Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elevate Care Northbrook during CMS and state inspections, most recent first.
A resident with paraplegia and other medical conditions was physically assaulted by another resident with psychiatric diagnoses after a verbal altercation escalated in the hallway outside the smoking room. The incident occurred when the staff member assigned to monitor the smoking room was away responding to a call light, resulting in a lack of supervision. The injured resident sustained a laceration and bruise, and it was found that there was no abuse care plan in place for this resident prior to the incident.
The facility did not follow its abuse prevention program policy for several residents identified as at risk for abuse. Despite assessment scores indicating risk and incidents of resident-to-resident altercations or allegations of abuse, required abuse prevention care plans were not initiated or updated as outlined in facility policy. Staff interviews confirmed awareness of the policy but inconsistent implementation.
A resident with a history of dysphagia and speech therapy recommendations for aspiration precautions was not provided with a care plan addressing her swallowing difficulties. She was allowed to eat independently without proper supervision or cues, leading to a choking incident. Staff attempted the Heimlich maneuver but demonstrated inconsistent technique and understanding of emergency procedures. The resident became unresponsive and died during transport to the hospital. The deficiency involved failure to follow care planning and emergency response protocols.
A resident with a history of dysphagia and speech therapy recommendations for aspiration precautions did not have these precautions incorporated into their care plan. Staff were inconsistent in their awareness and implementation of swallowing safety measures. During a meal, the resident choked on food, and despite staff intervention, later died en route to the hospital. The deficiency was due to the facility's failure to develop and implement a care plan addressing the resident's swallowing difficulties.
A resident with a history of type 2 diabetes and other medical conditions experienced an insulin overdose at a facility. Despite low blood glucose levels and symptoms of hypoglycemia, the resident was not immediately sent to the hospital. An RN administered glucagon, but the resident's condition did not improve significantly. The resident's wife eventually called EMS, leading to the resident's admission to the ICU. The facility failed to manage the situation according to the standards of care, resulting in a serious deficiency.
A resident with a Left Ventricular Assist Device (LVAD) was found unresponsive due to the device being wet with urine, causing it to malfunction. The facility lacked specific policies for LVAD care, relying instead on manufacturer guidelines and doctor's orders. Staff replaced the battery, temporarily improving the resident's condition, but she was transferred to the hospital for further care. The incident revealed a critical gap in adherence to LVAD care protocols.
A facility failed to properly label and store an insulin vial, affecting six residents with diabetes. An RN could not identify the owner of an unlabeled, half-filled lispro insulin vial, which should have been labeled with the resident's name, opening date, and expiration date. The facility's policy requires proper labeling and storage of medications, but this was not followed, leading to the deficiency.
A medication administration error occurred when an LPN documented two medications as given to a resident, despite the resident's refusal. This resulted in a 7.41% error rate, exceeding the acceptable 5% threshold. The resident had orders for Tiotropium Bromide and Wixela Inhub, which were not administered as required. The facility's policy on medication refusal was not followed, leading to inaccurate documentation.
A resident with a history of falls sustained a right arm fracture after falling from a hospital bed due to worn wheels that failed to lock properly. The incident occurred while the resident was assisted by a CNA, and the bed moved unexpectedly, causing the fall. The facility's maintenance policy failed to identify the worn wheels, leading to the deficiency.
The facility failed to provide onsite beautician services, affecting residents' rights to a dignified existence and self-determination. Despite having a beauty salon, the facility had not had a beautician for a significant period, requiring residents to rely on family for grooming. Staff confirmed the absence of these services, which contradicted the facility's policy.
The facility failed to ensure timely physician visits for residents, with missing documentation for required visits over a six-month period. Interviews revealed a lack of clarity among staff regarding visit frequency, contributing to the deficiency.
Failure to Protect Resident from Physical Abuse Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident. The incident involved a male resident with paraplegia, major depressive disorder, and other significant medical conditions, who was struck in the face by another male resident with schizoaffective disorder and dementia. The altercation began as a verbal dispute in the smoking room and escalated to physical violence in the hallway outside the smoking room. The injured resident sustained a laceration and bruise to the lip, which was observed by the surveyor the following day. At the time of the incident, the smoking room was supposed to be monitored by staff, but interviews revealed inconsistent supervision. The staff member assigned to monitor the smoking room was responding to a call light in another room when the altercation occurred, leaving the area unsupervised. Other staff members confirmed that the smoking room was not always consistently monitored, and one resident present during the incident stated that no staff were monitoring the room at the time. The lack of supervision allowed the situation to escalate without immediate intervention. Documentation and interviews indicated that the facility did not have an abuse care plan in place for the injured resident prior to the incident. The facility's abuse prevention policy affirms the right of residents to be free from abuse and outlines the importance of a secure environment, but the absence of consistent monitoring and a specific care plan contributed to the failure to prevent the physical abuse. The incident was reported to the police, and both residents were separated after the event, but these actions occurred after the deficiency had already taken place.
