Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Aspyre Of Waukegan during CMS and state inspections, most recent first.
A resident with dementia, poor safety awareness, and a known history of elopement and exit-seeking behavior was not adequately supervised despite repeated agitation and attempts to reach the elevator. Staff, including an LPN, CNA, social services, and activity staff, intermittently redirected and "watched" the resident but did not provide continuous 1:1 supervision. While the LPN and CNA were performing wound care on another resident, the resident moved down a hallway, accessed an alarmed stairwell door, descended interior stairs, exited a second alarmed door, and traveled across the parking lot and a busy four-lane street to a nearby apartment complex, where the resident was later found unresponsive. The surveyor confirmed that the stairwell door alarm was difficult or impossible to distinguish from the loud call light system from much of the unit, and staff reported they could not differentiate the door alarm from call bells, contributing to delayed recognition of the resident’s elopement and forming the basis of the deficiency.
A resident with COPD and oxygen dependence developed severe respiratory distress overnight, with O2 sats in the 60s and repeated complaints of not being able to breathe. The RN increased oxygen and notified the DON, but did not notify the physician or NP while the resident remained in distress. The resident later became unresponsive, CPR was started, 911 was called, and the resident died that morning from acute respiratory failure.
Failure to prevent and assess a pressure ulcer: A resident with diabetes, dementia, and other chronic conditions was identified as high risk for skin breakdown, but no pressure-relieving interventions were in place before a new unstageable pressure injury developed. Staff observed the resident sitting in a recliner without a pressure-relieving cushion, and a foam dressing was noted on the right buttock before the wound was later documented as an unstageable injury to the right ischium with heavy exudate and necrotic tissue.
Food Safety and Hand Hygiene Deficiencies: A dietary staff member used a dishwasher that was not dispensing chemical sanitizer and still put clean dishware and utensils away. Staff also left an open package of lunch meat unlabeled in the refrigerator, stored scoops inside bulk food bins, and an aide touched the floor while preparing meal carts and then handled food items without washing hands.
The facility lacked a documented Water Management Program risk assessment, specific Legionella control measures, and monitoring for those measures. It also failed to place EBP signage and PPE carts for a resident with an indwelling catheter and a resident with a wound, and a CNA was observed providing incontinent care with the same soiled gloves, opening drawers, and then removing gloves without washing hands.
Failure to Apply Ordered Splints for Residents With Limited ROM: Several residents with contractures or other ROM limitations were observed without their ordered hand splints or braces in place. Records showed active orders and restorative plans for splint use with morning care, but staff and restorative charting did not document application, and one resident’s splint could not be located in the room.
Medication storage was not secured as required when a medication room was found unlocked, with fluconazole left on the counter and an unlocked refrigerator containing insulin pens, Trulicity, and other resident medications. The refrigerator also held a container with liquid that saturated medication boxes, and a narcotic box on a med cart was not double locked even though it contained Norco, a Schedule II controlled substance.
Pureed rice was not prepared to the required smooth consistency for residents on pureed diets. A sampled tray contained rice that was very thick and had chunks throughout, and the Dietary Manager tasted it and said it was not the right consistency, too gritty, and should be smooth like baby food with no chunks. The facility’s diet sheet defined pureed food as very smooth with no solid pieces.
A resident’s PASRR was not completed after a new SMI diagnosis was added. The facility provided an older OBRA screening that did not identify the SMI, and the Administrator stated the PASRR was only ordered after surveyor request. The facility policy states a PASRR level 2 is required when a resident has an SMI diagnosis.
PASRR screening was not completed for a resident with SMI diagnoses, including schizophrenia, major depression, and anxiety. The record contained only an older OBRA screening that did not identify SMI, and no PASRR was present in the EMR. Staff stated the admission dept looks for PASRRs at admission, and the Administrator said the PASRR was ordered later.
Unsafe transfer and missing fall interventions were observed for two residents. A CNA assisted one resident with dementia and unsteadiness from bed to wheelchair without using the gait belt, instead lifting under the arms and pulling the resident into the chair after the resident could not stand using the walker. Another resident with dementia, weakness, COPD, and other diagnoses was observed in a low bed without floor mats in place, and later the mats were folded at the foot of the bed despite staff stating the resident is a fall risk with attempts to self-transfer.
Failure to provide ordered nutritional supplements for a resident with significant weight loss. A resident with diagnoses including dementia, major depressive disorder, psychotic disturbance, weakness, cognitive communication deficit, and PTSD was underweight and had a 6.2% weight loss in one month. Although the dietitian increased the nutritional shake to 120 ml TID, staff observed the resident at meals without the supplement, and the MAR did not show the shake as ordered or signed off as given.
Medication administration errors occurred when an LPN gave a resident’s scheduled AM meds outside the ordered time. The resident’s MAR showed Amiodarone and Metoprolol were ordered for 9:00 AM, but the morning med pass was still ongoing at 11:30 AM, and staff stated the morning med pass should occur between 8:00 AM and 10:00 AM. The facility’s policy required meds to be given at the right time, within 60 minutes before or after the scheduled time unless otherwise specified.
