Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Crescent Care Of Elgin during CMS and state inspections, most recent first.
The facility did not provide CNAs with the required annual 12 hours of continuing competence training, including dementia management, despite caring for multiple residents with dementia and Alzheimer’s disease. Review of orientation materials and sampled CNA personnel files showed no dementia-related in-services, and interviewed CNAs reported they did not track their annual training hours or recall receiving dementia training. The HR coordinator stated dementia training hours were not tracked and she was unaware such training was required for CNAs to work on the floor. The Administrator and DON reported there was no specific policy for staff education requirements, that only a few hours of general training were provided at hire and annually, and that they believed dementia-specific training was not required because the facility did not operate a memory care unit.
Surveyors found that multiple opened inhaler medications on two medication carts were not labeled with open or discard dates, despite active orders for routine and PRN use. During observations with two RNs, several aerosol inhalers, including Symbicort, Fluticasone-Umeclidinium-Vilanterol, Atrovent (Ipratropium Bromide HFA), Levalbuterol, and Albuterol, were discovered opened and unlabeled. One RN was unsure why the inhalers were not labeled, and another acknowledged that all opened inhalers should be labeled with open dates. The facility’s medication labeling and storage policy required medications and biologicals to be labeled per accepted pharmaceutical practices, with nursing staff responsible for safe medication storage.
Surveyors found that three residents were keeping multiple medications, including inhalers, nasal sprays, eye drops, ointment, lidocaine patches, and nebulizer solutions, at their bedside without physician orders authorizing bedside storage or documented assessments for self-administration. These residents reported that the medications were always kept in their rooms and that facility staff had not provided instruction on their use, despite long-term personal use. Record review showed active medication orders but no self-administration assessments or related care plans, contrary to facility policy requiring licensed nurse evaluation, IDT documentation, periodic review, and specific MD orders for medications to be kept at the bedside. The DON acknowledged that medications from home should be secured and that staff should contact family and the MD and complete an assessment before allowing residents to self-administer medications in their rooms.
Surveyors found that the facility failed to provide required written notices for hospital transfers and bed-hold rights for two residents who were repeatedly sent to the ER for hypotension, COPD exacerbations, and chest pain. Although clinical events, vital signs, 911 calls, and family notifications were documented, there was no documentation of written reason-for-transfer forms or bed-hold notices in the medical record for any of the transfers, and the ombudsman was not notified. The DON reported that staff do not provide written transfer notices, may rely on marketing staff for bed-hold information, and do not notify the ombudsman, despite a facility policy requiring written bed-hold notices at admission and at each transfer, along with documentation of ombudsman notification.
A resident with multiple comorbidities, including prior amputation due to ulcer and documented sacral pressure injury from the hospital, was admitted without the sacral wound being identified or care-planned. Only the amputation site was documented on the initial comprehensive skin assessment, and no MD orders or TAR entries were obtained for sacral wound treatment. During incontinence care, staff found an old, peeling bordered foam dressing on the sacrum; when the wound care nurse assessed the area, she identified a large sacral pressure wound with slough and minimal granulation. The facility’s protocol requiring admission skin assessment and physician-authorized wound treatment orders was not followed for this resident’s sacral pressure ulcer.
The facility failed to provide sufficient staff to meet the ADL needs of 79 residents, resulting in unmet care needs. Residents were left in soiled incontinence briefs for extended periods, and staff were overwhelmed with responsibilities, including passing meal trays and assisting residents with high care needs. The staffing schedules revealed consistent understaffing, with only six CNAs available during the day shift, despite the facility's assessment tool indicating a need for more staff.
The facility failed to maintain window coverings in good repair, affecting 13 residents. Observations showed torn, non-adjustable paper shades and some rooms without any coverings, impacting residents' comfort and privacy. The Maintenance Director cited halted remodeling due to financial issues, leaving rooms without permanent shades for over six months.
The facility failed to provide timely incontinence care for two residents, leading to deficiencies in their care. One resident reported her brief was wet and had not been changed since early morning, despite her care plan requiring checks every two hours. Another resident was found with wet clothing and redness around the rectal area, indicating a lack of timely care. Both CNAs assigned to these residents were responsible for twelve residents each, which may have contributed to the delay in care.
A resident's room had a damaged electrical outlet with exposed wires near their metal bed frame, posing a safety hazard. The resident, who is dependent on staff for repositioning, reported that the bed frequently hits the outlet. The Maintenance Director was aware of the issue but had not implemented measures to prevent further damage. The resident has multiple health conditions and requires assistance with all ADLs.
