Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Elevate Care Waukegan during CMS and state inspections, most recent first.
A resident who required supervision or touching assistance with eating, as documented on the MDS, was observed eating alone in their room using a small, child-sized plastic spoon without any supervision, cueing, or touch assist. Due to vision loss and difficulty straightening fingers, the resident gripped the flexible plastic spoon with a loose fist, causing food to repeatedly fall off the spoon without being noticed, leading to frustration and only partial meal consumption. An LPN reported that only plastic spoons were available and did not know why, while the Dietary Manager stated plastic was used when there was not enough metal flatware. Resident council minutes also showed that two residents had complained about receiving plastic ware.
A resident receiving anticoagulation therapy for an upper extremity thrombosis had multiple physician orders for INR testing, and blood was reportedly drawn, but PT/INR tests were not completed and no lab results were documented for several ordered test dates. The DON acknowledged that although lab orders were placed correctly, the anticoagulation testing was not performed, and the physician reported frequently ordering INRs without receiving any results. The resident was later hospitalized with a supratherapeutic INR of 12.0 and a markedly prolonged PT, while the facility was unable to provide a relevant policy during the survey.
Wet plastic insulated plate bases were observed being removed from the dish rack, stacked, and stored before air drying. During lunch service, those wet plate bases were then taken from storage and placed onto trays for service. The FSD stated dishes should be air dried before stacking, and the facility policy says dishes and trays should be left in the racks before stacking.
A facility failed to keep resident rooms clean and failed to provide bath linen for several residents. One resident had medication splashed on the wall, nightstand, and bed linens, while another had dried tube feeding on the floor beside the bed. Multiple residents reported missed showers or bed baths because towels and washcloths were unavailable, and one resident said room trash was not changed and another said the floor was not mopped. The ED said staffing and access to locked linen supplies contributed to the shortage, and Resident Council minutes showed ongoing concerns about lack of linen.
A facility failed to ensure residents who needed extensive assistance received showers and personal hygiene care. Four residents were observed with greasy or unkempt hair and, in some cases, overgrown facial hair; staff confirmed they were dependent on staff for bathing or grooming, and one resident said he was not offered a shower while another said a bed bath and hair wash were missed because towels and washcloths were unavailable. Shower documentation was missing for multiple residents, and one resident was not listed on the shower schedule.
Pureed foods were served at an unappetizing temperature. A resident on a puree diet with slightly thick liquids reported that meals were cold and returned lunch because it was cold. During meal observation, puree green beans and puree beef stew for multiple residents on puree diets were plated and served at 98 degrees Fahrenheit, and the FSD stated the foods should have been over 100 degrees Fahrenheit.
Failure to follow a resident’s communication care plan was identified when the resident was observed trying to communicate by moving his mouth and arm, becoming frustrated when not understood, and no communication binder was found in the room. A CNA said the resident had a communication board but did not know where the binder was after the resident was moved to a different bed. The care plan directed communication via pointing, nodding, and use of the communication binder.
A resident's POLST indicated DNR, but the physician order sheet listed Full Code. An LPN said she would follow the system order if the resident were found pulseless, and the DON stated the POLST and code order should always match the resident's wishes. The facility policy required advance directive forms and physician orders to reflect the resident's CPR or DNR choice.
Failure to Timely Initiate Resident Grievance: A resident reported missing personal items to a staff member assigned to round on her, but the concern was not promptly documented or forwarded. The resident later stated she had not heard anything back and that the staff member only wrote down a list and said it would be turned in to the Administrator. The Administrator initially reported no grievances for the month, and the grievance form was not available until later, despite the facility policy calling for prompt resolution and same-day submission of grievances.
A resident with vascular dementia, depression/anxiety, and insomnia was started on Seroquel for anxiety without documented behaviors or non-pharmacological interventions in the EMR. Psychiatry notes showed the resident was alert, denied anxiety and depression, had no agitation or outbursts, and staff reported no concerns, yet the chart did not explain why the psychotropic was initiated. The DON stated behavior monitoring and documentation of attempted non-pharmacological interventions should be in the record before starting a psychotropic medication.