Failure to Implement Abuse Prevention Program Policy
Penalty
Summary
The facility failed to implement its abuse prevention program policy for all four residents reviewed. According to facility policy, an abuse/trauma assessment is to be completed upon admission, quarterly, annually, and as needed following any allegation or incident of abuse. If a resident scores above 2 on the assessment, an abuse prevention care plan should be initiated and updated after any investigation of abuse or resident-to-resident altercation. However, multiple instances were identified where these procedures were not followed. For one resident, an abuse/trauma assessment indicated a score of 8 after a physical altercation, but the abuse prevention care plan was not updated as required. Another resident had assessment scores of 4 and 9, both indicating risk, yet no abuse prevention care plan was initiated or updated after a resident-to-resident altercation. A third resident had assessment scores of 6 and 9, but again, no care plan was initiated or updated following a physical altercation. In the case of a fourth resident, an assessment score of 3 indicated risk, but no care plan was formulated, and after an allegation of verbal abuse, neither a new assessment nor an updated care plan was completed. Interviews with facility staff confirmed that the responsible personnel were aware of the policy requirements but did not consistently implement them. The facility's policy clearly outlines the need for ongoing assessment and care planning for residents at risk of abuse, but these steps were not taken in the reviewed cases, resulting in a failure to follow established procedures for abuse prevention and care planning.
Failure to Implement Swallowing Precautions and Emergency Response for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a care plan for a resident with a documented history of dysphagia, despite recommendations from speech therapy for swallowing precautions. The resident was admitted with multiple diagnoses, including acute respiratory failure, dysphagia, COPD, and mild cognitive impairment. The resident's Minimum Data Set indicated a need for supervision or touching assistance with eating, and speech therapy recommended a mechanical soft diet with strict aspiration precautions. However, the care plan did not address the resident's swallowing difficulties or include specific interventions for aspiration precautions. During a mealtime, the resident was allowed to eat independently, despite her history and recommendations for supervision and assistance. The certified nurse assistant (CNA) offered to assist, but the resident refused, and the CNA did not provide verbal cues or reminders to eat slowly or take small bites, as recommended by speech therapy. The resident began to choke while eating, and staff attempted the Heimlich maneuver and called for additional help. Multiple staff members performed abdominal thrusts, but the food was not fully expelled, and the resident became unresponsive. There was confusion among staff regarding the proper technique for the Heimlich maneuver, and the resident was found by EMS to be unresponsive with low oxygen saturation. Interviews revealed inconsistent understanding among staff regarding the resident's need for aspiration precautions and the appropriate interventions during a choking event. Some staff were unaware of the resident's dysphagia, and dietary and nursing staff did not coordinate to ensure the care plan reflected the resident's swallowing risks. The facility's policies required comprehensive care planning and specific emergency procedures for choking, but these were not followed, resulting in the resident's choking incident and subsequent death during transport to the hospital.
Failure to Develop and Implement Care Plan for Dysphagia Leading to Fatal Choking Incident
Penalty
Summary
The facility failed to provide care in accordance with professional standards by not developing and implementing a care plan for a resident with a documented history of dysphagia, despite clear recommendations from speech therapy for swallowing and aspiration precautions. The resident, who had diagnoses including acute respiratory failure, oropharyngeal dysphagia, COPD, and mild cognitive impairment, was admitted with a need for supervision or touching assistance during eating. Speech therapy recommended a mechanical soft diet, thin liquids, and strict aspiration precautions, including eating slowly, taking small bites, and sitting upright. However, these recommendations were not incorporated into the resident's care plan, and staff were not consistently aware of or implementing these precautions. During a meal, the resident was served a turkey hotdog in a bun and was being supervised by a CNA, who offered assistance with cutting the food but was refused by the resident. The CNA did not provide verbal cues or reminders to eat slowly or take small bites, as recommended by speech therapy. The resident began choking, and staff attempted the Heimlich maneuver and suctioning, but only small pieces of food were expelled. There was inconsistency among staff regarding the resident's swallowing precautions, with some staff unaware of the need for aspiration precautions and others stating that supervision and cuing were required. After the choking episode, the resident initially appeared alert and responsive according to facility staff, but EMS found the resident unresponsive with low oxygen saturation upon arrival. The resident was transported to the hospital, where she expired en route. Interviews with dietary and clinical staff revealed a lack of awareness and implementation of a care plan addressing the resident's swallowing difficulties, and the dietary care plan only addressed food preferences, not swallowing safety. The facility's policy required a comprehensive care plan to address all identified needs, but this was not done for the resident's dysphagia.