The facility failed to follow its water management plan and infection control policies, including neglecting weekly checks for Legionella prevention and improper hand hygiene during resident care. Staff did not adhere to Enhanced Barrier Precautions, and urinary catheter care was inadequate, with drainage bags placed on the floor and improper glove use observed.
The facility did not follow its policy to offer the updated COVID-19 vaccine to eligible residents, as shown by the lack of documentation for four residents with various medical conditions. The Nurse Consultant confirmed that these residents should have been offered the vaccine, in line with CDC recommendations.
A resident with a history of urinary infections and other medical conditions experienced catheter-related trauma due to the facility's failure to secure an indwelling urinary catheter. The unsecured catheter was pulled out, causing bleeding and discomfort. The facility's policy required securing the catheter to prevent such incidents, which was not adhered to in this case.
The facility did not follow its policy to offer and administer pneumococcal vaccines according to CDC guidelines for three residents. Despite consent, these residents did not receive the recommended follow-up vaccinations, as confirmed by a nurse consultant. The facility lacked documentation to show that the necessary vaccines were offered or administered.
The facility's arbitration agreements were found deficient as they lacked language stating that signing was not a condition for admission or care. Additionally, agreements did not include provisions for rescinding within 30 days or mutual decision-making for arbitrator selection. This affected all 70 residents, with specific deficiencies noted in agreements signed by three residents.
Failure to Provide Required Annual CNA Dementia Training
Penalty
Summary
The facility failed to provide the required 12 hours per year of continuing competence training for CNAs, including dementia management training, for a census of 68 residents. Surveyors’ review of the CNA orientation packet showed no evidence of dementia-related in-services, and the Human Resources Coordinator stated that dementia training hours are not tracked and that she had not been informed dementia training was required for CNAs to work on the floor. A sample review of three CNA personnel files revealed no documentation of dementia training, and three CNAs interviewed reported they do not keep track of their annual training hours and did not recall receiving dementia training in the past year. Review of the facility’s diagnosis report identified 31 current residents with diagnoses of dementia and/or Alzheimer’s disease. The Administrator and DON stated the facility does not have a specific policy regarding staff education requirements, including dementia training, and reported that the facility provides only 6 hours of general staff training upon hire and 3 hours of annual training thereafter. They also stated they believed they were not required to provide a specific number of dementia training hours because the facility does not have a memory care unit.
Failure to Label Opened Inhaler Medications on Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication labeling practices related to multiple residents’ inhaler medications. During an observation of the first-floor medication cart #2 with an RN, one resident’s Symbicort inhalers were found opened without any label indicating the open or discard dates, despite an active order for Symbicort 160-4.5 mcg/act, 2 puffs inhaled orally twice daily. On the same cart, another resident’s Fluticasone-Umeclidinium-Vilanterol inhaler was also opened and not labeled with an open or discard date, even though there was an active order for one inhalation orally once daily. The RN present stated she was unsure why the opened inhalers were not labeled. On the second floor, during a check of medication cart #1 with another RN, a third resident’s Symbicort, Atrovent (Ipratropium Bromide HFA), and Levalbuterol aerosol inhalers were all opened and not labeled with open or discard dates, despite active orders for Symbicort twice daily, Levalbuterol every 6 hours as needed, and Ipratropium Bromide four times daily. On the same cart, a fourth resident’s Albuterol inhaler was also opened and not labeled with an open or discard date. The RN on the second floor stated that all opened inhalers should be labeled with open dates to ensure they are stored and discarded properly. The facility’s undated Medication Labeling and Storage policy stated that medications and biologicals are to be labeled in a manner consistent with currently accepted pharmaceutical practices and that nursing staff are responsible for maintaining medication storage in a safe manner.
Failure to Assess and Obtain Orders for Resident Self-Administration of Medications at Bedside
Penalty
Summary
The deficiency involves the facility’s failure to obtain physician orders for medications to be kept at the bedside and to complete required self-administration of medication assessments and care plans for three residents. One resident with emphysema and chronic bronchitis had multiple prescribed respiratory inhalers, nasal spray, and topical hydrocortisone ointment stored on the bedside table. The resident reported that these medications were always kept in the room and that no one at the facility had instructed her on their use. Review of the physician order sheet confirmed active orders for all of these medications but no orders authorizing them to be kept at the bedside. The electronic medical record contained no self-administration of medication assessment form, and there was no care plan addressing self-administration. A second resident had ordered ophthalmic drops and an over-the-counter saline nasal spray kept in the room and stated that these medications were always kept there and that the nurse had not taught him how to use them, although he had used them for a long time. The physician order sheet contained an order for the eye drops but no order for the nasal spray or for bedside storage of either medication, and there was no self-administration assessment or related care plan in the record. A third resident kept lidocaine patches, saline nasal spray, nebulization solution vials, and lubricant eye drops on the nightstand, stating they were kept there for easier access and that no assistance or teaching was needed. The physician order sheet contained orders for these medications but no authorization for bedside storage, and the record lacked a self-administration assessment and care plan. The facility’s own policy required a licensed nurse to complete a self-administration evaluation, IDT documentation and care planning, periodic reevaluation, and a physician order specifying which medications could be kept at the bedside, none of which were completed for these residents. The DON confirmed that medications brought from home should be locked and that staff should contact family and the physician and complete an assessment before allowing bedside self-administration.
