Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avantara Lake Zurich during CMS and state inspections, most recent first.
Wet dishes and insulated plate tops were stacked before air-drying on the clean side of the dish machine. A Dietary Aide removed trays from the dish racks and, when space ran out, stacked them while still wet; insulated plate tops were also stacked upside down and on top of each other, allowing water to collect in them. The FSD later directed the aide to stack the plate tops differently.
Failure to maintain resident dignity during meals. CNAs were observed feeding residents while talking to each other in Spanish in front of English-speaking residents, and staff were also speaking across the dining room in Spanish while residents were eating. An RN was observed standing while feeding a resident despite an empty chair being available. The DON stated staff should sit when feeding residents and speak English in the dining room so residents can understand what is being said.
Failure to Maintain Pressure Relief and Ordered Wound Care: A resident with bilateral heel DTIs was observed sitting with shoes and no heel dressings in place while crying in pain, and another resident with stage 3 heel and knee pressure injuries had heels resting on the wheelchair footrest, a heel dressing stuck to the wound, and a band aid used instead of the ordered knee dressing. Additional residents were found with heel protectors not in place or air mattresses not turned on or set incorrectly, and two residents reported the beds felt hard or uncomfortable.
Failure to Respect Resident Dignity and Personal Property: A resident with multiple chronic conditions became upset when staff entered her room, turned on the light, and opened her refrigerator to inspect and remove food items without her consent. The resident repeatedly told staff to get out, reported they would not leave her room, and said they were invading her personal property; staff also reported the interaction escalated and included physical contact. The resident later complained to the Ombudsman, and there was no EHR documentation of the incident.
Failure to provide timely incontinence care affected two residents who were dependent on staff for toileting hygiene. One resident with multiple chronic conditions was found saturated with urine, with redness to the buttocks, a strong urine odor, and a wet brief and bedding; the other resident with dementia was left in a chair for hours and later found with a wet brief soiled with urine and stool. Both care plans called for frequent toileting assistance and peri care, and staff stated incontinence care should be provided at least every two hours.
Inadequate perineal care after an incontinent episode was identified for a resident with dementia, CKD, and frequent urine and bowel incontinence who required substantial assistance with toileting and personal hygiene. A CNA removed the soiled brief and pants and wiped only the buttocks area, but did not cleanse the front area or the resident’s legs before dressing her in clean clothing. Staff stated the front and back areas should be cleaned when residents are incontinent, and the DON said soiled legs should also be cleaned.
Failure to provide person-centered dietary support for a resident with dementia. A resident with Alzheimer’s disease, dementia, and moderate protein calorie malnutrition had a care plan intervention to consider finger foods, but during multiple meals he was observed eating non-finger foods with his hands, spreading food on his hands, clothing, table, floor, and drinks. Staff, including a RN, CNA, and Memory Care Manager, did not offer finger foods or a clothing protector, and did not encourage utensil use despite the resident’s preference to eat with his hands.
Unattended Medications Left at Bedside: The facility failed to ensure medications were consumed after administration for two residents reviewed for pharmacy services. One resident was found in bed with a medication cup containing four pills left on the table, and another resident had a cup with two pills on the bedside table; in both cases, no staff were present and the residents were not self-administering medications per RN statements and care plans. An RN stated nurses should not leave meds unattended and should stay with the resident to ensure the medication is taken.
Medication Administration Errors: A RN failed to administer ordered meds as prescribed during med pass, including a missed diuretic and a missed nebulizer treatment that was signed off as given, and another RN gave an oral vitamin B12 tablet instead of the ordered IM injection for a resident with vitamin B12 deficiency anemia. The MAR/EMAR documentation did not match what residents actually received, resulting in a 20% med error rate.
Failure to maintain infection control practices during resident care. A CNA did not change gloves or perform hand hygiene after incontinence care and before moving from soiled to clean tasks for a resident with significant incontinence and cognitive impairment. In another event, a wound nurse used the same contaminated gloves for peri-care and barrier cream application, and a RN supervisor provided enteral feeding to a resident with a feeding tube while wearing gloves only instead of the required gown and gloves under EBP.