Failure to Manage Insulin Overdose in Resident
Penalty
Summary
The facility failed to manage a resident with an insulin overdose according to the standards of care, resulting in a delayed transfer to the hospital. A registered nurse (RN) found the resident groggy and sleepy with a very low blood glucose (BG) level in the 30s. The RN administered glucagon and juice, which slightly increased the BG level, but did not document the administration on the medication administration record (MAR). The resident admitted to self-administering insulin but could not specify the amount or timing. Despite the low BG levels and symptoms of hypoglycemia, the resident was not immediately sent to the hospital. A licensed practical nurse (LPN) later administered glucagon at 10:00 AM, as documented on the MAR, but the resident's BG remained low, and his speech was slurred. The LPN stated that she would have insisted on sending the resident to the hospital if he had been her patient. Another RN on the day shift was not informed of any issues during the nurse-to-nurse report and did not call the resident's provider about the low BG. The resident's wife, concerned about her husband's condition, called emergency medical services (EMS), leading to the resident's admission to the intensive care unit (ICU) with an insulin overdose and hypoglycemia. The director of nursing (DON) and the resident's physician and nurse practitioner all indicated that a BG level below 70 is considered low and requires immediate attention. The physician and nurse practitioner emphasized that the resident's BG levels were not stable and that he should have been sent to the hospital. The resident's medical history included type 2 diabetes, chronic kidney disease, and other conditions that complicated his care. The facility's failure to promptly address the resident's hypoglycemia and insulin overdose resulted in a serious deficiency in the quality of care provided.
Failure to Follow LVAD Care Guidelines Leads to Resident Hospitalization
Penalty
Summary
The facility failed to adhere to manufacturer guidelines for the care of a Left Ventricular Assist Device (LVAD), which resulted in a resident being emergently transferred to a hospital. The resident, a cognitively intact female with a history of acute and subacute endocarditis, ventricular tachycardia, and an LVAD implant, was found unresponsive in her room. The LVAD, which is crucial for her heart function, was discovered to be wet with urine, causing it to malfunction. The staff did not have a specific policy for LVAD care but relied on manufacturer recommendations and doctor's orders. On the evening of the incident, the resident's family member called the facility, prompting a nurse to check on the resident, who was found unresponsive with low oxygen saturation. The LVAD was not functioning, and no alarms were sounding because the device was completely off. The staff replaced the battery, which temporarily improved the resident's condition, but she was still not at her baseline and was subsequently transferred to the hospital. The hospital records indicated that the LVAD had low voltage and was completely off at the time of the incident. Interviews with facility staff revealed that the LVAD was wet, which is against the manufacturer's guidelines that state the device must be kept dry at all times. The Director of Nursing acknowledged the lack of a specific policy for LVAD care and confirmed that the device malfunctioned due to being wet. The cardiologist involved in the resident's care expected the staff to assist with LVAD management, including battery replacement, despite the resident's ability to manage the device independently. The incident highlighted a critical gap in the facility's adherence to LVAD care protocols, leading to a potentially life-threatening situation for the resident.
Improper Labeling and Storage of Insulin Vials
Penalty
Summary
The facility failed to adhere to its medication storage policy by not ensuring that an insulin vial was properly labeled and stored according to accepted professional practices. During an inspection of the medication storage and labeling on a specific unit, a registered nurse was unable to identify the resident to whom an unlabeled and half-filled vial of lispro insulin belonged. The nurse acknowledged that the insulin vial should have been labeled with the resident's name, the date it was opened, and the expiration date to prevent the administration of expired insulin. The deficiency affected six residents who had active physician orders for lispro insulin, which was being administered daily. The residents involved had specific orders for insulin administration based on sliding scale parameters for managing diabetes. The medication administration records for these residents showed consistent daily administration of lispro insulin over the past 60 days, indicating that the insulin was a critical component of their diabetes management. The facility's medication storage policy, last revised on a specified date, requires that medications be labeled with the date opened and stored according to manufacturer guidelines. The policy also mandates that medications with missing or illegible labels be destroyed and reordered. The manufacturer's instructions for lispro insulin specify that opened vials should be stored in the refrigerator or at room temperature for up to 28 days, after which they should be discarded. The facility's failure to comply with these guidelines resulted in the deficiency noted in the report.