A resident with multiple complex medical conditions was prescribed doxycycline for three days following hospital discharge, but due to an order entry error in the eMAR, only a single dose was administered. The DON confirmed the order was entered incorrectly, resulting in the resident not receiving the full course of antibiotic therapy as prescribed.
The facility did not ensure that kitchen staff followed proper hand hygiene and dish sanitization procedures. A dietary aide handled both dirty and clean dishes without washing hands, and the dishwasher was found to be operating without sanitizer. Required checks of the dishwasher's sanitizing function were not consistently documented, affecting all 77 residents.
The facility failed to properly store, prepare, and distribute food, affecting 71 residents. Observations included expired and undated food items, lack of proper labeling and covering, and absence of thermometers in refrigeration units. Food carts were delivered uncovered, exposing food to air, contrary to facility policies.
The facility failed to maintain a homelike environment, with multiple rooms and shared bathrooms exhibiting peeling paint, holes in walls, and missing baseboards. Eight residents expressed dissatisfaction with these conditions, which were acknowledged by the Maintenance Director as ongoing issues. Despite recognizing the problem, the Maintenance Director hesitated to address it due to pending remodeling plans and lack of a clear policy.
The facility failed to manage and document controlled medications properly, leading to discrepancies in medication counts and potential safety issues. An LPN did not have the incoming nurse sign the accountability log, and there was a lack of an Individual Controlled Drug Administration Record for a resident's Clonazepam. Discrepancies were noted in medication counts, and residents had medications without active orders, improperly stored with pill slots covered with tape. The DON acknowledged the need for proper accounting and disposal of controlled medications.
The facility failed to properly label and store medications for five residents, including insulins and eye drops. Observations revealed opened and undated insulin vials, improper storage of insulin pens, and an undated eye drop container without an active order. The DON confirmed that medications should be stored according to package instructions, and the facility's policy requires adherence to pharmacy recommendations and regulatory guidelines.
The facility failed to assist residents with activities of daily living, including eating and oral care. A resident with Alzheimer's and dysphagia struggled to feed herself due to a soiled mask and lack of staff assistance. Another resident with hand contractures was left unsupervised, resulting in untouched drinks and spilled food. Two residents with oral hygiene needs had unkempt teeth and food residue, despite the facility's policy for daily care. The DON acknowledged the need for staff assistance, but observations showed a failure to meet these standards.
A resident with dementia and other health issues was served thin liquids instead of the prescribed nectar-thickened liquids. The CNA corrected the error after noticing the discrepancy. The facility's policy requires dietary staff to prepare meals according to prescribed diets, with CNAs performing a final check before serving.
The facility failed to provide proper urinary catheter care for two residents, leading to increased infection risk. Staff routinely disconnected and cleaned catheter bags with a vinegar solution, contrary to best practices and without physician approval. This practice was inconsistent with the facility's policy, which contributed to the deficiency.
The facility failed to follow infection control protocols by not wearing PPE for two residents on Enhanced Barrier Precautions. Staff were observed providing care without gowns, despite knowing the requirement for PPE during high-contact activities. Both residents had orders for EBP due to their medical conditions.
A resident with dementia and a history of falls sustained an unwitnessed fall resulting in a femur fracture. The facility failed to conduct required neurological assessments at specified intervals for 72 hours post-fall, as per their policy. The resident's electronic medical record showed a lack of assessments from late morning to midnight on the day of the fall, which was confirmed by the DON.
A facility failed to implement fall interventions for a resident with a history of falls and dementia. The resident was found in bed without floor mats and the bed was not in the lowest position, contrary to the care plan. The DON confirmed the required interventions were not in place.
A resident with an acute injury experienced a delay in receiving a STAT x-ray, which was ordered due to suspected deep vein thrombosis. Despite orders being placed, the x-ray was not performed until over 24 hours later, revealing a fracture. The LPN expected the x-ray to be done the same day, and the NP advised staff to follow up with the x-ray company or send the resident to the emergency department if necessary. The facility's administrator was investigating the delay.
The facility failed to document and communicate visitor restrictions for two residents, leading to a deficiency in maintaining safety. One resident's father, who was verbally aggressive, was not properly restricted in the records, and another resident's son, who brought illegal substances, was not documented as restricted. The facility's policy requires such restrictions to be clearly posted and documented, which was not done.
