Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Riverwoods during CMS and state inspections, most recent first.
A resident with decreased appetite, hypernatremia, low blood sugars, and suspected UTI had UA/C&S ordered twice, but both urine culture results were invalid. The EMR showed one specimen was not received and another was rejected because the specimen cup had no name. The NP reported the resident later developed a right-sided facial droop and pocketing food, and the DON stated the straight cath attempt did not yield urine and the nursing contact form entry did not progress.
A resident experienced prolonged tooth pain and swelling after repeated requests for dental care were not addressed, resulting in a tooth infection that required antibiotics. Despite being added to the dental list and having physician orders for a dental evaluation, the resident was not seen by a dentist for several months.
A resident who was cognitively intact reported that a CNA was mean to her, including not responding to her call light and putting her to bed late. After the resident requested not to be cared for by this CNA, the CNA entered the resident's room despite being told not to, confronted the resident about the report, allegedly made a threatening statement, and slammed the door. Staff interviews and facility policy review confirmed the incident constituted a failure to protect the resident from mental and verbal abuse.
Two residents receiving hospice care were given PRN Lorazepam orders for anxiety without required stop dates. The Assistant DON confirmed that stop dates were inconsistently applied and that chart audits are used to identify missing information, despite facility policy mandating a 14-day limit for PRN psychotropic medications unless otherwise documented.
A resident reported that a CNA confronted her about a previous complaint, made a threatening statement, and slammed her door. The incident was reported to another CNA and then to the weekend manager, but the full details were not promptly communicated to the administrator, resulting in a delay of about 24 hours before an abuse investigation was initiated, contrary to facility policy requiring immediate reporting.
A resident with a history of cancer and cataracts was not assisted in obtaining timely follow-up appointments for oncology and ophthalmology care, despite repeated orders and documentation by the nurse practitioner. The facility's process for scheduling appointments failed, resulting in significant delays and ongoing frustration for the resident.
Three residents with pressure injuries or high risk for pressure ulcers did not receive proper care due to staff failing to set low air loss mattresses to the correct weight-based settings and not providing a functional pressure prevention wheelchair cushion. These actions were inconsistent with physician orders, manufacturer guidelines, and facility policy.
A resident with open wounds, including an unstageable pressure ulcer, did not have Enhanced Barrier Precautions (EBP) implemented as required. There was no EBP signage or PPE available outside the room, despite daily wound care and facility policy stating that such precautions are necessary for residents with open wounds.
A resident with morbid obesity, rheumatoid arthritis, and a history of falls was not safely positioned during incontinence care, resulting in a fall from bed and multiple toe fractures. The CNA providing care was unable to reposition the resident to the center of the bed and was the only staff present, despite the resident's size and limited hand strength. Other staff confirmed that proper positioning and adequate assistance were not provided, leading to the incident.
The facility failed to prevent and manage pressure ulcers for several residents, resulting in advanced-stage ulcers. A resident developed a stage 3 ulcer due to misidentification, while another had a reopened ulcer that was not promptly addressed. Inadequate documentation and failure to reposition residents contributed to these deficiencies.
The facility failed to ensure proper food safety practices, including incorrect use of hairnets by dietary staff, lack of knowledge about dishwasher sanitization, and improper food storage management. Dietary aides wore hairnets incorrectly, and staff misunderstood the dishwasher's sanitization process, leading to inadequate dish sanitization. Additionally, expired and undated food items were found in storage, posing a risk of resident illness.
The facility did not offer bedtime snacks to four residents who expressed hunger between dinner and breakfast. Although snacks were available at nurse's stations, they were only provided upon request, and there was no documentation of snack distribution. The facility's policy requires monitoring of snack acceptance, which was not being followed.
A resident with multiple health conditions reported only one care plan meeting in the past year, contrary to the facility's policy of quarterly meetings. Staff failed to document offers for additional meetings or conduct interdisciplinary team discussions, despite frequent communication with the resident and his mother, who is his surrogate decision maker.
A resident with multiple medical conditions, including peripheral vascular disease and a stage 4 pressure ulcer, was found with a necrotic wound on her left heel due to the facility's failure to offload her heels as per care plan. The CNA and wound care director were unaware of the wound, and the facility's policy for daily skin assessments and prompt reporting was not followed.
The facility failed to manage tube feeding for two residents properly. One resident missed feedings due to a lack of coordination with dialysis appointments, while another resident's gastrostomy tube placement was not checked before feeding, and the tube was not flushed afterward. Both residents had a history of dysphagia and required enteral feeding.
