Elevate Care Country Club Hills: Fractured Toe Missed - IL
Nobody at the facility knew any of this until the daughter returned that evening and handed a bottle of medication to the nurse at the station.
The resident, identified in inspection records as R149, had been living at the facility at 18200 South Cicero Avenue. Her toe had first drawn attention when it appeared red — staff believed the daughter had accidentally bumped it against the resident's wheelchair during one of the family's regular showers. That explanation, offered by family to at least one nurse, became the working theory. What nobody did was document it, investigate it formally, or treat it as a wound requiring medical follow-up.
The wound care coordinator, identified as V24, told inspectors on November 19 that the facility had been treating the toe with betadine and assessing it daily. She said there were no signs of infection. Then inspectors told her what the urgent care visit had found. V24 said she was not aware the toe was infected, not aware antibiotics had been prescribed, and not aware there was a fracture.
The Director of Nursing, identified as V2, said the wound care doctor had seen the resident and she was receiving treatment. She said R149 "always refuses ADL care." When the inspector asked whether that refusal pattern was care planned, V2 said she was not sure. V2 also said she did not know the toe was infected or how the fracture occurred.
The LPN working the 3-to-11 shift on October 25, identified as V51, said R149 was already out on pass when her shift began. When the daughter returned and handed over the antibiotic, V51 learned for the first time about the infection and the fracture. The inspector asked V51 whether she had documented the family's report about bumping the toe on the wheelchair. She said no. Then she changed her answer: the family hadn't actually reported that to her directly, she said. She had just assumed it, because the family always gave the resident showers. She said she was not sure how the resident got the fracture.
The administrator, identified as V1, said she had investigated and reported the injury as one of unknown origin. She said it was not unsubstantiated because the resident had not complained of pain before the family took her out. The injury, she said, started as redness after the wheelchair bump, and the family had reported that to a nurse.
Meanwhile, the facility's own records told a different story about R149's daily care. Shower sheets showed scheduled bathing marked mostly as refused, with no documented skin assessments. A certified nursing assistant, identified as V49, told inspectors she had no issues with the resident at all. She said R149 was pleasant, cooperative with dressing and tooth brushing, and never refused ADL care as far as she was concerned. The resident was typically set up at the bathroom sink and brushed her own teeth.
The wound care coordinator, when asked whether nurses should be documenting refusals in progress notes rather than just on shower sheets, said she was not sure. That was a question for the nurses, she said.
Federal inspectors who completed the survey on November 20 cited the facility for causing actual harm to a small number of residents, the second-most serious harm level in the federal classification system.
R149's daughter did not wait for the facility to notice. She came in, gave her mother a shower, and walked her out the door. A fracture and an infection were waiting to be found. The facility's records, in the meantime, had the resident down as refusing care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Elevate Care Country Club Hill from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
ELEVATE CARE COUNTRY CLUB HILL in COUNTRY CLUB HILLS, IL was cited for violations during a health inspection on November 20, 2025.
Nobody at the facility knew any of this until the daughter returned that evening and handed a bottle of medication to the nurse at the station.
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.