A resident with a pelvic fracture, who was alert and oriented, was unable to locate her call light when she needed to use the bedpan. After waiting for assistance and not being checked on by staff, she urinated in her brief and remained soiled, leading her to call 911 for help. Staff later found her wet and upset, with the call light tied to the bed rail and not visible to her.
A resident with severe cognitive impairment and multiple medical conditions exited the facility through an unsecured front entrance during the night, undetected by staff due to a non-functioning door alarm. The resident was found across a major highway, confused, hypothermic, and injured, and was subsequently hospitalized with an acute subdural hematoma, hypothermia, and injuries from an unwitnessed fall.
A cook at the facility was observed handling food with contaminated gloves, failing to follow proper handwashing and glove application procedures. Despite having a designated handwashing station, the cook washed hands in a food prep sink and applied gloves with wet hands, leading to potential cross-contamination. The Food Service Director acknowledged these improper practices, which violate the facility's hygiene standards.
The facility failed to maintain proper infection control measures, including inadequate isolation precautions for residents with influenza and improper use of PPE by staff. Residents with feeding tubes and catheters were not managed with enhanced barrier precautions, and staff did not consistently follow hand hygiene protocols, leading to potential cross-contamination.
A facility failed to provide least restrictive interventions before using a physical restraint on a resident with a history of falls and cognitive deficits. The resident was observed with a lap belt restraint during supervised activities, which was not released as required. Staff interviews revealed the restraint was used due to the resident's fall risk and agitation, but the facility did not consistently follow its policy to release the restraint during supervised activities.
A resident with congestive heart failure was not weighed daily as ordered, with only two weights documented in January. The facility's policy requires daily weight monitoring for such residents, but staff interviews confirmed this was not done, despite the resident's condition necessitating close monitoring.
A resident with a suprapubic catheter experienced issues with catheter drainage and pain due to the absence of a required dressing, leading to skin redness and discomfort. The facility failed to follow physician orders for catheter site care, and the facility's policy lacked specific instructions for suprapubic catheter care.
Two residents with indwelling catheters in a facility experienced inadequate catheter care, leading to hospitalizations for urinary tract infections. The facility failed to document catheter care, monitor urine output, and prevent cross-contamination. Catheter bags were mixed up between residents, and catheter tubing was found kinked, preventing proper drainage. The facility's policy on catheter care was not followed, resulting in significant health risks for the residents.
A resident with multiple health conditions was left unsupervised while taking medications, resulting in pills being scattered on the floor. The resident, who was shaky and unable to take medications independently, did not have water available initially and accidentally knocked over the medication cup. RNs and the DON confirmed the need for supervision during medication administration, which was not provided, violating the facility's medication pass policy.
A long-term care facility failed to accurately assess and supervise residents at risk of elopement, leading to incidents where one resident left the facility unsupervised and another wandered to a different floor. The facility did not maintain accurate elopement risk records, and there were delays in updating care plans and notifying family members. Staff interviews revealed issues with securing exit doors and using alarm systems.
A resident with a history of aggressive behavior hit another resident in the face, highlighting a failure in the facility's abuse prevention measures. Despite known behavioral issues, the resident's care plan lacked updated interventions, and non-pharmacological strategies showed no change in outcomes. The facility's policy on abuse was not effectively implemented, as evidenced by the incident and the lack of contact information for the nurse on duty.
Wet Dishes and Plate Tops Stacked Before Air-Drying
Penalty
Summary
The facility failed to ensure dishes were air-dried prior to stacking. During observation on the clean, outfeed side of the dish machine, a Dietary Aide removed trays from the dish racks immediately after they came out of the dish machine without allowing them to air dry. The aide placed trays on an adjacent cart in a way that allowed them to air dry at first, but when space ran out, began stacking the trays top to bottom on top of previously placed trays while they were still wet. The aide also stacked insulated plate tops with the tops facing down and placed additional insulated plate tops directly on top of the last on the bottom rack of the cart. The Food Service Director later told the aide that the plate tops needed to be stacked differently, and the aide inverted them, draining the water that had accumulated in them. The facility’s Cleaning and Sanitation Food Safety policy states that after sanitizing, equipment and utensils must be air-dried and given ample space to self-drain.