The facility failed to remove narcotics for two discharged residents from a medication cart, as observed during a review. The medications, Tramadol and Morphine, were found in the cart despite the facility's policy to return or destroy them promptly. The RN acknowledged the oversight, and the DON confirmed the policy for handling such medications.
Two residents were left unsupervised with their medications, contrary to the facility's policy requiring staff to administer and observe medication intake. An LPN and an RN admitted to leaving medications with the residents without supervision, acknowledging the failure to ensure medications were taken as ordered.
Laboratory Tests Not Completed as Ordered
Penalty
Summary
The facility failed to ensure laboratory tests were completed as ordered for one resident who was reviewed for laboratory services. The resident had a decreased appetite for about a week, and the nurse practitioner reported that the resident’s daughter said this pattern usually occurred when the resident had a UTI. The nurse practitioner also stated the resident had hypernatremia and low blood sugars, and that a UA/C&S was ordered twice but both results came back as invalid. The resident was described as slowly getting worse, then developed a right-sided facial droop and began pocketing food. The nurse practitioner noted the resident had no fever, no hypotension, and no elevated white count on CBC, and that the resident remained alert and tracking when spoken to. Record review showed two urine culture results in the EMR: one dated 4/15/26 stating the specimen was invalid and no urine specimen was received, and another dated 4/20/26 stating invalid. A later lab report dated 4/20/26 stated the specimen was rejected because there was no name on the specimen cup. The DON stated an LPN obtained the straight catheter order but could not get urine, contacted the nurse practitioner, and IV fluids were started; the nursing contact form entry never went anywhere from there. The nurse practitioner stated she ordered the UA/C&S twice at the facility and did not know why the results were not coming back.
Failure to Provide Timely Dental Evaluation Resulting in Tooth Infection
Penalty
Summary
The facility failed to ensure that a resident was evaluated by a dentist after repeated requests and documented oral health concerns. The resident reported ongoing tooth pain and had been using an over-the-counter numbing agent for relief while waiting for a dental evaluation. Despite the resident and his family requesting a dental visit during care plan meetings and through direct communication with staff, there was no documentation that the resident was seen by a dentist over a period of several months. Physician's orders and nursing notes indicated that a referral to the dentist was made and the resident was added to the in-house dentist list, but no follow-up or dental evaluation occurred during this time. As a result of the lack of timely dental care, the resident developed a tooth infection, which led to swelling and required antibiotic treatment. The resident's physician and nurse practitioner both confirmed that the resident should have been evaluated by a dentist, and that the prolonged oral pain and chipped tooth could have contributed to the infection. The facility's policy stated that it would assist residents in arranging on-site health services, including dental care, as needed per resident request, but this was not followed in this case.
Failure to Protect Resident from Mental and Verbal Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from mental and verbal abuse. A cognitively intact resident reported that a Certified Nursing Assistant (CNA) was mean to her, including putting her to bed late and not answering her call light for assistance. The resident stated she reported these concerns to a supervisor and subsequently requested that the CNA no longer provide her care. Despite being instructed by the facility scheduler not to enter the resident's room, the CNA entered the room to confront the resident about the report, during which the resident alleged the CNA said, 'I will show you how mean I am,' and then slammed the door. The resident expressed feeling uncomfortable and did not want the CNA to care for her again. Interviews with staff confirmed that the resident reported the incident to another CNA, who relayed the resident's account of the confrontation and door slamming. The CNA involved admitted to entering the resident's room after being told not to, but denied making threatening statements or intentionally slamming the door. Facility policy defines mental and verbal abuse as conduct that causes or has the potential to cause humiliation, intimidation, fear, or degradation, including harassing or threatening residents. The events described were found to be inconsistent with the facility's abuse prevention policy.
Failure to Include Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that physician orders for as-needed (PRN) psychotropic medications included a required stop date for two residents who were receiving Lorazepam for anxiety. Specifically, one resident had two separate PRN orders for Lorazepam, both lacking a stop date, and another resident also had a PRN Lorazepam order without a stop date. Both residents were on hospice care at the time. During an interview, the Assistant Director of Nursing acknowledged that sometimes a 14-day stop date is provided and sometimes it is not, and that chart audits are performed to identify and correct such omissions. Facility policy requires that PRN psychotropic medications not be used beyond 14 days unless the prescribing practitioner documents the clinical rationale and expected duration for continued use.