Failure to Supervise Exit-Seeking Resident and Respond to Ineffective Door Alarms
Penalty
Summary
The deficiency involves the facility’s failure to adequately supervise and protect a resident with dementia, poor safety awareness, and known exit-seeking behaviors, resulting in the resident eloping from the second floor through alarmed doors. The resident had diagnoses including Parkinsonism, COPD, dementia, unsteadiness on feet, combined systolic and diastolic heart failure, atrial fibrillation, and cognitive communication deficit. The resident had a documented history of elopement behavior, including an elopement attempt in December shortly after admission, which led to relocation to the second floor and implementation of hourly face checks. An elopement risk assessment identified the resident as at risk for elopement, and the care plan documented the resident as an elopement risk/wanderer with impaired safety awareness and a history of attempts to leave the facility unattended. On the day of the incident, multiple staff members reported that the resident was very agitated, repeatedly stated a desire to go home, and kept going to the elevator, requiring frequent redirection. The LPN notified the DON and the NP, obtained orders for lab work and a UA/C&S, and involved social services to speak with the resident. The resident’s son was contacted and spoke with the resident, after which the resident appeared unhappy and continued to express a desire to go home. Staff, including the LPN, CNA, social services assistant, and activity staff, took turns watching and redirecting the resident, but there was no clear, continuous 1:1 supervision assigned despite the resident’s ongoing exit-seeking behavior that day. The activity aide was told to watch the resident and was positioned near the elevator and then in the dining area, but she did not maintain direct observation of the resident when he moved down the hallway. During a period when the LPN and CNA were performing wound care on another resident, the activity aide allowed the resident to move down the hallway in his wheelchair and did not maintain close supervision. Shortly thereafter, staff realized the resident could not be found. The RN reported hearing a faint door alarm under the loud call light system and discovered the resident’s wheelchair outside the stairwell door, indicating the resident had exited into the stairwell. The surveyor later confirmed that the stairwell door alarm was difficult or impossible to distinguish over the loud call light system from much of the hallway and near the nurse’s station, and that staff on the unit could not differentiate the door alarm from call light bells. The resident’s exit path was reconstructed: he traveled down the hall, through the alarmed stairwell door, descended 14 interior steps, exited through a second alarmed door, went down exterior steps, onto a deck and ramp, crossed the facility parking lot and a busy four-lane street, and continued through an adjacent apartment complex parking lot, where he was later found unresponsive. EMS documentation and staff interviews indicated that staff believed the resident had left the facility approximately 30–40 minutes before EMS was called, confirming a significant lapse in effective supervision and response to the alarmed exits. The surveyor’s observations and staff interviews demonstrated that the facility did not ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for this resident. The alarm system on the stairwell door was not reliably audible over the existing call light system, limiting staff’s ability to promptly detect and respond to the resident’s use of the exit. Staff assigned to monitor the resident did not maintain continuous observation despite his known elopement risk and active exit-seeking behavior, and there was confusion among staff about their monitoring responsibilities. These combined factors allowed the resident to leave the secured floor, exit the building through alarmed doors, and travel a considerable distance off facility property before being located, constituting the basis for the cited deficiency.
Failure to Notify Physician During Resident Respiratory Distress
Penalty
Summary
The facility failed to ensure a resident with COPD, CHF, vascular dementia, diabetes, and oxygen dependence received a higher level of care when the resident developed respiratory distress. The resident’s physician orders included oxygen at 2 L per minute, titrate to 3-4 L as needed, and to notify the physician for oxygen saturations below 92%. The resident’s death certificate listed acute respiratory failure as the cause of death. During the overnight shift, the resident was found in the doorway gasping for air and calling for help, stating, “I cannot breathe.” The CNA notified the RN, who assessed the resident and found oxygen saturation in the 60s. The RN increased oxygen from 2 L to 4 L, later used a nonrebreather mask, and monitored the resident as the resident continued to complain of shortness of breath and repeatedly removed the oxygen. The RN notified the DON, but did not notify the resident’s physician or NP while the resident remained in respiratory distress with very low oxygen saturation. The DON instructed the RN to apply a nonrebreather mask and to notify the physician or send the resident to the hospital, but the physician was still not contacted at that time. The NP later stated that if she had been notified, she would have sent the resident to the hospital. The resident became unresponsive later that morning, CPR was initiated, 911 was called, and the resident died the same day.
Failure to Prevent and Assess a Pressure Ulcer
Penalty
Summary
The facility failed to identify and assess a pressure ulcer before a new unstageable pressure ulcer developed and failed to implement pressure relieving interventions for a resident at risk for pressure injuries. R59 had diagnoses including type 2 diabetes, unspecified dementia, hypertensive heart disease, dysphagia, and bilateral hearing loss, and her Braden Scale dated 12/17/25 showed she was at risk for developing pressure ulcers. Her current care plan identified her as at risk for skin impairment, but no pressure relieving interventions were in place prior to 2/23/26. On 2/22/26, R59 was observed sitting in a reclining wheelchair without a pressure relieving cushion; she was thin, underweight, and yelling for help. Staff transferred her to bed for incontinence care, and a foam dressing was noted to her right buttock. She was then transferred back to her recliner without a cushion. The wound nurse later confirmed R59 was high risk for pressure ulcers and did not have pressure relieving interventions in place prior to developing the pressure ulcer. R59's wound progress note dated 2/23/26 documented an unstageable pressure injury to the right ischium measuring 2.4 cm x 0.8 cm x 0.2 cm with heavy serous exudate and 80% necrotic tissue.