Failure to Maintain Resident Dignity During Meals
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner for 4 of 30 residents reviewed for dignity, including R152, R12, R14, and R113. During the lunch meal on May 4, 2026, V13 and V16 CNAs were feeding residents at one table while talking to each other in Spanish in front of English-speaking residents, and staff were also observed speaking across the dining room to each other in Spanish while the dining room was full of residents eating lunch, including R12, R14, and R113. On May 5, 2026, at 12:45 PM, V19 RN was standing next to R152 while feeding him lunch, with an empty chair available next to the RN. On May 6, 2026, V13 CNA stated staff should be sitting when feeding residents so they are at eye level, and said English should be spoken in the dining room because it is the residents' home and residents may think staff are talking about them if staff do not speak English. V2 DON stated staff should be sitting down to feed residents and should be speaking English so everyone is able to understand them, and said this is done to provide dignity to residents. The facility's Privacy and Dignity Policy revised July 3, 2025 states that resident privacy and dignity is to be respected by staff at all times.
Failure to Maintain Pressure Relief and Ordered Wound Care
Penalty
Summary
The facility failed to ensure pressure-relieving interventions were in place and failed to ensure ordered treatments were in place for five residents reviewed for pressure injuries. One resident with Alzheimer’s disease, bipolar disorder, anxiety disorder, dementia, and major depressive disorder had bilateral heel deep tissue pressure injuries and was observed sitting in a high-back wheeled recliner with her heels resting on the footrest, one shoe off and the other shoe pressing against the injured heel areas. During the observation, she was crying out and moaning in pain, and when she was later transferred to bed, no heel dressings were in place even though orders called for daily cleansing, betadine, and foam dressings. Staff later documented that she was removing her dressings and heel protectors, but at the time of the observation she was not refusing treatment or removing the heel protectors. Another resident with stage 3 pressure injuries to both heels and the left knee was observed with her heels resting directly against the wheelchair footrest platform while wearing gripper socks. Her heel dressings showed dried brownish blood, and during wound care the wound nurse removed a heel dressing that had a tan foam dressing stuck to the wound. The resident also had a band aid on the left knee despite an order for Medi honey and a bordered foam dressing. The resident reported that the foam dressing had been ripped off over the weekend and replaced with a band aid. The resident also reported that the low air loss mattress had not been plugged in the prior night and that she was resting on the bed frame, and staff confirmed that the mattress should be plugged in and on to function properly. A third resident was observed in bed with only socks on while her heels rested directly on the air mattress, with heel protector boots not in place and placed elsewhere in the room. The next day, her mattress appeared lumpy and deflated, her heels were in a deflated section of the mattress resting on the bed frame, and the air mattress controller was not on until a CNA turned it on. Another resident with pain, scoliosis, osteoarthritis, and a low body weight was observed on a low air loss mattress set at 320 pounds and stated the bed was very hard and caused back and hip pain. A fifth resident was observed on an air mattress set at 350 pounds while his weight was 248.6 pounds, and he stated the bed was uncomfortable and hard. The wound nurse stated the mattress settings should be maintained according to the resident’s weight and body habitus.
Failure to Respect Resident Dignity and Personal Property
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity and was able to retain and use personal possessions. The resident, R76, had diagnoses including type 2 diabetes, chronic kidney disease, hypertension, atrial fibrillation, CHF, and an acquired absence of the right leg below the knee. On 5/5/26, staff entered her room to inspect and remove items from her refrigerator because food items were considered expired or spoiled, and the interaction escalated when staff remained in the room while the resident repeatedly told them to get out. During the incident, V25 opened the resident’s refrigerator and began removing items, including food described as spoiled or without dates, while the resident was asleep and then became upset and yelled for staff to leave. V23 stated the situation escalated after staff did not leave the room and continued removing items from her fridge, and he said the matter could have been handled differently because it was the resident’s home. The resident reported that V25 turned on the light, said she was doing an inspection, opened the refrigerator without asking, and would not leave when asked, which upset her because staff were invading her personal property. The resident and V25 each reported physical contact during the confrontation, with the resident stating she pushed V25 on the lower back to get her away from her property and V25 stating the resident punched her in the back. The resident said staff were disrespectful and unprofessional, and V28, the Ombudsman, reported receiving a call from the resident about how the situation was handled. The resident’s care plan included behaviors of anger and depression, and the EHR contained no documentation of the incident on 5/5/26.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide incontinence care to residents who required staff assistance with toileting. For R17, who had diagnoses including type 2 diabetes, hypertension, COPD, asthma, osteoporosis, and chronic kidney disease, staff observed that she was saturated with urine and had redness to her buttocks. She told staff she was soiled and needed to be changed, and later the wound nurse found her incontinent brief wet, with urine soaked through the pad and sheet and a strong urine odor present. R17 was incontinent of bowel and bladder, had a history of pressure injury to her bottom, and her care plan directed staff to remind, offer, and assist with toileting, provide prompt peri care every shift and as needed, and round at least every two hours to check for incontinence. For R14, who had diagnoses including Alzheimer's disease, dementia, major depressive disorder, and scoliosis, the MDS showed she was not cognitively intact, was dependent on staff for toileting hygiene and personal hygiene, and was always incontinent of bowel and bladder. She was observed in the dining room for several hours without getting out of her chair, and when staff transferred her to bed, her incontinence brief was wet with urine and soiled with stool, with a urine odor present. Her care plan directed staff to keep her skin clean and dry, and staff stated that incontinence care should be done at least every two hours. The DON also stated that incontinence care should be provided as often as residents need it, but at least every two hours.
