The resident, who requires supplemental oxygen and has a tracheostomy, was admitted with multiple serious conditions including chronic respiratory failure, dysphagia, and encephalopathy following a stroke. She cannot speak and was unable to respond to questions during the January 29 inspection.
A certified nursing assistant reported the small superficial skin alteration on the resident's left buttock to a licensed practical nurse on January 23. But treatment didn't begin until January 27 — a four-day delay that the wound care coordinator acknowledged could have worsened the injury.
The licensed practical nurse told inspectors she reported the wound to the wound care team but failed to document the discovery anywhere in the resident's medical record. "She knows if it is not documented that it means it was not done," according to the inspection report.
The wound care coordinator couldn't recall anyone telling him about the resident's skin problem until January 27, when he finally called the doctor for a treatment order. He admitted to inspectors that he realized there was a delay in treatment.
The resident didn't receive her first wound care until January 27, according to her treatment records. The physician's order for daily wound care — cleansing with normal saline, applying zinc oxide paste, and covering with silicone foam — wasn't written until January 28, five days after staff discovered the problem.
The Director of Nursing, who has worked at the facility since June 2025, told inspectors she expects nurses to provide interventions promptly to prevent further tissue breakdown. She acknowledged the resident's buttock wound was very small despite the three-day treatment delay.
The facility's own policy requires timely communication of medical problems to attending physicians and timely notification by nursing staff to the medical director. Job descriptions for both registered nurses and licensed practical nurses specifically document requirements for timely physician notification.
Nobody had documented the initial wound discovery.
The inspection found the facility failed to follow its change-in-condition policy, dated July 8, 2024, which was designed "to ensure that medical care problems are communicated to the attending physician in a timely, efficient, and effective manner."
Current treatment orders show the resident receives wound care on her left buttock every day and as needed each shift. Her progress notes from January 27 detail the treatment protocol: cleanse with normal saline, pat dry, apply zinc oxide paste, and cover with silicone bordered foam.
The resident remains non-verbal and bedbound, dependent on supplemental oxygen through her tracheostomy. Her brief mental status assessment shows severe cognitive impairment related to her stroke and other neurological conditions.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, but noted that delayed wound care can lead to serious complications in vulnerable residents. The facility must submit a plan of correction to continue participating in Medicare and Medicaid programs.
The four-day gap between wound discovery and treatment represents the kind of communication breakdown that can have serious consequences for residents who cannot advocate for themselves. The resident's multiple medical conditions and inability to communicate made timely intervention especially critical.
The inspection was conducted in response to a complaint about the facility's care practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elevate Care Chicago North from 2026-01-30 including all violations, facility responses, and corrective action plans.