Food Safety and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to ensure that dishware and utensils were sanitized before use. During observation, the dietary staff member operating the dishwasher tested the low-temperature chemical dishwasher multiple times and the test strips did not read any chemical concentration. Despite those results, the staff member continued to run and put away dish racks of plate covers, trays, plates, serving trays, and silverware. The dietary manager later stated that the dishwasher should be tested before use three times a day and that if the proper chemical concentration was not reading, maintenance should be notified and dishes should be soaked in a sink of sanitizer before being used. The facility also failed to properly store food and maintain hand hygiene during food preparation. An open package of lunch meat was found in the refrigerator without a label, and the dietary manager stated it should have been dated because it is only good for one week after opening. Scoops were observed stored inside bulk sugar and thickener bins, although the facility policy states scoops should be kept covered in a protected area near the containers rather than in the containers. In addition, a dietary aide preparing meal carts did not have gloves on, placed hands on the floor for balance while reaching for a tray, and then handled nutritional supplement cups for lunch trays without washing hands in between; the dietary manager stated hands should be washed after touching the floor before handling food items.
Water Management, EBP, and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to have a Water Management Plan that included a documented assessment of where Legionella and other opportunistic waterborne pathogens could grow and spread, specific control measures based on that assessment, and a system to monitor those control measures. The facility’s two-page Water Management Program stated general goals such as identifying building water systems needing legionella control measures, assessing risk, applying control measures, and ensuring the program is effective, but it did not document a risk assessment specific to the building or identify what control measures were needed, how they would be monitored, or what actions would be taken if they were not met. The Administrator stated the facility did not have a documented risk assessment, and Maintenance stated water came from the city to a boiler and two hot water holding tanks, but he was unaware of a Water Management Program or any risk assessment; the only routine described was flushing vacant rooms every three days and keeping water temperatures between 105-110 degrees. The facility also failed to ensure Enhanced Barrier Precautions were in place for residents with wounds and an indwelling urinary catheter, and staff failed to remove gloves and wash hands after dirty care. One resident with an indwelling catheter had no EBP sign or PPE cart outside the room, despite the care plan documenting EBP for the catheter and requiring gown and gloves for high-contact care activities. Another resident with a full-thickness wound to the right leg also had no EBP sign or cart outside the room, and the physician order sheet had no EBP orders. In a separate observation, two CNAs provided incontinent care to a resident with stool-soiled linens; one CNA used the same soiled gloves while opening drawers, continued care, removed the gloves, and did not wash hands. The Infection Control Nurse stated staff should change gloves and wash hands from dirty to clean tasks, and the facility hand hygiene policy stated hand hygiene is required after glove removal and when hands are visibly soiled.
Failure to Apply Ordered Splints for Residents With Limited ROM
Penalty
Summary
The facility failed to ensure residents with limited range of motion had splints in place as ordered for 4 of 12 residents reviewed for ROM. R63 was observed multiple times without the ordered left hand and elbow brace, despite diagnoses including aphasia, hemiplegia and hemiparesis following cerebral infarction and contractures of the left knee, left elbow, left shoulder, and left hand. His physician order summary and restorative charting showed an active order for the brace to be worn for 4 hours with morning care and removed at lunch, and the restorative nurse confirmed the brace should have been on in the morning. R16 was observed in bed using only her right hand, with her left hand flaccid and her brace not in place, although she reported she had a brace for her left hand that was not put on very often. Her records showed an active order for a left hand brace for 4 hours daily with morning care, but February restorative charting had no staff initials to show it was applied. R6 was observed several times without bilateral hand splints, and her records showed active orders for bilateral hand splints for 2 hours daily with morning care; February restorative charting also had no staff initials indicating application. R32 was observed in bed, in a recliner, and in the dining room with his right hand in a closed position and without his right resting hand splint, and staff could not locate the splint in his room. His restorative plan and care plan required a right resting hand splint for two hours in the morning, and staff confirmed it should have been in his room and applied as ordered.
Unlocked Medication Storage and Improper Controlled Substance Security
Penalty
Summary
Medication storage was not maintained in accordance with accepted professional principles because the first-floor medication room was left unlocked during observation. In that room, a bag of fluconazole tablets was found on the counter, and the refrigerator was also unlocked. The unlocked refrigerator contained multiple insulin pens for R29, R13, and R48, as well as a box of Trulicity for R50. The refrigerator also contained a container with an insulin pen for R50, a box of acetaminophen suppositories, and a box of bisacodyl suppositories for R64. The container had about 1/4 inch of liquid in the bottom, and the medication boxes were saturated. On the second-floor west medication cart, the narcotic box was not locked and could be opened with a key; it contained Norco, a Schedule II controlled substance for R48. The DON stated that medication rooms should be locked at all times and that controlled substances should be locked in the lock box inside the locked medication cart at all times.
Pureed Diet Food Not Prepared to Required Consistency
Penalty
Summary
The facility failed to ensure that pureed rice was prepared in a form designed to meet the needs of residents on pureed diets for 6 of 6 residents reviewed for pureed diets (R5, R23, R37, R39, R49, and R64). The facility's Diet Type Report printed on 2/23/26 showed that these residents were on pureed diets. During observation on 2/22/26 at 12:55 PM, a pureed diet tray was sampled and the pureed rice was very thick with chunks of rice throughout. At 12:57 PM, V3, the Dietary Manager, tasted the rice and was observed chewing it. V3 stated that the rice was not the right consistency, that it was too gritty, and that pureed food should be smooth like baby food and not have chunks in it. The facility's Pureed Diet Sheet stated that a pureed diet is food with a very smooth consistency or foods that have been well processed in a food processor or blender to a very smooth consistency or texture, with no solid pieces or parts noticeable in the food.