Inadequate Perineal Care After Incontinence Episode
Penalty
Summary
The facility failed to ensure a resident’s skin was cleansed after an incontinent episode for R74, who was admitted with diagnoses including insomnia, chronic kidney disease, Alzheimer’s disease, dementia, and mood disorder. Her care plan directed staff to keep her skin clean and dry. The MDS showed she was not cognitively intact, had not exhibited behavior of rejecting care, required substantial/maximal assistance with toileting hygiene and personal hygiene, and was frequently incontinent of urine and always incontinent of bowel. On May 4, 2026, R74 was observed walking in the halls of the memory care unit with pants wet past her knees toward the inside of her legs. Two CNAs brought her to her room to change her clothes. One CNA removed her soiled brief and pants and wiped her buttocks area, but did not wipe the front of her or cleanse her legs from the soiled pants before putting on new pants, a new brief, and her shoes. On May 6, 2026, a CNA stated that residents’ front and back areas should be cleaned when they are incontinent, and the DON stated residents’ front and back areas should be cleaned and their legs should be cleaned if they get soiled. The facility’s Incontinence and Perineal Care policy states perineal care is provided to ensure cleanliness and comfort, prevent infection and skin irritation, and observe the resident’s skin condition.
Failure to Provide Person-Centered Dietary Support for a Resident With Dementia
Penalty
Summary
The facility failed to implement person-centered dietary interventions for a resident with dementia and a documented preference to eat meals using his hands. R112’s face sheet listed diagnoses including COPD, Alzheimer’s disease, dementia, and moderate protein calorie malnutrition. The care plan identified an alteration in neurological status related to dementia with an intervention to accommodate eating issues to maximize independence and nutritional intake, and an alteration in nutritional status related to dementia with an intervention to consider finger foods. During multiple observed meals, R112 was seen attempting to eat non-finger foods with his hands, resulting in food being spread on his hands, clothing, the table surface, the floor, and in his drinks. At lunch on 5/4/26, no finger foods or clothing protector was offered and R112 was not encouraged or cued to use utensils. At breakfast on 5/5/26, R112 ate with his fingers and did not attempt utensils; a RN and CNA interacted with him but did not offer a clothing protector or finger foods, nor encourage utensil use. At lunch later that day, R112 again ate with his fingers, and although the Memory Care Manager asked if he wanted to use his hands over a fork and he said yes, she did not encourage utensil use or offer finger foods. She stated she was not aware the care plan included finger foods, and the DON stated the facility honors independent self-feeding with encouragement and prompting, with finger foods as an intervention for those who self-feed.
Unattended Medications Left at Bedside
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure medications were consumed after administration for 2 of 6 residents reviewed for pharmacy services. On 05/04/2026, R164 was observed in bed in her room with a clear plastic medication cup on the table containing four pills, and no staff were present; R164 stated she was not sure if the pills were hers. RN V7 stated R164 did not self-administer medications, and R164’s care plan did not indicate that she could self-administer medications. Also on 05/04/2026, R33 was observed in her room with a clear plastic medication cup on the bedside table containing two white oval pills, with no staff present; R33 stated she would take the pills later. RN V6 stated R33 did not self-administer medications, and R33’s care plan did not indicate that she could self-administer medications. On 05/05/2026, RN V8 stated nurses should not leave medications unattended when administering medications and should stay with the resident to make sure the medication is consumed.