Failure to Report Injury of Unknown Origin and Abuse Allegation: A resident with severe cognitive impairment was found with a head hematoma and abrasion, but staff gave conflicting accounts of when the injury was first noticed and the administrator had no injury investigation available. In a separate incident, a family member reported that a CNA was rude and handled a resident roughly during care, but the administrator treated it as a customer service issue rather than an abuse allegation and did not report it as required by policy.
A resident was not referred for a PASARR Level II evaluation after a new diagnosis of psychosis was documented during the stay. The resident had been admitted with anxiety and major depression, and the PASARR Level 1 screening had previously shown no SMI and no need for a Level II review. The Social Service Coordinator stated that a new severe mental illness diagnosis would require a Level II evaluation, but she was unsure how new diagnoses were communicated and said she had system issues when corporate told her to complete the PASARR.
Unsupservised meal service for a resident with dysphagia. A resident with dx including dysphagia, hemiplegia/hemiparesis, and DM2 was ordered a mechanical soft diet with nectar thick liquids, but was observed eating lunch alone in his room while seated in a wheelchair. He was drinking unthickened water and coughing after water and bites of food. A CNA stated the resident was supposed to be supervised and assisted during meals for safety, and the care plan did not include the dysphagia dx or interventions.
A resident's indwelling urinary catheter was not secured, and the drainage tubing was hanging off the bed with the tubing fully supported by the catheter inside the bladder. The resident did not have an external securing device in place, and a CNA said the securing device may have fallen off. An LPN stated that catheter securing devices are used to prevent yanking on the catheter that may cause damage or pain.
Failure to provide ordered nutritional supplements was cited for a resident with dysphagia, hemiplegia/hemiparesis, type 2 DM, and other diagnoses who appeared thin and underweight during a noon meal. The resident was served lunch without the frozen nutritional treat that was ordered to come with meals, despite documentation calling for frozen nutritional treats and a nutritional shake BID and a care plan identifying risk for compromised nutritional status.
A resident with a G-tube was observed receiving Osmolite 1.2 via feeding pump while in bed sleeping. The DON stated weights are checked on admission, weekly x4, and then monthly for residents on tube feedings so the Dietician can assess whether caloric needs are being met. However, the resident’s record showed only one weight had been obtained, despite physician orders for admission, weekly, and monthly weights and the facility’s tube feeding policy requiring weight monitoring.
A resident's oxygen was not administered according to the physician order when the concentrator was observed set at 5 L instead of the ordered 3 L/min via nasal cannula. The DON stated nurses should follow the physician order when setting oxygen levels and noted residents can have respiratory issues if oxygen is set too high. The facility policy requires oxygen to be used safely and the flow meter set to the ordered rate.
Failure to stop an antibiotic as ordered for a resident with osteomyelitis. The resident was admitted on cephalexin 500 mg QID for a 7-day course, but the MAR showed the ABX continued for weeks beyond the hospital discharge order. An ID NP noted there was no end date on the med and that clarification was needed, and the IP stated the resident should have stopped the cephalexin after 7 days.
Medication administration errors resulted in a 20% error rate after staff failed to follow ordered directions for two residents. An RN gave Metoprolol without checking the resident’s pulse immediately before administration, and an LPN gave several scheduled meds outside the ordered times, including doses that were late by more than one hour per the DON and facility policy.
A resident with schizoaffective disorder missed multiple doses of lithium and lorazepam because the meds were not reordered before they ran out, with eMAR notes stating the doses were awaiting delivery. An LPN said nursing staff must call or fax the pharmacy for refills, and the facility policy required reordering meds four days in advance to ensure an adequate supply.
The facility failed to provide prescribed therapeutic diets for two residents. One resident with dysphagia and other diagnoses was served thin liquids despite an order for nectar thick liquids, and a CNA poured and delivered water without thickener. Another resident with swallowing difficulties was supposed to receive puree foods with slightly thickened drinks, but the diet order remained listed as mechanical soft, and staff heated and served food without knowing the resident was on a puree diet.