Failure to Provide Written Transfer Reasons, Bed-Hold Notices, and Ombudsman Notification
Penalty
Summary
Surveyors identified that the facility failed to provide required written notifications related to hospital transfers, bed-hold rights, and ombudsman notification for multiple residents. One resident, originally admitted on 12/4/25, experienced hypotension with blood pressures of 73/39 and 79/32, pulse changes, and a temperature increase, leading the NP to order transfer to the ER via 911. Progress notes documented the vital signs, the NP’s order, the 911 call, transport to the hospital, and that the son and daughter were notified, but there was no documentation in the electronic medical record of a written reason-for-transfer form or a bed-hold notice being provided to the resident or POA. Another resident, originally admitted on 4/15/2018, had three separate transfers related to COPD exacerbations and a complaint of possible heart attack. Progress notes showed episodes of shortness of breath with low oxygen saturation despite nebulizer treatment, 911 calls, transport to the ER, hospital admissions for COPD exacerbation, and a later transfer for chest pain with normal vital signs and oxygen saturation. For all three transfers, the electronic medical record contained no uploaded reason-of-transfer forms or bed-hold notices, and progress notes did not indicate that written notices were given to the resident or representative. In an interview, the DON stated the facility does not give residents or POAs anything in writing regarding the reason for transfer, that nurses only provide clinical information to paramedics, that they do not notify the ombudsman, and that no written reason-of-transfer forms, bed-hold notices, or ombudsman notification documentation could be produced, despite a facility policy requiring written bed-hold notices at admission and each transfer and documentation of ombudsman notifications.
Failure to Assess and Treat Known Sacral Pressure Ulcer
Penalty
Summary
The facility failed to assess, monitor, and obtain treatment orders for a resident with a known sacral pressure wound. The resident was admitted with multiple comorbidities, including a prior surgical amputation of the left foot due to a foot ulcer, type II diabetes mellitus, peripheral vascular disease, congestive heart failure, and other chronic conditions. The resident was cognitively intact but totally dependent on two staff for transfers and required partial to moderate assistance with bed mobility. Hospital records immediately prior to admission documented a sacral pressure wound measuring 7 cm x 8.5 cm x 0.1 cm, described as purplish, non-blanchable erythema and an open deep tissue injury. Despite this, on admission and during a comprehensive skin assessment on 11/25/25, only the left lower extremity amputation wound was documented, and no sacral wound was recorded. During incontinence care observed on 12/1/25, staff noted an undated bordered foam dressing on the resident’s sacrum that appeared old and was peeling. A CNA removed the dressing and notified the nurse. The wound care nurse initially believed the dressing was a pain patch, then, upon assessment of the sacrum, identified a pressure wound with slough and a small area of granulation, measuring 9 cm x 8.5 cm x 0.1 cm. The wound care nurse stated she had not been informed of the sacral wound and that it had not been present at her last assessment. Review of the physician order sheet and treatment administration records for November and December showed no treatment orders for a sacral pressure wound, and the care plan contained no interventions for a sacral wound. The facility’s own clinical protocol required skin examination of new admissions for ulcerations and physician-authorized wound treatment orders, but these were not implemented for this resident’s sacral pressure ulcer.
Inadequate Staffing Leads to Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient staff to meet the Activities of Daily Living (ADL) needs of all 79 residents. On multiple occasions, residents were left in soiled incontinence briefs for extended periods due to inadequate staffing. For instance, one resident reported being left in a wet brief from 3:00 AM until after 9:00 AM, despite the care plan requiring checks every two hours. This resident, who has moderate cognitive impairment and is dependent on staff for all ADLs, was not provided timely incontinence care, highlighting the staffing shortfall. Another resident, who is always incontinent of bowel and bladder and requires substantial assistance with transfers, was found sitting in a wheelchair with wet clothing and a strong odor of urine and stool. The resident's care plan also mandates regular checks and cleaning after incontinence episodes to prevent skin breakdown. However, the resident was not attended to promptly, resulting in redness and tenderness around the rectal area, indicating a failure to meet the care plan's goals. The facility's staffing schedules revealed consistent understaffing, with only six CNAs available during the day shift to care for 79 residents, despite the facility's assessment tool indicating a need for more staff. CNAs were overwhelmed with responsibilities, including passing meal trays and assisting residents with high care needs, such as those requiring mechanical lifts and feeding assistance. The staffing coordinator confirmed the inability to meet the ideal staffing levels due to restrictions on using agency staff, further exacerbating the issue.