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications as ordered, with 30 opportunities and 6 errors resulting in a 20% medication error rate. During observation of the morning medication pass, a registered nurse prepared medications for a resident and gave a medication cup containing 6 pills even though the resident stated there were usually 7 morning pills. The nurse did not check the EMAR before signing off the medications, and the resident’s MAR showed that furosemide 20 mg was ordered as part of the morning pass but was not administered. The same resident was also observed during the morning medication pass when the nurse prepared oral medications but did not administer the ordered ipratropium-albuterol inhalation solution. The nurse stated she would return later because the resident was lying flat and needed to be sitting up, and the resident later stated he had not yet received the nebulizer treatment. The MAR showed the inhalation treatment was signed off as given even though it was not received. In a separate event, a resident with vitamin B12 deficiency anemia had an order for cyanocobalamin 1000 mcg/mL injection every Monday, but a registered nurse administered an oral vitamin B12 tablet instead of the ordered injection. The DON stated the physician was aware that the oral tablet had been given and that the nurse missed the medication verification.
Failure to Maintain Hand Hygiene, Glove Changes, and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff changed gloves and performed hand hygiene to prevent cross contamination during resident care. One resident with insomnia, chronic kidney disease, Alzheimer's disease, dementia, mood disorder, and frequent urinary and bowel incontinence required substantial to maximal assistance with toileting hygiene and personal hygiene. During care, a CNA removed the resident’s soiled brief and pants, wiped the buttocks area, but did not wipe the front or cleanse the legs from the soiled pants, then placed on clean pants, a clean brief, and shoes without changing gloves or performing hand hygiene. Facility staff stated that gloves should be changed when moving from dirty to clean tasks and that residents’ front and back areas should be cleaned, with gloves changed and hand hygiene performed whenever contaminated items are touched. The facility also failed to ensure required enhanced barrier precautions were used for a resident with hemiplegia, hemiparesis following cerebral infarction, dysphagia, and a feeding tube. The resident’s care plan identified enhanced barrier precautions related to the feeding tube, and signage on the room door indicated staff must wear gloves and gown for high-contact care activities, including device care or feeding tube use. During enteral feeding administration, a RN supervisor entered the room wearing gloves only and did not wear a gown. The RN supervisor later stated that gown and gloves were required for the resident’s enteral feeding and acknowledged not wearing the gown. In another event, a wound nurse provided peri-care to a resident and, using the same contaminated gloves, applied barrier cream to the buttocks and touched several surfaces before removing the gloves.
Resident Left Unattended and Unable to Access Call Light
Penalty
Summary
A resident with a recent pelvic fracture, who was alert and oriented, reported that on her first night in the facility she was unable to locate her call light when she needed to use the bedpan. The resident stated that no staff came to check on her, resulting in her urinating in her brief and remaining in a soiled state. She described feeling frustrated, humiliated, and eventually scared due to the lack of assistance, which led her to call 911 for help. When staff responded after being notified by the police, the resident was found wet and upset, and the call light was discovered tied to the bed rail, though the resident had not seen it. Staff interviews confirmed that the resident was alert, oriented, and able to communicate her needs, but had not received timely assistance. The LPN and CNA involved acknowledged the resident's distress and the delay in care. The facility's policy requires staff to respect residents' privacy and dignity at all times, but this was not upheld in this instance, as the resident was left unattended and in a state of discomfort for an extended period.