Failure to implement EBP for a resident with an open wound. A resident with an unstageable right heel pressure ulcer had no EBP sign or isolation cart outside the room on multiple observations, and the MAR/POS showed no EBP order until later. The ICP confirmed residents with open wounds should be on EBP, while the facility’s EBP policy did not include open wounds.
Failure to Screen, Offer, and Administer Flu and Pneumococcal Vaccinations: A resident was not screened for, educated on, or offered the flu shot upon admission, and although the resident consented to the pneumococcal vaccine after screening and education, the vaccine was never given. The IP stated residents should be screened for, educated on, and offered influenza and pneumococcal immunizations upon admission, and acknowledged the resident's immunizations were missed.
Failure to Screen, Educate, and Offer COVID-19 Immunization on Admission The facility failed to screen, educate, and offer the COVID-19 vaccine upon admission for two residents. Their immunization records showed they were not screened for, educated on, or offered the vaccine until later, and the IP confirmed the vaccine was not offered at admission.
A resident was burned when a ceiling light fixture in his room overheated, caught fire, and dropped melted plastic onto him while he was in bed eating breakfast. Staff reported fire and smoke in the room, pulled the resident away, and called 911. The resident sustained 2nd degree burns to his R upper arm and a superficial partial thickness burn to his L middle finger; the maintenance director said the fixture had a loose contact and was the original unit in the room.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with ALS reported that a CNA attempted to damage and then turned off his oxygen concentrator and disabled his call light. The incident was reported internally to nursing supervisors and the Administrator, and the CNA was suspended during the investigation. However, the Administrator did not report the abuse allegation to the State Agency as required by facility policy.
Two residents who were dependent on staff for ADLs did not receive required oral care as ordered and outlined in their care plans. Both had visible debris and poor oral hygiene observed during the survey, despite staff statements that oral care is performed daily and facility policy requiring regular oral hygiene.
A resident with a history of stroke and on tube feeding experienced significant weight loss due to the facility's failure to monitor their weight as recommended. Despite being on a specific feeding regimen, the resident's weight was not recorded in December, leading to a 9.36% weight loss by January. The facility's policy required monthly weights and more frequent monitoring for those at nutritional risk, which was not followed.
The facility failed to provide palatable food, as observed during a lunch service where chicken was found to be hard, tough, and dry. Several residents reported dissatisfaction with the meal, and a test tray confirmed the chicken was overcooked. The Assistant Food Service Manager acknowledged the issue, stating that the chicken should be juicy.
A resident with chronic respiratory issues was observed self-administering a nebulizer treatment without the required assessment or physician's order. The facility's policy mandates an assessment and physician order for self-administration, but the resident's records lacked both. The Respiratory Therapy Manager provided the medication without knowing the requirement, and the resident's care plan did not address self-administration.
A resident was involved in a physical altercation with another resident, resulting in the resident being knocked out of her wheelchair. Both residents were alert and oriented, and the incident was witnessed by a CNA who intervened. The resident reported pain but refused further assessment. The facility's Administrator substantiated the abuse, and the involved resident was arrested and not allowed to return to the facility.
A facility failed to follow its abuse policy for a resident with a criminal history, leading to a deficiency. The resident's background check was delayed due to an error in recording race, and a HIT for domestic battery was not acted upon. The facility's policy required immediate fingerprinting, but this was not done, resulting in an incident with another resident. The admissions staff admitted to the error, and the necessary follow-up actions were not executed.
The facility failed to provide meaningful activities for two residents with dementia, leading to deficiencies in meeting their needs. One resident, who enjoys puzzles and arts, was left in bed without engagement, while another, who benefits from sensory activities, was not offered any activities and was repeatedly redirected to sit down. The lack of personalized activity offerings and insufficient staffing contributed to the residents' inactivity and dissatisfaction.
A resident with limited ROM was not evaluated for a brace and did not receive prescribed ROM exercises. Despite an order for evaluation dated in November, the resident had not been assessed for a splint by January, and documentation showed inconsistent delivery of ROM exercises.
The facility failed to supervise medication administration for two residents. One resident was found with an unconsumed Adderall pill, and another had multiple medications left at their bedside. Both instances lacked physician orders for self-administration, contrary to facility policy requiring nurse supervision during medication ingestion.