Facility Fails to Maintain Window Coverings, Affecting Resident Comfort
Penalty
Summary
The facility failed to provide a clean, homelike environment for its residents by not maintaining window shades or equivalent coverings in good repair. Observations revealed that several residents' rooms had temporary, pleated paper shades that were torn and could not be adjusted, leaving residents unable to control the amount of light entering their rooms. In some cases, rooms lacked any window coverings entirely, exposing residents to the courtyard/patio without privacy. Residents expressed dissatisfaction with the inability to adjust the shades, which affected their comfort and the ambiance of their rooms. The deficiency affected 13 out of 18 residents reviewed, with some residents unable to be interviewed due to cognitive impairments. The Maintenance Director acknowledged that a remodeling update had been initiated but halted due to financial constraints, leaving resident rooms without permanent window shades for over six months. The facility had received a quote for window treatments, but the previous administrator did not proceed with the purchase, and the remodeling has not resumed under the new administration.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for two residents, leading to deficiencies in their care. One resident, who was frequently incontinent of urine and always incontinent of stool, reported that her brief was wet and had not been changed since 3:00 AM, despite the next shift starting at 6:00 AM. The resident's care plan required checking every two hours and cleaning the peri-area with each incontinence episode, which was not adhered to. The CNA assigned to her care was responsible for twelve residents, which may have contributed to the delay in care. Another resident, who was always incontinent of bowel and bladder, was found sitting in a wheelchair with wet sweatpants and a strong odor of urine and stool. Upon being transferred back to bed, it was observed that the resident's incontinence brief was wet with urine and stool, and there was redness around the rectal area and sacrum. The resident's care plan also required checking every two hours and cleaning the peri-area with each incontinence episode, which was not followed. The CNA assigned to this resident was also responsible for twelve residents, including two who required feeding assistance, which may have impacted the timeliness of care provided.
Exposed Electrical Wires Near Resident's Bed
Penalty
Summary
The facility failed to ensure a safe environment for a resident by not addressing a damaged electrical outlet in the resident's room. The outlet box was hanging off the wall with exposed electrical wires, located approximately two to four inches from the resident's metal bed frame. The resident, who is dependent on staff for repositioning in bed, reported that the bed frequently hits the outlet during repositioning, which was confirmed by the Maintenance Director. The resident has multiple diagnoses, including rheumatoid arthritis and major depressive disorder, and is dependent on staff for all activities of daily living. The Maintenance Director acknowledged the ongoing issue with the outlet, stating that it had been reported three months prior but had not been adequately addressed. Despite being informed of the hazard by the surveyor, the Maintenance Director had not implemented any interventions to prevent further damage to the outlet. The resident's electronic medical record and Minimum Data Set indicate moderate cognitive impairment and frequent incontinence, further emphasizing the need for a safe environment. The deficiency was observed over several days, with no corrective actions taken to secure the outlet or prevent future incidents.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to adhere to its water management plan, specifically in the prevention of Legionella growth. The Maintenance Director admitted to not performing weekly checks and recording the temperatures of the hot water boiler/storage tank, nor flushing the eye wash stations weekly as required. Additionally, the ice machine was cleaned less frequently than the monthly schedule outlined in the plan, and the cooling tower was inspected only monthly instead of weekly. This lack of adherence to the water management plan was confirmed by the facility administrator, who acknowledged the need for weekly documentation of water temperatures. The facility also failed to follow its policy regarding catheter care and hand hygiene, which was observed during the care of several residents. For instance, two CNAs were observed providing incontinence care to a resident without performing hand hygiene between glove changes. They also failed to change gloves appropriately during the care process, which included cleaning the perineal area and applying barrier cream. Similar lapses in hand hygiene and glove changes were noted during the care of another resident, where CNAs did not perform hand hygiene before donning new gloves after providing incontinence care. Furthermore, the facility did not adhere to Enhanced Barrier Precautions for a resident with a history of ESBL and an indwelling urinary catheter. Staff failed to use gowns during direct care and placed the urinary drainage bag on the floor, contrary to facility policy. Hand hygiene was again neglected during the care process, as staff did not wash hands between tasks or after handling the urinary catheter. These deficiencies in infection prevention and control practices were observed across multiple residents, indicating a systemic issue within the facility.