Failure to Secure Front Entrance Results in Resident Elopement and Injury
Penalty
Summary
The facility failed to ensure that the front entrance was safely supervised and/or secured, resulting in a resident with severe cognitive impairment and multiple medical conditions exiting the building without staff knowledge. The resident, who was at high risk for falls and had a care plan indicating the need for a safe environment and supervision, was last seen in bed by a CNA during the night shift. Staff discovered the resident missing approximately 45 minutes later and began searching the facility, initially believing that door alarms would have sounded if the resident had exited. Upon checking, staff found that the front door alarm was not activated or not functioning, and the alarm did not sound when tested. The resident was eventually found by police across a four-lane highway, wearing only a hospital gown, a brief, and shoes, in cold weather conditions. The resident was confused, had sustained injuries including a missing tooth and abrasions, and was hypothermic with a body temperature of 93.2°F. Emergency department records confirmed an acute subdural hematoma, hypothermia due to cold environment, and an unwitnessed fall. The resident was admitted to the hospital for further care. Interviews with staff and review of video footage confirmed that the resident exited through the front door during the early morning hours, and that the door alarm system was not functioning as required. The facility's elopement policy required adequate supervision and a safe environment for all residents, but these measures were not effectively implemented, allowing the resident to leave the facility undetected.
Removal Plan
- Conducted a full house audit of all residents to identify those who are an elopement risk.
- Conducted in-services with all staff on the elopement policy.
- Evaluated and inspected the front door alarm system and found it to be in good working condition.
- Installed a lock box over the kill switch located in the ceiling, with access limited to supervisory/authorized staff.
- Installed a new code panel on the internal set of glass doors requiring a code to exit the facility.
- Checked all other exit doors and found them to be fully engaged and functioning.
- Checked all bed/chair/personal alarms and found them to be in good working condition.
- Checked doors equipped with the Wander Guard system and found them to be properly functioning.
- Initiated a QA audit tool for maintenance to check the alarmed doors and wander guard equipped doors for proper functioning.
- In-serviced all staff on the importance of immediately responding to exit door alarms.
- In-serviced all staff on ensuring that the front exit door alarm is consistently activated.
- Initiated a QA audit tool to ensure that the front alarm door is properly functioning.
- Held an emergency QAPI meeting attended by the Medical Director to develop and approve the plan of correction.
- Agreed to discuss all trends identified in the monthly QAPI meeting until resolution.
Improper Food Handling and Hygiene Practices Observed
Penalty
Summary
The facility failed to ensure proper food handling and hygiene practices, leading to potential cross-contamination. During an observation, a cook, identified as V6, was seen washing his hands and then applying gloves with wet hands, which is against hygiene standards. V6 proceeded to handle food items, including frozen vegetables and carrots, with the same contaminated gloves. He also touched various surfaces, such as the trash can lid and freezer handle, without changing gloves, further increasing the risk of cross-contamination. The Food Service Director, V5, acknowledged the improper practices and stated that there is a designated handwashing station that should be used instead of the food prep sink. Despite this, V6 continued to wash his hands in the food prep sink and apply gloves with wet hands. V5 confirmed that hands should be dry before applying gloves to prevent bacteria from remaining on the hands and emphasized that touching food with contaminated gloves is unacceptable. The facility's hygiene standards and procedures, as well as the cook's job description, clearly outline the proper handwashing and glove usage protocols. These include washing hands with soap and warm water, drying them thoroughly before applying gloves, and changing gloves after handling garbage or dirty equipment. The failure to adhere to these standards poses a risk of foodborne illness due to cross-contamination, as highlighted by the Centers for Disease Control and Prevention (CDC).
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures, as evidenced by multiple instances of non-compliance with contact and droplet isolation precautions. One resident, diagnosed with influenza, was observed outside of her isolation room in the group dining area without a mask, despite orders for strict droplet isolation. The infection control preventionist confirmed that the resident should have remained in her room and meals should have been delivered there. Additionally, staff were observed not wearing the required personal protective equipment (PPE) when entering the resident's room, which could lead to cross-contamination. Another resident with a gastrostomy tube did not have enhanced barrier precautions (EBP) signage or PPE available outside their room, which is necessary for residents with feeding tubes to prevent infection. The infection control preventionist acknowledged the oversight and noted that staff should ensure EBP signs and PPE are in place. Furthermore, a resident with influenza was not properly isolated, as staff entered the room without the required PPE and failed to perform hand hygiene, increasing the risk of spreading the infection. Additional deficiencies were noted in the handling of residents with catheters and during incontinence care. Staff did not adhere to proper PPE protocols, such as wearing gowns and changing gloves between tasks, which are critical to preventing cross-contamination. The facility's policies on hand hygiene and infection control were not consistently followed, as evidenced by staff not performing hand hygiene after glove removal and not wearing appropriate PPE during high-contact care activities.