The facility failed to ensure proper PPE use and isolation signage for residents on isolation. A CNA entered a resident's room on contact isolation for ESBL without wearing required PPE. Additionally, two residents who tested positive for COVID-19 lacked isolation signs and PPE outside their rooms, as confirmed by an LPN and the Infection Preventionist. These actions violated the facility's infection control policies.
The facility failed to assess and administer influenza and pneumonia vaccinations to three residents, leading to a deficiency in their immunization practices. A resident received an influenza vaccine late, and two residents did not receive timely pneumonia vaccinations. The Infection Control Preventionist Nurse acknowledged the oversight and lack of documentation regarding communication attempts with a resident's POA.
A resident with a hand contracture suffered a foul odor and an open wound due to inadequate hand and nail care. Despite being dependent on staff for personal hygiene, the resident's fingernails were excessively long, causing a cut to the palm. Facility staff failed to follow policies for nail care and bathing, resulting in the resident's injury and requiring intervention by the wound care team.
A resident with a history of chronic conditions experienced a fall and subsequent pain, but the facility delayed X-ray reporting and treatment. The X-ray, revealing a fracture, was not reviewed until over 20 hours later, delaying hospital transfer. Staff interviews highlighted communication and procedural issues.
A resident at high risk for falls experienced an unwitnessed fall resulting in a right hip fracture due to inadequate supervision. Despite a care plan indicating high fall risk, the facility failed to continuously monitor and document the resident's condition post-fall, delaying hospital evaluation. The resident, previously ambulatory with assistance, required a total lift and non-weight bearing status after the incident.
A resident in a long-term care facility, who was a Full Code, did not receive immediate CPR due to staff's inability to quickly verify the code status. The resident was found unresponsive and pulseless, but the CNA and RN involved were unsure of the code status and had to check the electronic medical record, causing a delay. This delay contributed to the resident's death, highlighting a deficiency in the facility's process for identifying code status.
A resident experienced verbal abuse from a staff member, V12, who used profanity and inappropriate language during an altercation about an oxygen concentrator. Despite attempts by other staff to de-escalate the situation, V12 continued the confrontation at the nurses' station, witnessed by multiple staff members. The facility's investigation confirmed the incident as a violation of the resident's right to be free from abuse.
A resident was physically abused by another resident after wandering into their room and taking food. The incident resulted in a fall and injuries, including a laceration and bruising. A housekeeper witnessed the altercation and confirmed the push. The facility's policy requires such incidents to be reviewed as potential abuse.
A facility failed to monitor a resident for 72 hours after a fall where she hit her head. The resident was observed with discoloration on her forehead, and the DON confirmed that required post-fall procedures, including vital signs and neuro checks, were not completed. Initial vital signs were recorded, but further monitoring was not conducted as per policy.
The facility failed to ensure a resident room was free from cockroaches, despite multiple reports and observations of the pests. The Maintenance Director was aware of the issue but had not taken steps to seal the room or repair the hole in the bathroom wall where the pests were entering. The facility's Pest Control policy was not followed, and the problem persisted for weeks without resolution.
Failure to Provide Required Eating Assistance and Appropriate Utensils
Penalty
Summary
The deficiency involves the facility’s failure to provide required supervision and appropriate assistance with eating for a resident who needed supervision or touching assistance, resulting in the resident being left alone in the bedroom to eat with inadequate utensils. The resident’s MDS documented a need for supervision or touching assistance with eating, including verbal cueing and/or steadying/contact guard assistance throughout or intermittently during the activity. During a noon meal observation, the resident was seated alone in a wheelchair at an overbed table with the meal tray and was given a small, child-sized plastic spoon. The resident, who reported losing vision and being unable to straighten their fingers, gripped the tiny handle with a loose fist; when the resident attempted to scoop food, the flexible plastic spoon bent downward and the food repeatedly fell off without the resident noticing, leading to visible frustration and intake of only about 50% of the meal. Staff interviews revealed that only plastic flatware was being used on the unit, with an LPN stating there were no metal spoons and not knowing why plastic was used, and the Dietary Manager stating plastic was used when there was not enough metal flatware. Resident council minutes also documented that two residents had previously complained about receiving plastic ware. These observations, interviews, and record reviews show that the resident who required supervision and assistance with eating was not provided with the necessary supervision, cueing, or appropriate utensils during the meal, and that the facility’s practice of substituting plastic flatware when metal flatware was insufficient contributed to the deficiency.
