Elevate Care Palos Heights: Medication Plan Failures - IL
When a federal inspector visited on May 27, 2026, and asked the medical director directly whether it was acceptable for the resident, identified in inspection records as R13, to be on aspirin when his care plan explicitly said to avoid it, the medical director said yes. He explained that R13 was on a low dose of Eliquis and a low dose of aspirin, and that aspirin can be appropriate for heart health. He also said no one had called him about the aspirin. He said he was not sure why the care plan had been written the way it was.
That answer did not resolve the problem. It illustrated it.
The care plan existed. It said avoid aspirin. The medication administration record showed aspirin being given daily. Those two documents, both active, pointed in opposite directions, and no one on staff had flagged the conflict.
The LPN case manager, identified as V22, was the one who explained what had happened. R13 had not been on aspirin when he first arrived at the facility. He returned from a hospital stay with the medication added to his orders. V22 said she should have revised the care plan at that point to reflect the change. She had not. She told the inspector she would take care of it then, during the inspection itself.
The director of nursing and V22 told the inspector together that a resident's care plan should match the physician's order, and that they were not sure why R13's did not. For a care plan like R13's to exist, they said, an order must have come from a physician.
A second resident, R15, presented a different version of the same failure. R15 is 78 years old, with a history that includes repeated falls, chronic respiratory failure with hypoxia, coronary artery disease, and long-term use of antiplatelet and antithrombotic medications. His active physician orders and medication administration record showed him taking two blood thinners simultaneously: aspirin 81 mg once daily for heart health, and Plavix 75 mg once daily for coronary artery disease.
His care plan addressed neither one.
There was no care plan for his antiplatelet medications at baseline. There was no care plan for his antithrombotic medications. The combination of aspirin and Plavix carries bleeding risk, and a care plan for those medications would direct staff on what to watch for and how to respond. R15 had none.
When the inspector asked V22 whether R15 had any antiplatelet care plan in his baseline documentation, she said no. She explained that R15 had just been admitted and that she had not completed his care plan yet.
The inspection found that the facility's own comprehensive care plan policy, last revised in November 2017, describes the purpose of care planning as directing the care team and incorporating each resident's goals, preferences, and services needed to maintain their highest practicable well-being. The policy for individualized daily care similarly notes that each resident's circumstances may require staff to depart from standard procedure, and that the resident's individual needs take precedence.
Both R13 and R15 were on blood-thinning medications. Both had care plan gaps that staff acknowledged on the spot. In R13's case, the gap meant a standing instruction to avoid a drug that was being administered daily. In R15's case, the gap meant two antiplatelet agents with no documented care guidance at all.
The inspection classified the harm level as minimal or potential. That classification reflects what inspectors could confirm had already occurred, not what the documentation gap made possible going undetected.
V22 said she would fix R13's care plan during the visit. R15's care plan had not been completed at the time the inspector was in the building.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elevate Care Palos Heights from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 14, 2026 · Our methodology
ELEVATE CARE PALOS HEIGHTS in PALOS HEIGHTS, IL was cited for violations during a health inspection on May 27, 2026.
He explained that R13 was on a low dose of Eliquis and a low dose of aspirin, and that aspirin can be appropriate for heart health.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.