Failure to Implement Least Restrictive Interventions Before Restraint Use
Penalty
Summary
The facility failed to ensure that least restrictive interventions were provided before implementing a physical restraint for a resident, identified as R90, who was observed with a lap belt restraint in place during supervised activities. On multiple occasions, R90 was seen with the restraint secured while sitting in his wheelchair, including during meal times and activities, without the restraint being released. Interviews with staff revealed that the restraint was used due to R90's history of falls and agitation, but it was noted that the resident could not consistently remove the restraint on command due to cognitive deficits. The facility's policy requires non-restraining interventions to be utilized first, and physical restraints should only be used as a last resort. However, the restraint was applied after R90's fall shortly after admission, and the staff did not consistently release the restraint during supervised activities as required. R90's care plan indicated a high risk for falls and included the use of a self-release belt, but the resident was unable to remove it consistently. The facility's failure to adhere to its restraint policy and ensure the restraint was released during supervised activities led to the deficiency.
Failure to Conduct Daily Weights for Resident with CHF
Penalty
Summary
The facility failed to ensure daily weights were conducted for a resident with congestive heart failure, as ordered by the physician. The resident, admitted with diagnoses including Chronic Diastolic Congestive Heart Failure, Type 2 Diabetes, and hypertension, had a physician's order to monitor weight daily before breakfast and notify the physician of any significant weight gain. However, the electronic Medication Administration Record (eMAR) for January 2025 showed that only two weights were documented, with 14 out of 16 weights not completed. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed that the resident was not being weighed daily as required. The facility's policy for residents with congestive heart failure mandates daily weight monitoring to manage fluid balance, yet this protocol was not followed. The Director of Nursing acknowledged the oversight, noting that the Certified Nursing Assistants were responsible for taking daily weights and reporting them to the nurses for documentation and physician notification, which was not occurring as ordered.
Failure to Provide Proper Suprapubic Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic catheter, leading to a deficiency. The resident, identified as R32, reported issues with his catheter not draining properly and experiencing pain. Upon inspection by a registered nurse (RN), it was observed that the resident did not have a dressing over the suprapubic catheter, and urine was leaking around the catheter tubing, causing skin redness. The catheter drainage bag showed no drainage, and sediment was present in the tubing. The nurse manager confirmed that the resident was supposed to have a dressing in place, as per the physician's orders, but it had not been applied. Further examination by a licensed practical nurse (LPN) revealed drainage around the catheter tubing and reddened skin at the urostomy site. The LPN cleaned the area with saline and applied a new dressing, although the resident experienced discomfort during the process. The physician's orders required wound care to the catheter site, including cleaning with normal saline, applying skin prep, and covering with a dry dressing twice daily and as needed. The facility's indwelling catheter policy did not include specific care instructions for a suprapubic catheter, contributing to the oversight in care.
Inadequate Catheter Care and Cross-Contamination Risks
Penalty
Summary
The facility failed to provide appropriate catheter care and prevent cross-contamination for two residents with indwelling catheters. Resident 1, who was admitted with multiple diagnoses including neuromuscular dysfunction of the bladder, had a suprapubic catheter in place. The facility's records showed no documentation of catheter care, urine output, or dressing changes around the catheter stoma site. During an observation, it was noted that Resident 1's catheter tubing was kinked, preventing urine from draining properly, and the catheter bag was placed above the bladder level, causing urine to back up into the tubing. Resident 1 was hospitalized with a urinary tract infection and acute kidney injury. Resident 2, who shared a room with Resident 1, also had an indwelling catheter and was admitted with diagnoses including obstructive reflux uropathy. The facility's records showed no evidence of catheter care or scheduled catheter changes as ordered. Resident 2 expressed concerns about the handling of catheters, noting that catheter bags were often mixed up between her and her roommate. She reported that catheter care was only performed during showers or when incontinent of stool. Resident 2 was hospitalized with a urinary tract infection and electrolyte imbalance, and her catheter was changed at the hospital. The facility's policy on urinary catheter care emphasized the importance of preventing catheter-associated urinary tract infections by ensuring proper catheter maintenance, including keeping the drainage bag below the bladder level and monitoring for kinks in the tubing. However, the facility failed to adhere to these guidelines, resulting in inadequate catheter care and cross-contamination risks for the residents involved.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure proper supervision of a resident during medication administration, leading to a deficiency in pharmaceutical services. The incident involved a resident who was admitted with multiple diagnoses, including Type 2 Diabetes, hypertension, and chronic congestive heart failure, among others. The resident, who had no cognitive impairment, was found with several pills scattered on the floor in her room. She reported that she did not have water to take her medications when they were initially brought to her, and due to shakiness, she accidentally knocked the cup of medications over. The Registered Nurse (RN) acknowledged that the resident was shaky and should have been supervised while taking her medications. Another RN confirmed that it is not acceptable to leave medications at a resident's bedside for safety reasons and that supervision is necessary to ensure medications are taken. The Director of Nursing (DON) stated that the resident is not capable of taking medications independently and should be supervised during administration. The facility's policy requires adherence to medication pass procedures, which were not followed in this instance.
