informed of these findings and confirmed that staff are expected to keep the medication refrigerator locked and to mark the date when medications are opened. The facility's own policy requires all medications and biologicals to be securely stored in locked compartments and for staff to record the date opened on medication containers when the expiration date is affected by opening. These observations demonstrate noncompliance with both facility policy and accepted professional standards for medication storage and labeling.
Failure to Provide Adequate Transfer Assistance Results in Resident Injury
Penalty
Summary
The facility failed to adhere to its Transfer policy by not providing a two-person assist while transferring a dependent resident from bed to wheelchair, resulting in the resident falling from a mechanical lift. This incident involved a resident who was identified as requiring a two-person mechanical lift transfer, as indicated by a color-coded sticker on the resident's bed. On the day of the incident, a CNA and a private caretaker attempted to transfer the resident, but during the process, the resident slid out of the sling and fell to the floor, sustaining multiple fractures and a small hematoma. The resident involved is an elderly female with a history of adult failure to thrive, secondary malignant neoplasm, and acute on chronic diastolic heart failure. Her care plan specified the use of a full-body lift with two-person assistance for all transfers. Despite this, the transfer was conducted improperly, leading to the resident's fall and subsequent injuries. The facility's Director of Nursing acknowledged the ongoing investigation and noted that private caregivers are not trained by the facility to perform transfers, which may have contributed to the incident.
Failure to Ensure Safe Medication Self-Administration
Penalty
Summary
The facility failed to ensure that no medication was kept at a resident's bedside without a physician's order and did not assess a resident for safe medication self-administration. During an observation, a resident was found with multiple medications, including Calmoseptine ointment, Biofreeze roll-on, and artificial tears eye drops, in her bedside drawer. The resident, who was alert and oriented, reported using these medications for pain and other conditions without any documented physician orders or assessments for self-administration safety. The resident also mentioned that her medications were disorganized due to a recent room transfer and that she did not want to bother the busy nursing staff for assistance. The Assistant Director of Nursing and the Director of Nursing confirmed that residents are not allowed to keep medications at their bedside without a physician's order and an assessment by the interdisciplinary team. The resident's care plan did not include any orders for the medications found at her bedside or any indication that she was assessed for self-medication administration. The facility's policies on medication storage and self-administration were not followed, as there were no orders or assessments documented for the resident to self-administer and store medications in her room.
Failure to Obtain Tracheostomy Tube Size Order and Implement Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the appropriate tracheostomy tube size for a resident with a tracheostomy tube and did not implement the prescribed oxygen therapy. The resident, who was admitted with acute and chronic respiratory failure, a tracheostomy, traumatic subdural hemorrhage, and a persistent vegetative state, was observed with a tracheostomy tube connected to oxygen at 6 liters per minute. The resident's medical records did not indicate the tracheostomy tube size, and the active physician order sheet lacked this information as well. Additionally, the care plan specified a trach collar with 35% FiO2, but the resident was observed receiving 40% FiO2 instead. The facility's policy requires verification of the physician's order for the appropriate trach tube size and oxygen concentration, which was not followed in this case. During the survey, the Assistant Director of Nursing and the Director of Nursing acknowledged the oversight and confirmed that the facility should have obtained and documented the physician's order for the tracheostomy tube size. They also admitted that the prescribed oxygen therapy should have been implemented as per the care plan. The facility's policy on tracheostomy tube changes and oxygen therapy emphasizes the need for appropriate equipment and adherence to physician orders, which were not met in this instance. This deficiency affected one resident out of the 26 reviewed for respiratory care.
Failure to Perform Complete Assessment and Notify Physician of Significant Change in Condition
Penalty
Summary
The facility failed to perform a complete assessment and notify the physician of a significant change in condition for a resident. On 06/20/2023, a family member noticed that the resident was unresponsive and instructed another family member to call the nurse. The Registered Nurse (RN) did not document a complete set of vital signs during the resident's change in condition and did not call for a rapid response team, as she was unaware if the facility practiced rapid response. The Director of Nursing (DON) stated that nurses are expected to call a rapid response and obtain a complete set of vital signs during an emergency, and to inform the attending physician after the emergency is addressed. The physician confirmed that he would want to be informed of any emergency situations involving his residents. Review of the resident's progress notes and vital signs summary indicated that the last set of vital signs was checked at 8:57 AM on 06/20/2023, and there was no documentation of an attempt to obtain a complete set of vital signs or inform the physician of the resident's condition. The facility's policy on physician-family notification for changes in condition requires informing the physician and family of significant changes, including life-threatening conditions. However, the facility was unable to provide policies on rapid response, vital signs, and management of change in condition upon request.
Failure to Supervise High-Risk Resident Leads to Injury
Penalty
Summary
The facility failed to ensure adequate supervision for a resident at high risk for falls, resulting in the resident sustaining a head injury. The resident, who has severe cognitive impairment and is completely dependent on staff for toileting and other personal hygiene tasks, was left unattended in the bathroom by a CNA. The CNA left the resident on the toilet to attend to the resident's roommate, during which time the resident fell and sustained a laceration to the head that required staples. The incident was confirmed by both the CNA and the RN on duty, who stated that the resident should not have been left alone due to his fall risk and dependency on staff assistance. The resident's medical history includes Parkinson's disease, neurocognitive disorder with Lewy bodies, dementia, left foot drop, and abnormalities of gait and mobility. The resident's care plan indicated a high risk for falls due to generalized weakness and cognitive impairment. The facility's Fall Prevention Program Policy explicitly states that residents requiring staff assistance should not be left alone after being assisted to bathe, shower, or toilet. Despite this policy, the resident was left unattended, leading to the fall and subsequent injury. The incident was documented in the facility's Serious Injury Incident Report and the resident's Nurse's Notes, which detailed the events and the medical response following the fall.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Glenview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glenview Terrace | 0.7 mi | ★★★★★ | 4 | 1 |
| Niles Nsg & Rehab Ctr | 1.2 mi | ★★★★★ | 3 | 0 |
| Elevate Care Niles | 1.6 mi | ★★★★★ | 10 | 0 |
| Citadel Of Northbrook, The | 1.9 mi | ★★★★★ | 2 | 0 |
| Vi At The Glen | 2 mi | ★★★★★ | 0 | 0 |
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