Failure to Monitor Anticoagulation Lab Results Leading to Supratherapeutic INR
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and complete laboratory monitoring of a resident’s anticoagulation therapy. The resident had a diagnosis of thrombosis of the right upper extremity and was receiving anti-clotting medication regulated by INR (International Normalized Ratio) testing. A physician’s order dated 03/02/2026 directed that an INR blood test be drawn, and the DON stated that the blood was drawn on 03/03/2026. However, the resident’s medical record contained no results for this INR order, and the DON reported that although the laboratory orders were placed correctly, the PT (Prothrombin Time) and INR tests were not completed. The resident’s prior INR result in the record was from 01/16/2026, with an INR of 1.2, and no subsequent INR results were documented for the ordered tests. According to the DON, additional INR tests were scheduled on 03/13/2026, 03/14/2026, 03/16/2026, 03/17/2026, and 03/18/2026, but no INR results were obtained for any of those dates. The resident was later discharged from the facility and admitted to the hospital, where hospital laboratory results on 03/19/2026 showed a PT of 96.6 seconds (normal 12.3–15.1) and an INR of 12.0 (normal 0.8–1.2). The attending physician explained that a supratherapeutic INR indicates too much Coumadin, that the resident’s therapeutic INR range should have been 2–3, and that INR levels are used to regulate the resident’s anti-clotting medication. The physician stated that INR tests were ordered frequently at the facility but that no laboratory results were received. The facility did not provide a policy related to this issue at the time of the survey.
Wet Plate Bases Stacked and Stored Before Air Drying
Penalty
Summary
The facility failed to ensure plastic insulated plate bases were air dried before being stacked and stored. On 3/9/26 at 9:47 AM, three employees were observed at the dish machine, and a Dietary Aide removed clean and sanitized trays and plastic insulated plate bases from the dish rack while they were still wet, stacked them, and placed them in a cart under the outfeed table. During lunch service from 11:37 AM until 12:38 PM, wet insulated plate bases were then pulled from the storage cart and placed onto trays for service. The Food Service Director stated at 1:00 PM that all dishes should be air dried before stacking. The facility’s Mechanical Ware Washing policy states it is especially important to air dry dishes before stacking and to leave dishes, trays, and other items in the racks before stacking them.
Failure to Maintain Clean Rooms and Provide Bath Linen
Penalty
Summary
The facility failed to ensure resident rooms were clean and failed to provide linen for bathing for 5 of 34 residents reviewed for a clean, comfortable, homelike environment. R11 was observed in bed with orange liquid splashed on the wall and nightstand beside her bed, and her bed sheet had multiple areas of orange substance. R11 stated the substance was from medications given that morning and said her sheets needed to be changed. Later, the wall and nightstand were still splattered with the orange substance, and R11 said her bed bath and hair wash were not provided because the facility did not have washcloths or towels. R151 was observed in bed with tube feeding running, and dried brown tube feeding was on the floor next to the bed on two separate observations. During a group meeting, R41 and R66 said they did not receive showers or baths because the facility ran out of towels and washcloths. R41 stated the linen shortage had been an ongoing problem for 6 months since laundry was brought in-house, and R66 said the garbage in her room was not changed from Friday to Monday. R124 stated the floor in his room was not mopped. The Environmental Director stated a sick third-shift laundry aide left no one to do laundry, and that staffing issues and staff not knowing how to access the locked linen area contributed to the lack of towels and washcloths. Housekeeping was expected to mop resident rooms daily and clean spills when seen, and garbage was to be removed daily and as needed. Resident Council Minutes from August 2025, September 2025, and February 2026 documented concerns about lack of linen.