Failure to Immediately Report Alleged Abuse to Administration
Penalty
Summary
The facility failed to ensure that an allegation of abuse was immediately reported to administration for one resident. The resident reported that a CNA confronted her about a previous complaint, stated "I will show you how mean I am," and then slammed the resident's door. The resident expressed discomfort and a desire not to be cared for by the CNA again. The resident reported the incident to another CNA, who then informed the weekend manager. However, the full details of the incident, including the potentially abusive statement and door slamming, were not communicated to the weekend manager or the administrator in a timely manner. As a result, the facility's initial abuse investigation was not initiated until approximately 24 hours after the allegation was made. The administrator confirmed that she was not informed of the specific allegations until the following day, delaying the start of the investigation. The facility's policy requires immediate reporting of any abuse allegations to the administrator, either directly or through a supervisor, but this protocol was not followed in this instance.
Failure to Schedule Timely Medical Appointments for Resident
Penalty
Summary
A resident with a history of malignant neoplasm of the nasal cavities, ear, and sinuses, as well as age-related cataracts, was not assisted in obtaining timely medical appointments as ordered and indicated by their medical condition. The resident reported ongoing difficulty in getting follow-up appointments scheduled for both a suspicious bone lesion on the hip and for cataract evaluation, despite repeated requests to staff. Review of the electronic medical record (EMR) confirmed that orders for an ophthalmology follow-up for cataracts and an oncology consultation for a suspicious bone lesion were entered, but no appointments had been scheduled for these services. Progress notes from the nurse practitioner documented the need for these appointments over several weeks, yet the necessary follow-ups were not arranged. The facility's process for scheduling appointments involved nurses filling out forms and management auditing physician orders, but this process failed to ensure timely scheduling for the resident. The Director of Nursing and Administrator acknowledged that the staff member responsible for scheduling appointments had been let go, resulting in missed appointments and a backlog. The nurse practitioner repeatedly communicated the need for these appointments to both the scheduler and nursing staff, but the resident continued to experience delays and expressed frustration over the lack of progress.
Failure to Ensure Proper Pressure Ulcer Prevention and Equipment Use
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevention for three residents with existing pressure injuries or at high risk for developing them. For two residents with physician orders for low air loss mattresses, staff did not set the mattresses to the correct weight-based settings as required. One resident's mattress was set for 250 lbs instead of the actual weight of 151 lbs, and another's was set for 320 lbs instead of 148 lbs. These incorrect settings were observed on multiple occasions, and the wound nurse confirmed that proper weight-based settings are necessary for effective pressure redistribution and wound healing, as outlined in the mattress operation manual and physician orders. Additionally, a third resident, identified as high risk for pressure ulcers and with existing moisture-associated skin damage, was observed using a wheelchair cushion that was bottomed out and sunken in the middle, resulting in direct pressure on the sacral area. The cushion remained in poor condition over several days, and nursing staff acknowledged the issue but did not immediately replace it. Facility policy requires the use of pressure-reducing pads in chairs for residents at moderate to high risk, but this was not followed for the resident in question.
Failure to Implement Enhanced Barrier Precautions for Resident with Open Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with open wounds. During observation, it was noted that the resident, who had wounds on his legs and feet including an unstageable pressure ulcer on the right posterior ankle, did not have EBP signage posted at the entrance to his room, nor was any Personal Protective Equipment (PPE) available outside the room. The resident was receiving daily wound care, and the Infection Preventionist confirmed that residents with open wounds should be on EBP according to facility policy. The facility's EBP policy, effective since January 2024, is intended to minimize the risk of multi-drug resistant organism (MDRO) transmission among residents.
Failure to Provide Safe Incontinence Care Resulting in Resident Fall and Fractures
Penalty
Summary
A deficiency occurred when a resident with morbid obesity, rheumatoid arthritis, and a history of falls was not provided incontinence care in a safe manner. The resident had recently been admitted and required assistance with mobility. During incontinence care, a CNA was the only staff member present and was informed by a nurse that the resident required one-person assistance. The resident was turned to his right side and instructed to hold onto the side rail with his left hand, despite having joint deformities and weakness in his hands due to rheumatoid arthritis. The resident became positioned very close to the edge of the bed, and the CNA was unable to move him back to the center due to his size. While the CNA was providing care, the resident reported that his hands were getting weak and indicated he could not hold on much longer. Before the CNA could respond, the resident lost his grip, fell off the bed, and sustained fractures to his toes on both feet. The incident was witnessed by the CNA, who confirmed that the resident's upper body fell over the side rail first, followed by his lower body. The resident was subsequently sent to the hospital, where multiple fractures were confirmed, and he was returned to the facility with non-weight bearing orders. Interviews with other CNAs and the Restorative RN confirmed that residents should always be positioned in the center of the bed during care to prevent falls. The Therapy Director stated that, given the resident's size and new admission status, a second staff member should have been present for safety, especially since the CNA was unable to reposition the resident alone. The facility's fall prevention policy requires the use of professional standards of practice, which were not followed in this instance.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to identify and manage pressure ulcers effectively for several residents, leading to advanced-stage ulcers. Resident R97 developed a stage 3 pressure ulcer on the left buttock, which was initially misidentified as an abrasion. The wound care nurse acknowledged that the ulcer should have been identified earlier, especially since the resident was compliant with offloading and repositioning. The facility's policy mandates skin assessments during care activities, but these were not adequately performed, resulting in the late identification of the ulcer. Resident R26 had a stage 3 pressure ulcer on the right buttock that reopened, but the wound care team was not notified promptly, delaying the assessment and implementation of treatment orders. The wound care nurse noted that the resident did not follow recommendations, contributing to the ongoing pressure wounds. The delay in addressing the reopened wound highlights a lapse in communication and timely intervention by the nursing staff. Resident R47 had a stage 3 pressure ulcer on the sacrum, but there was a gap in documented wound treatment, with no evidence of dressing changes for several days. Additionally, Resident R8, who had a stage 4 pressure ulcer, was not repositioned as required, and no positioning devices were in place. Resident R35 had a stage 3 pressure ulcer on the left buttock, and the pressure relief cushion in her wheelchair was inadequate, not fitting properly and showing signs of wear. These deficiencies indicate a failure to implement and monitor preventive measures and treatments for pressure ulcers across multiple residents.