Failure to Complete PASRR After SMI Diagnosis Change
Penalty
Summary
The facility failed to ensure a PASRR was completed after a resident’s Serious Mental Illness diagnosis changed. R4 was admitted with a primary diagnosis of hemiplegia affecting the left side, and schizoaffective disorder was added to her diagnoses on 12/13/19. When the surveyor requested PASRR documentation, the facility provided an Interagency Certification of Screening Results (OBRA) dated 5/13/19, which did not identify R4 as having an SMI diagnosis. During interview on 2/23/2026 at 1:24 PM, the Administrator stated the PASRR for R4 was ordered to be done that day. The facility’s PASRR screening policy dated 8/2022 states that a PASRR level 2 should be completed if a resident has an SMI diagnosis.
PASRR Screening Not Completed for Resident with SMI
Penalty
Summary
PASARR screening for Mental disorders or Intellectual Disabilities was not completed for a resident with a serious mental illness diagnosis. R54 was admitted with diagnoses including Other Schizophrenia, Major Depression Recurrent, and anxiety disorder, but the only document in the record was an Interagency Certification of Screening results (OBRA) dated 4/16/15 that did not identify a serious mental illness diagnosis and was valid for 90 days. No PASRR was found in the resident’s electronic medical record. The Social Services Director and Admissions and Marketing staff stated the admission department looks for PASRRs when a resident is admitted, and the Administrator stated the PASRR for R54 was ordered by the facility on 2/23/2026. The facility’s PASRR screening policy dated 8/2022 states no residents will be admitted without a PASRR level 1 and that a PASRR 2 will be completed if there is a diagnosis of Severe Mental Illness.
Unsafe Transfer and Missing Fall Interventions
Penalty
Summary
The facility failed to safely transfer a resident with diagnoses including traumatic subdural hemorrhage, dementia, and unsteadiness of feet. During observation, a CNA assisted the resident from bed to wheelchair by placing the wheelchair at the side of the bed, helping the resident sit at the edge of the bed, and placing a walker in front of him. The resident attempted to stand by pulling up on the walker twice, but was unable to do so. The CNA then placed his hands under the resident’s armpits and lifted him to a standing position, then instructed the resident to turn and sit in the wheelchair. The CNA went behind the wheelchair, pulled the back of the resident’s pants to seat him, and later stated he did not use the gait belt because the resident wanted to do things himself. The facility also failed to ensure fall interventions were in place for a resident with diagnoses including dementia, weakness, COPD, Alzheimer’s disease, bipolar disorder, schizophrenia, chronic pain, and weakness. The resident was observed lying in a low bed with his head resting on the right side rail, and no floor mats were placed on the floor. On a later observation, the resident was lying in the low bed eating breakfast, and the floor mats were folded at the foot of the bed. Staff stated the resident is a fall risk, tries to get out of bed, and his fall interventions include a low bed, placement in a supervised area, and floor mats. The resident’s care plan identified him as high risk for falls, unaware of his safety needs, with attempts to self-transfer, and noted a prior fall involving sliding off the bed with floor mat intervention in place.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
The facility failed to ensure nutritional supplements were given to a resident with significant weight loss. R11 had diagnoses including major depressive disorder, unspecified dementia, severe psychotic disturbance, weakness, cognitive communication deficit, and post-traumatic stress disorder. Her dietitian evaluation dated 02/03/26 showed she was underweight at 91 lb., with a 6.2% weight loss since 12/31/25, and the recommendation was to increase her nutritional shake to 120 ml three times a day. The facility’s weight report showed her weight decreased from 97 lb. on 12/31/25 to 91 lb. on 1/30/26. During observation, R11 was seen in the dining room at breakfast and lunch with food trays in front of her, but her nutritional supplement shake was not provided. This occurred on 2/22/26 at breakfast and noon meal, and again on 2/23/26 during the noon meal. An LPN stated nursing gives nutritional shakes to residents and documents them on the MAR, but did not include R11 as receiving one. The dietitian stated she entered the order and nursing documents the supplement in the resident’s medical record, while the DON stated nutritional shakes are signed off by nursing on the MAR. R11’s February 2026 MAR did not show the ordered nutritional shake 120 ml three times a day as ordered or signed off as given.
Medication Pass Not Given at Ordered Time
Penalty
Summary
The facility failed to administer medications as ordered at the ordered times, resulting in a medication error rate of 7.6% with 2 errors out of 26 opportunities. This applied to 1 of 4 residents observed during the medication pass. During observation on 2/22/26 at 11:00 AM, an LPN prepared R6’s morning medications, including Amiodarone 200 mg via g-tube twice daily for arrhythmia and Metoprolol 25 mg, half tablet twice daily for hypertension, and crushed and administered the medications separately through the resident’s g-tube. At 11:30 AM, the LPN stated R6 was her last resident for the morning medication pass. On 2/26/26 at 10:51 AM, another LPN stated the morning medication pass should be from 8:00 AM to 10:00 AM. R6’s MAR for February 2026 showed orders for both medications to be given at 9:00 AM, and the facility’s medication administration policy stated medications should be given at the right time, 60 minutes before or after the scheduled time unless otherwise specified.