Medication Administration Error Exceeds Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered for one resident, resulting in a medication error rate of 7.41%, which exceeds the acceptable threshold of 5%. During a medication administration observation, a surveyor noted that an LPN documented two medications as given to a resident, although the surveyor did not observe these medications being administered. Upon inquiry, the LPN admitted that the resident had refused the medications and acknowledged that they should have documented the refusal instead of marking the medications as given. The resident involved had physician orders for Tiotropium Bromide Monohydrate Capsule and Wixela Inhub Aerosol Powder, both due at 9:00 AM. The LPN failed to follow the facility's policy, which requires re-offering the medication, documenting the refusal, and notifying the prescriber after a certain number of refusals. The Director of Nursing confirmed that the documentation was inaccurate and emphasized the importance of accurate medication administration records.
Deficient Bed Maintenance Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure that a resident's hospital bed was in good working order, leading to a fall and subsequent injury. The resident, an elderly female with multiple medical diagnoses including a history of falls, was admitted to the facility and later sustained a fall from her bed. The incident occurred while the resident was sitting on the edge of the bed, assisted by a CNA, when the bed moved, causing her to fall and sustain a right arm fracture. The root cause of the fall was identified as a worn rubber part on the bed's wheel, which resulted in inadequate brake traction. This deficiency was confirmed through interviews and record reviews, revealing that the bed's wheels were not in good working condition. The CNA assisting the resident at the time of the fall reported that the bed slid when the resident leaned on it, despite the bed being locked. Further investigation by the facility's Director of Nursing and Director of Environmental Services confirmed that the bed's wheels were worn and needed replacement. The facility's maintenance policy requires equipment to be maintained in a safe and operable condition, but the worn wheels on the resident's bed were not identified until after the incident. This oversight led to the resident's fall and injury, highlighting a lapse in the facility's maintenance procedures.
Lack of Onsite Beautician Services Affects Resident Rights
Penalty
Summary
The facility failed to provide the services of an onsite beautician, which affected four residents who were reviewed for resident rights. Interviews with residents and staff revealed that the facility had not had a beautician or barber for a significant period, despite having a beauty salon on the premises. Residents expressed dissatisfaction with the lack of grooming services, stating that they had to rely on family members to take them out for haircuts and styling. The absence of these services was confirmed by various staff members, including the Director of Social Services, a Certified Nurse Aide, the Life Enrichment Director, and the Administrator. The facility's policy, titled 'On-site Health care services,' dated September 2015, mandates the availability of onsite services, including beautician/barber services. However, the Administrator acknowledged that the last time a beautician was available was in May 2023. This lack of service provision was contrary to the facility's policy and affected the residents' right to a dignified existence and self-determination, as they were unable to access desired grooming services within the facility.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that residents were personally seen by their physician for an initial comprehensive visit upon admission and at least once every 60 days while in the facility. This deficiency was identified for four residents, each with significant medical diagnoses. The absence of physician progress notes for these residents over a six-month period was noted during the investigation, indicating a lack of compliance with required physician visits. Resident 1, a male with medical conditions including myopathy and hemiplegia following a cerebral infarction, did not have any physician progress notes provided. Similarly, Resident 4, a male with cerebral palsy and other conditions, also lacked documentation of physician visits. Resident 5, a female with asthma and diabetes, had the most recent physician notes dated several years prior, as did Resident 6, a female with chronic obstructive disease and anxiety disorder. These findings suggest a systemic issue with maintaining up-to-date physician documentation for residents. Interviews with facility staff, including the Director of Nursing and the Medical Director, revealed a lack of clarity regarding the frequency of required physician visits. The Medical Director admitted to not seeing Resident 1 upon admission due to being out of the country and expressed uncertainty about the missing documentation. The facility's Physician Services Policy outlines the responsibilities and standards for physician care, but the lack of adherence to these policies contributed to the deficiency.
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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 Northbrook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grove Of Northbrook,the | 0.1 mi | ★★★★★ | 1 | 0 |
| Northbrook Health And Rehab | 0.8 mi | ★★★★★ | 0 | 0 |
| Whitehall Of Deerfield | 2.2 mi | ★★★★★ | 2 | 0 |
| Aliya Of Highwood | 3.5 mi | ★★★★★ | 11 | 0 |
| Brandel Health And Rehab | 3.5 mi | ★★★★★ | 1 | 0 |
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