Deficiencies in Food Safety Practices
Penalty
Summary
The facility failed to ensure proper use of hairnets by dietary staff, as observed with a dietary aide who repeatedly wore her hairnet incorrectly, only covering the bun on top of her head. This was noted during various activities, including while seated in the kitchen office and while testing the dishwasher sanitation level. The Food Service Director confirmed the importance of hairnets in preventing cross-contamination and stated that staff must fully cover their hair to maintain food safety. The facility's policy mandates the use of hair restraints in all food production, dishwashing, and serving areas. The facility also failed to ensure staff were knowledgeable about the dishwasher's sanitization process. Dietary aides incorrectly monitored the dishwasher's temperature, believing it should reach 100 degrees, and recorded this in the logbook. However, the dishwasher was a chemical-sanitizing type, requiring a sanitizer solution level of 50 ppm or higher. A test revealed the sanitizer level was below 10 ppm, indicating improper sanitization. The maintenance staff identified that the hose was not reaching the sanitizer solution, preventing proper dish sanitization. The Food Service Manager acknowledged the need for staff to use test strips to verify the sanitizer concentration and record the ppm in the log. Additionally, the facility failed to manage food storage properly, as evidenced by expired and undated food items found in the walk-in refrigerator and dry storage room. Items such as cooked rice, beef-flavored base, salad dressing, thickener, flour, oatmeal, sugar, and various dry goods lacked proper labeling or had expired dates. The Food Service Manager stated that staff should check dates daily to ensure food quality and safety, as expired food poses a risk of resident illness. The facility's policy requires all stored foods to be labeled with expiration dates and re-dated upon opening according to safe food storage guidelines.
Failure to Offer Bedtime Snacks to Residents
Penalty
Summary
The facility failed to offer bedtime snacks to four residents, as identified during a resident council meeting. These residents, who have no cognitive impairments, expressed that they were not routinely offered snacks before bed, despite feeling hungry between dinner and breakfast. The facility assessments for these residents did not contain any documentation regarding the offering, refusal, or acceptance of snacks. The Dietary Manager/Registered Dietician stated that snacks are provided to all units and are supposed to be distributed by the aides, but residents only receive them if they request them. The Director of Nursing confirmed that snacks are available at nurse's stations, but they are not proactively offered, nor is there any documentation of snack distribution. The facility's policy indicates that the acceptance and tolerance of snacks should be monitored, but this was not being done in practice.
Failure to Conduct Regular Care Plan Meetings
Penalty
Summary
The facility failed to offer and conduct regular care plan conferences for a resident, identified as R26, who was reviewed for care plans. R26, who has diagnoses including chronic embolism, peripheral vascular disease, alcoholic cirrhosis, morbid obesity, and dementia without behavior, reported having only one care plan meeting in the past year, which primarily focused on physical therapy. The facility's records confirmed only one care plan conference summary dated 11/10/23, attended by R26 and his mother. Despite the facility's policy requiring quarterly care plan meetings, the facility did not document any offers for additional meetings or conduct interdisciplinary team (IDT) discussions regarding R26's care. Interviews with facility staff revealed a lack of documentation and misunderstanding of the requirements for care plan meetings. The social services representative, V17, stated that care plan meetings are held every three months, but R26's mother, who is his surrogate decision maker, declined additional meetings. However, V17 admitted to not documenting these offers or discussions. Similarly, the Director of Nursing, V2, acknowledged frequent communication with R26 and his mother but failed to document these interactions or conduct IDT meetings. The facility's policy emphasizes the importance of involving the resident and their representative in care planning, yet this was not adhered to in R26's case.