Antibiotic Order Not Followed Due to Medication Entry Error
Penalty
Summary
The facility failed to ensure that an antibiotic was administered as ordered for one resident. The resident, who had multiple diagnoses including pneumonia, major depressive disorder, osteoporosis, severe protein calorie malnutrition, hypothyroidism, chronic obstructive pulmonary disease, and other conditions, was discharged from the hospital with instructions to receive doxycycline 100 mg daily for three days. However, the electronic Medication Administration Record (eMAR) showed that the order was incorrectly entered as a one-time dose rather than a daily dose for three days. As a result, the resident received only one dose of doxycycline instead of the full prescribed course. The Director of Nursing confirmed that the order was entered incorrectly and that only a single dose was administered, contrary to the hospital discharge instructions and facility policy for safe medication administration.
Failure to Sanitize Dishes and Ensure Hand Hygiene in Kitchen
Penalty
Summary
The facility failed to ensure proper kitchen sanitation practices, specifically regarding the use of the dishwasher and hand hygiene among dietary staff. On observation, a dietary aide was seen unloading clean dishes, loading dirty dishes, and then handling clean dishes again without washing hands in between, which could lead to cross contamination. Additionally, the sanitizer bucket connected to the dishwasher was found to be empty, and test strips confirmed that no sanitizing agent was present in the dishwasher at the time of inspection. The dietary manager acknowledged that the dishwasher should be checked three times daily to ensure proper function and sanitizer levels, and that handwashing is required when moving from dirty to clean dishes. Record review revealed that the facility's dishwasher sanitizer check sheet had missing entries for several meal periods, indicating that required checks were not consistently performed. The facility's policy requires dish machines to be checked prior to meals and mandates handwashing before handling clean dishes after touching dirty ones. The infection control nurse confirmed the importance of proper dish sanitization to prevent the spread of foodborne illnesses and gastrointestinal viruses. These failures applied to all 77 residents in the facility.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and distribute food in a manner that would prevent foodborne illnesses, affecting 71 residents who consumed food from the kitchen. During an initial tour of the kitchen, several deficiencies were observed in the dry food storage area, including expired tomato juice, and various food items such as mashed potatoes and tortillas that lacked 'received on' or expiration dates. Additionally, an opened box of instant food thickener and long grain rice were left exposed to air without 'opened on' dates. The milk refrigerator lacked a thermometer, and undated milk was served to residents despite staff acknowledging the absence of dates. The kitchen cooler contained staff personal items and uncovered food items like juice cups, cheese, bologna, and cut vegetables, all without proper dating or covering. Further inspection revealed improper storage in the kitchen freezers, with raw pork chops stored above tator tots, and various undated and uncovered food items such as sausages, pancakes, and chicken. A second freezer contained improperly covered and undated cooked enchiladas, corn, and ice cream with a broken lid. Food carts delivered to dining halls were uncovered, exposing trays and open cups to air. The facility's policies on food receiving, storage, and preparation were not adhered to, as evidenced by the lack of proper labeling, dating, and covering of food items, as well as the absence of functioning thermometers in refrigeration units.
Facility Fails to Maintain Homelike Environment Due to Peeling Paint and Structural Issues
Penalty
Summary
The facility failed to maintain a homelike environment for its residents, as observed during a survey. Multiple rooms and shared bathrooms were found with peeling paint, holes in the walls, and missing baseboards. These conditions were noted in the rooms and shared bathrooms of eight residents, all of whom expressed dissatisfaction with the state of their living environment. The residents' cognitive statuses varied, with some being moderately impaired and others cognitively intact, yet all were aware of and concerned about the environmental deficiencies. The Maintenance Director acknowledged the ongoing issues with the facility's physical environment, including paint and wallpaper peeling, holes in walls, and missing baseboards. Despite recognizing the problem, the Maintenance Director expressed hesitation in addressing these issues due to potential future remodeling plans, which were pending approval from corporate. The lack of a clear policy or immediate plan to rectify the environmental deficiencies contributed to the ongoing neglect of the residents' right to a safe, clean, and homelike environment.