Failure to Offer COVID-19 Vaccine to Eligible Residents
Penalty
Summary
The facility failed to adhere to its policy of offering and administering the COVID-19 vaccine to residents, as evidenced by the lack of documentation for four residents. These residents, identified as R1, R22, R32, and R39, were not documented as having been offered the updated 2023-2024 COVID-19 vaccine, despite their eligibility and the facility's policy requiring such an offer. The facility's policy, dated October 2023, mandates that all residents and employees without medical contraindications be offered the vaccine annually, in line with CDC recommendations. The residents involved had various medical conditions, including chronic obstructive pulmonary disease, asthma, heart failure, type 2 diabetes mellitus, epilepsy, anemia, rheumatoid arthritis, and chronic kidney disease. The facility's failure to document the offer of the updated vaccine was confirmed through interviews and record reviews, with the Nurse Consultant acknowledging that these residents should have been offered the vaccine. The CDC's guidelines recommend the updated vaccine for everyone six months and older, emphasizing the importance of following these guidelines to ensure resident safety.
Failure to Secure Indwelling Catheter Leads to Resident Trauma
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling urinary catheter, leading to catheter-related trauma. The resident, who was cognitively intact and had a medical history including type 2 diabetes, prostate cancer, and a history of urinary infections, was observed with an unsecured catheter. This resulted in the catheter being pulled out approximately four inches, causing moderate bleeding around the tip of the penis and soaking through the incontinence brief. The catheter tubing was noted to be freely dangling between the resident's legs, which was confirmed by a registered nurse as improperly secured. The facility's policy and procedure for urinary catheter care required that the catheter be secured with a strap to prevent pulling and tugging, which was not followed in this instance. The care plan for the resident included maintaining comfort and preventing infection, with interventions such as assessment and notifying the physician for any changes. However, the failure to secure the catheter as per the policy and care plan led to the observed trauma and discomfort for the resident.
Failure to Administer Follow-up Pneumococcal Vaccines
Penalty
Summary
The facility failed to adhere to its policy of offering and administering pneumococcal vaccines in accordance with CDC guidelines, affecting three residents. The first resident, a [AGE] year-old with multiple health conditions, consented to receive pneumococcal vaccinations and was administered the PPSV23 vaccine. However, there was no documentation to show that a second pneumococcal vaccine was offered or administered, as per CDC guidelines. Similarly, the second resident, also with multiple diagnoses, consented to pneumococcal vaccinations and received the PPSV23 vaccine, but again, there was no documentation of a follow-up vaccine being offered or administered. The third resident, with a history of rheumatoid arthritis and other conditions, consented to receive pneumococcal vaccines but had only received the PCV13 vaccine in 2012. The facility's policy, which aligns with CDC recommendations, requires that residents who have received PPSV23 should be offered a second pneumococcal vaccine, and those who received PCV13 should receive a PPSV23 dose. The lack of documentation for these follow-up vaccinations indicates a failure to comply with the established vaccination policy, as confirmed by the nurse consultant during the survey.
Deficient Arbitration Agreements in Facility
Penalty
Summary
The facility's arbitration agreements were found to be deficient as they did not include necessary language indicating that signing the agreement was not a condition for admission or receiving care. This issue was identified during interviews and record reviews, where it was noted that the facility's most recent arbitration agreements lacked this critical information. Additionally, the facility failed to update previously signed agreements to include language that allowed residents to rescind the agreement within 30 days and to ensure that the selection of an arbitrator and meeting location would be mutually decided by the parties involved. These deficiencies affected all 70 residents residing in the facility. Specific examples of the deficiency were observed in the arbitration agreements of three residents. One resident's agreement, signed recently, did not include the necessary language about the agreement not being a condition for admission or care. Two other residents had agreements signed in 2022 that also lacked the required language about rescinding the agreement within 30 days and the mutual decision-making process for selecting an arbitrator and meeting location. The facility's Acting Administrator acknowledged the oversight in the updated contracts, confirming the absence of the required language.
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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 Elgin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Fox River | 0.5 mi | ★★★★★ | 0 | 0 |
| Aperion Care Elgin | 1.5 mi | ★★★★★ | 2 | 0 |
| River View Rehab Center | 1.7 mi | ★★★★★ | 28 | 0 |
| The Pearl Of Fox River Valley | 2.1 mi | ★★★★★ | 13 | 0 |
| Tower Hill Healthcare Center | 2.6 mi | ★★★★★ | 9 | 0 |
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