Failure to Offload Heels and Identify Wound
Penalty
Summary
The facility failed to ensure proper care and treatment for a resident's heel wounds, as observed during a survey. A resident was found lying in bed with her left heel on the mattress and her right heel on a pillow, despite having offloading boots available in the room. The CNA was unaware of a black area on the resident's left heel, and the wound care director was also not informed of this issue. The resident's care plan required offloading of heels using protective devices, but this was not adhered to, leading to the development of a necrotic wound on the left heel. The resident had a history of multiple medical conditions, including a stage 4 pressure ulcer, peripheral vascular disease, and moderate cognitive impairment, which necessitated substantial assistance for movement. The facility's policy required daily skin assessments and prompt reporting of changes, but these procedures were not followed. The resident's care plan also emphasized the need to keep the skin well-lubricated to prevent dryness and cracking, which was not adequately managed, contributing to the skin breakdown.
Deficiencies in Tube Feeding Management for Two Residents
Penalty
Summary
The facility failed to properly manage tube feeding for two residents, leading to deficiencies in care. For one resident, the tube feeding schedule was not coordinated with their dialysis schedule, resulting in missed feedings. The resident's tube feeding was supposed to run from 6:00 PM to 12:00 PM, but due to dialysis appointments, the feeding was not administered during dialysis. This issue was identified when the resident's tube feeding was found hanging on a pole while the resident was at dialysis, and the feeding was not resumed upon their return. The resident had a history of dysphagia and required enteral feeding due to difficulties swallowing. For another resident, the facility failed to check the placement of the gastrostomy tube before administering liquid nutrition and did not flush the tube after feeding. The resident was on a regimen of liquid nutritional formula four times a day via the gastrostomy tube. During an observation, a registered nurse administered the nutrition without verifying the tube's placement and neglected to flush the tube afterward, which is against the facility's policy. This resident had a history of dysphagia and required attention to their gastrostomy tube for liquid nutrition.
Failure to Remove Narcotics for Discharged Residents
Penalty
Summary
The facility failed to ensure that narcotics for discharged residents were removed from the medication cart, as observed during a review of one of the six medication carts. During the inspection, two medication cards with their reconciliation sheets were found in the narcotic box of the far-west medication cart, hidden behind a box of tissues. These medications belonged to two residents who had been discharged from the facility. The Registered Nurse (RN) acknowledged that the medications should not have been in the cart and should have been handed over to the Director of Nursing (DON) upon the residents' discharge. The first medication card contained Tramadol for a resident who had been discharged about a week prior, while the second card contained Morphine for another resident discharged about a month earlier. The facility's policy requires that medications for discharged residents be discontinued and either returned to the pharmacy or destroyed as soon as possible. However, this procedure was not followed, leading to the deficiency. The DON confirmed that the facility's policy is to send narcotics back to the pharmacy or destroy them if the pharmacy will not accept them, emphasizing that this should be done promptly to avoid any issues.
Medication Administration Policy Violation
Penalty
Summary
The facility failed to ensure medications were administered according to its policy and procedure for two residents. On the morning of July 1, 2024, a resident was observed with a cup containing thirteen different pills on her breakfast tray. She stated that the nurse usually leaves the medications for her to take after eating, and she was unsure of what the medications were. A Licensed Practical Nurse admitted to leaving the medications with the resident and acknowledged that she should have stayed to ensure the medications were taken. Another resident was found swallowing an unknown number of pills from a medicine cup without staff supervision. The resident mentioned that staff leave his medications on the bedside table for him to take after breakfast, and they no longer watch him take them. A Registered Nurse confirmed that the medications were left for the resident to take and admitted that she should have observed the resident to ensure the medications were taken as ordered. The facility's policy requires that medications be administered by authorized personnel and that residents be observed to ensure the dose is ingested, which was not followed in these instances.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Riverwoods
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Radford Green | 1.1 mi | ★★★★★ | 1 | 0 |
| Greek American Rehab Care Ctr | 1.7 mi | ★★★★★ | 18 | 0 |
| Addolorata Villa | 2 mi | ★★★★★ | 8 | 0 |
| Warren Barr Buffalo Grove | 2.1 mi | ★★★★★ | 1 | 0 |
| Serenity Estates Of Lincolnshire | 2.7 mi | ★★★★★ | 17 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.