Failure to Properly Manage and Document Controlled Medications
Penalty
Summary
The facility failed to properly manage and document controlled medications for several residents, leading to discrepancies in medication counts and potential safety issues. During an observation, it was found that a Licensed Practical Nurse (LPN) did not have the incoming morning nurse sign the accountability record log for controlled medications, and there was a lack of an Individual Controlled Drug Administration Record log for a resident's Clonazepam medication. Additionally, discrepancies were noted in the medication count for Clonazepam, with missing signatures for tablets removed on specific dates. The facility's Shift Change Accountability Record for Controlled Substances also showed multiple omitted nurses' signatures. Further observations revealed that residents had medications such as Hydrocodone and Lorazepam in their possession without active orders, and these medications were improperly stored with pill slots covered with tape or band-aids. The Director of Nursing acknowledged that all controlled medications need to be accounted for and disposed of appropriately when discontinued or not used. The facility's policy requires controlled substances to be signed out upon dispensing, with a maintained count by nurses of the off-going and oncoming shifts, and any irregularities reported to the Director of Nursing.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to properly label and store medications for residents receiving insulins and eye drops, affecting five residents. During an observation of medication storage, it was found that a resident's Levemir insulin vial was opened and undated, and another resident's Humulin R insulin vial was open and dated beyond the discard date. Additionally, a resident's Fiasp insulin vial was stored at room temperature despite instructions to refrigerate until opened. Another resident's insulin pens and vials were opened, unbagged, and stored in a multi-resident container, and a resident's Latanoprost eye drop container was open and undated, with no active order for the medication. The Director of Nursing acknowledged that insulin and eye drop medications should be stored according to package instructions and that multi-dose medications should be labeled when opened and discarded as indicated. The facility's policy on medication storage, dated March 2021, states that medications should be stored in accordance with pharmacy recommendations and regulatory guidelines. These observations indicate a failure to adhere to proper medication storage and labeling practices, potentially compromising medication safety administration.
Failure to Assist Residents with ADLs in LTC Facility
Penalty
Summary
The facility failed to provide adequate assistance to residents requiring help with activities of daily living, specifically in eating, oral care, and grooming. Resident 57, who has multiple diagnoses including Alzheimer's disease and dysphagia, was observed struggling to feed herself due to a soiled surgical mask and lack of consistent assistance from staff. Despite her need for substantial to maximal assistance with eating, she was left unsupervised multiple times, and her oral hygiene was neglected, as evidenced by overgrown facial hair and unkempt teeth. Resident 1, also diagnosed with Alzheimer's disease and hand contractures, was observed with untouched drinks and difficulty feeding herself due to her hand splints and a soiled surgical mask. Although she required supervision and assistance with eating and drinking, she was left unsupervised, resulting in spilled food and untouched beverages. Her care plan indicated a dependency on staff for all activities of daily living, including feeding. Residents 28 and 26, both with significant medical conditions affecting their ability to perform oral hygiene, were found with unkempt teeth and food residue. Despite the facility's policy requiring daily oral care, these residents were not adequately assisted, leading to a buildup of plaque and food residue. The Director of Nursing acknowledged the expectation for staff to assist residents with their daily living activities, including feeding and oral hygiene, but the observations indicated a failure to meet these standards.
Failure to Provide Correct Consistency of Liquids
Penalty
Summary
The facility failed to provide the correct consistency of liquids for a resident with an order for nectar-thickened liquids. The resident, identified as R60, had multiple diagnoses including dementia, muscle weakness, and respiratory infection, and required setup assistance for meals with an altered diet necessitating thickened liquids. On January 7, 2025, a Certified Nurse Assistant (CNA) served R60 lunch with drinks that were of thin liquid consistency, contrary to the nectar-thickened liquid requirement noted on the resident's meal ticket. The CNA acknowledged the error and corrected it by thickening the drinks after being prompted. The Director of Nursing (DON) confirmed that dietary staff are responsible for preparing meal trays according to prescribed diets, and CNAs are expected to perform a final check before serving meals to residents. The facility's policy on meal service emphasizes the importance of ensuring the accuracy of prescribed diets, including diet type, texture, and fluid consistency. The failure to adhere to these procedures resulted in the resident being served the incorrect type of liquids, which could potentially lead to complications such as choking and aspiration pneumonia.
Improper Urinary Catheter Care and Increased Infection Risk
Penalty
Summary
The facility failed to provide proper urinary catheter care for two residents, R44 and R67, as observed during a survey. For R44, a CNA reported changing the catheter bag from a hanging bag to a leg bag and cleaning the bags with a vinegar and water solution, despite the bag being labeled as sterile and not to be re-sterilized. The RN confirmed this practice, which was instructed during an in-service by the Infection Preventionist. The Nephrology Nurse Practitioner advised against disconnecting the catheter system due to increased infection risk, yet the facility continued this practice without physician approval. For R67, the urinary bag was observed on the floor and later placed under a blanket by a CNA. The CNA stated that the urinary bag is disconnected, cleaned with a vinegar solution, and hung to dry daily, with the cleaned bag from the previous shift being reattached. The LPN confirmed this routine, which involves switching between two bags every couple of weeks. The Infection Preventionist acknowledged that the practice of disconnecting and reusing bags increases infection risk, yet it was the facility's standard procedure. The Director of Nursing stated that the urinary bag is disconnected and cleaned twice daily to maintain cleanliness, although this practice was not approved by the facility's Medical Director or Urologist, nor was there a physician's order for it. The facility's policy on Foley catheter management indicated a different cleaning procedure, which was not being followed. This discrepancy in practice and policy contributed to the deficiency in providing appropriate catheter care and preventing urinary tract infections.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols by not wearing appropriate Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). On January 8, 2025, a Restorative Aide/CNA was observed in a resident's room without wearing a gown, despite the resident being on EBP. The aide provided incontinence care, assisted in changing clothes, and transferred the resident from the bed to a wheelchair without the required PPE. The resident had multiple diagnoses, including hemiplegia, hemiparesis, and dementia, and had an order for EBP since December 30, 2024. Similarly, another CNA was observed on the same day in a different resident's room without wearing a gown while transferring the resident and changing a catheter bag. This resident had diagnoses including Parkinson's disease and Alzheimer's disease and had an EBP order since April 18, 2024. Both staff members acknowledged the requirement to wear gowns and gloves for residents on EBP, especially during high-contact activities such as transferring and incontinence care. The facility's policy from December 2019 mandates the use of gloves and gowns for such activities, yet these protocols were not followed, leading to the deficiency.