Elopement Risk Management Failures in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments and adequate supervision for residents at risk of elopement, leading to two separate incidents involving residents R1 and R2. R1, who had severe cognitive impairment and was independently ambulatory, was initially assessed as not at risk for elopement. However, a subsequent assessment identified him as high risk. Despite this, R1 managed to elope from the facility by cutting off his wanderguard and exiting through an unlocked door without triggering the alarm. The incident report noted that R1 was found at a nearby gas station after being reported missing by another resident. The facility's policy required immediate notification of the resident's family and physician, but this was delayed by 24 hours. R2, another resident with a history of Alzheimer's disease and cognitive disorders, was found wandering on a different floor within the facility. Although R2 did not leave the building, the incident was not documented in her medical record, and there was a delay in updating her care plan to reflect her elopement risk. The facility's policy required regular elopement risk assessments, but R2's assessments were not conducted quarterly as required, with a significant gap between assessments. Staff interviews revealed that exit doors were not consistently secured, and there was confusion about the use of wander devices and alarm systems. Additionally, the facility failed to maintain accurate and up-to-date elopement risk signs and records. Discrepancies were found between the elopement risk signs posted at the nurse's station and those in the elopement binder, with some residents not listed or incorrectly listed. The facility's policy required these records to be updated regularly, but staff were unable to confirm when the last updates were made. This lack of accurate documentation and communication contributed to the facility's inability to adequately supervise and protect residents at risk of elopement.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident physical abuse, involving two residents. Resident R3, who has a history of Alzheimer's disease, dementia with moderate agitation, and other mental health conditions, was involved in an incident where they physically hit another resident, R6, on the face. This incident was witnessed by a Certified Nursing Assistant (CNA), who reported that R3 has a history of verbally aggressive behaviors and had previously exhibited physical aggression towards others. R3's care plan, which was initiated to address behavior problems related to dementia and adjustment issues, did not have any new or additional interventions added since its initiation. Despite R3's known history of aggressive behaviors, including verbal and physical aggression, the care plan remained unchanged. The facility's records show multiple instances of R3's aggressive behavior, including yelling, swatting at residents and staff, and threatening to hit them with a shoe, yet no pharmacological interventions were implemented, and non-pharmacological interventions showed no change in outcomes. The facility's policy on abuse and neglect emphasizes providing care in an environment free from abuse, yet the incident on 4/28/24 indicates a failure to adhere to this policy. The Director of Nursing acknowledged R3's known behaviors and stated that staff were to increase monitoring and keep R3 engaged in activities following the incident. However, the lack of updated interventions in R3's care plan and the absence of contact information for the nurse on duty during the incident suggest deficiencies in the facility's response to managing R3's behaviors and preventing further incidents of abuse.
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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.
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Nursing homes near Lake Zurich
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alden Long Grove Rehab &hc Ctr | 2.9 mi | ★★★★★ | 10 | 2 |
| Thrive Of Lake County | 3.7 mi | ★★★★★ | 20 | 0 |
| Avantara Long Grove | 4.3 mi | ★★★★★ | 0 | 0 |
| Prairieview At The Garlands | 4.9 mi | ★★★★★ | 3 | 0 |
| Little Sisters Of The Poor Of Palatine | 5.7 mi | ★★★★★ | 0 | 0 |
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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 August 2026) and official state health department websites.