Failure to Complete Post-Fall Assessments
Penalty
Summary
The facility failed to complete ongoing assessments for a resident who sustained a fall with injury. The resident, who had a history of repeated falls and impaired cognition due to dementia, was at high risk for falls and dependent on staff for care. After an unwitnessed fall from bed, the resident was initially assessed and found to have no immediate complaints of pain or obvious injuries. However, the resident later complained of left leg pain, and an X-ray revealed a proximal left femur fracture. Despite the injury, the resident's family did not want hospitalization, and the resident remained in the facility with orders for pain management and follow-up with an orthopedic physician. The facility's protocol required neurological assessments immediately after a fall and at specified intervals for 72 hours post-fall. However, the resident's electronic medical record showed a lack of post-fall assessments from late morning to midnight on the day of the fall. The Director of Nursing confirmed that no neurological or 72-hour post-fall assessments were completed during this period, which was a deviation from the facility's Neurological Assessment policy. This policy outlined specific intervals for monitoring key neurological checkpoints, which were not adhered to in this case.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident, who had sustained a recent fall with injury, had appropriate fall interventions in place. The resident, identified as R2, had a history of repeated falls and was at high risk due to impaired cognition related to dementia. R2 was dependent on staff for care and had previously fallen out of bed, resulting in a fracture. The care plan for R2 included keeping the bed in the lowest position and providing floor mats on the sides of the bed. However, during observations on December 11, 2024, R2 was found in bed without floor mats on either side, and the bed was approximately 4 feet off the ground. The Director of Nursing confirmed that the fall interventions for R2 included frequent monitoring, ensuring the bed was in the lowest position, and placing fall mats on the floor, none of which were in place at the time of observation.
Delay in X-ray Acquisition for Resident with Acute Injury
Penalty
Summary
The facility failed to ensure timely acquisition of x-rays for a resident with an acute injury. On November 27, 2024, a resident complained of pain during care, prompting a CNA to alert the nurse on duty. Despite the administration of pain medication and an assessment by the nurse, no immediate findings were noted. Later, the resident again complained of pain, leading the CNA to inform the nurse, who then involved the DON. Suspecting a deep vein thrombosis, the DON contacted the NP, who ordered a venous doppler and a STAT x-ray. However, the x-ray was not performed until the following morning, over 24 hours later, revealing a fracture in the resident's right tibia/fibula. The delay in obtaining the x-ray was noted by the LPN who was on duty during the day shift on November 27, 2024. She expected the x-ray to be completed that evening, but it was not done until the next day. The NP, who assessed the resident later that day, instructed the nursing staff to follow up with the x-ray company and indicated that the resident should have been sent to the emergency department if the x-ray could not be performed promptly. The facility's administrator acknowledged the delay and was investigating the cause. The facility's policy requires laboratory and diagnostic testing to be performed according to the order, with oversight by the DON or a designee, but this protocol was not followed in this instance.
Failure to Document and Communicate Visitor Restrictions
Penalty
Summary
The facility failed to ensure that restricted visitor information was properly documented and communicated for two residents, leading to a deficiency in maintaining resident safety. For one resident, who had severe cognitive impairment and required total assistance for all activities of daily living, the facility did not have the necessary documentation to restrict the resident's father from visiting, despite verbal instructions and awareness among staff. The father's access was supposed to be denied due to his aggressive behavior, but the information was not present in the electronic medical records or posted at the front desk as required by the facility's policy. Similarly, another resident reported that his son was no longer allowed to visit due to bringing illegal substances during a visit. However, there was no signage or documentation at the front desk to indicate this restriction. The facility's visitation policy allows for reasonable restrictions, including denying access to disruptive visitors, but the lack of proper documentation and communication of these restrictions led to the deficiency being identified during the survey.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 545 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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 Waukegan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elevate Care Waukegan | 2.2 mi | ★★★★★ | 25 | 0 |
| Waukegan Health And Rehab | 2.3 mi | ★★★★★ | 3 | 0 |
| Alpine Care Of Zion | 4.2 mi | ★★★★★ | 27 | 0 |
| Allure Of Zion | 5.1 mi | ★★★★★ | 18 | 0 |
| Claridge Healthcare Center | 7.4 mi | ★★★★★ | 9 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.