Failure to Provide Scheduled Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure residents who required extensive assistance received showers and personal hygiene care. Four residents reviewed for activities of daily living were observed with unkempt or greasy hair and, in some cases, overgrown facial hair, while staff and records indicated they depended on staff for bathing and grooming. R170, admitted with diagnoses including history of falling, heart disease, atrial fibrillation, anxiety, depression, and an occiput fracture, was observed in bed with unkept hair and an overgrown beard and stated he had not been offered a shower. Staff said he was a new resident, was a fall risk, and could not shower independently, and the facility did not provide shower documentation for him. R160, who had hemiplegia and hemiparesis following cerebrovascular disease, type 2 diabetes, peripheral vascular disease, venous insufficiency, and COPD, was observed in bed with unkept, disheveled, greasy hair and said he had not had his hair washed in a while; staff confirmed he was dependent on staff for all cares and that his hair needed to be washed. R3 was observed with overgrown facial hair on her chin and unbrushed, unkept hair; staff said she was dependent on staff for all cares, received bed baths, and needed her facial hair shaved, but her room was not listed on the shower schedule. R11 was observed with greasy, stringy hair and said she was supposed to receive a bed bath and hair wash but did not because staff did not have washcloths or towels; she said this happened often, and the facility could not provide shower documentation for her. The facility's Shower and Tub Bath Policy states it is to ensure resident cleanliness to maintain proper hygiene and dignity.
Pureed Foods Served at an Unappetizing Temperature
Penalty
Summary
The facility failed to ensure pureed foods were served at an appetizing temperature. R164’s speech therapy notes stated that the resident’s recommended diet consistency was pureed foods with slightly thick drinks. The resident was admitted on a regular diet, requested a downgrade to mechanical soft, and then asked to try puree because swallowing difficulties continued with mechanical soft foods; the diet was downgraded to puree after a diet slip was provided to the kitchen over the weekend. R164 later reported that the pureed food being served was cold and returned lunch because it was cold. In addition, the facility’s diet order report showed that R30, R31, and R37 were on pureed diets. During a meal observation, test trays for the puree meal were plated and sent to the second floor, and when the trays were served, the puree green beans and puree beef stew were both measured at 98 degrees Fahrenheit. The Food Service Director stated the foods should be over 100 degrees Fahrenheit, and the surveyor found both items were lukewarm rather than hot.
Failure to Follow Communication Care Plan
Penalty
Summary
The facility failed to follow a resident’s care plan interventions for communication for 1 of 34 residents reviewed. During observation, the resident was lying in bed and made several attempts to communicate by moving his mouth and left arm, but became frustrated when not understood and then waved a hand in a "never mind" gesture and looked away. No communication binder was found in the resident’s room. A CNA stated the resident did have a communication board, but the resident had been moved to a different bed and the CNA did not know where the communication binder was. The resident’s care plan, revised 01/06/2026, identified an alteration in the ability to communicate related to impaired cognitive abilities and impaired speech, and stated the resident communicates via pointing, nodding, and using his communication binder.
Mismatch Between POLST and Physician Code Status Order
Penalty
Summary
The facility failed to ensure that a resident with an advance directive for Do Not Resuscitate (DNR) had a physician order reflecting that wish. For one of 34 residents reviewed for advance directives, the resident's Physician's Order Sheet showed an order for Full Code, while the resident's IDPH Uniform Practitioner Order for Life-Sustaining Treatment (POLST) form indicated the resident wished to be DNR. During interview, an LPN stated that if a resident were found pulseless, she would check the order in the system and, if it said Full Code, she would start CPR. The DON stated that once a POLST form is completed by the resident or resident representative, the DNR order is entered into the system if that is what they elect, and that the POLST form and order should always match the resident's wishes. The facility's Advanced Directives policy states that if a resident or health care representative indicates an advance directive regarding CPR or DNR/Scope of Treatment, the appropriate forms will be completed to indicate their wishes and written physician orders shall be specific and address each advance directive.
Failure to Timely Initiate Resident Grievance
Penalty
Summary
The facility failed to initiate a resident-reported grievance in a timely manner for 1 of 34 residents reviewed for grievances. On 03/09/2026, R11 was observed in bed in her room on the third floor and stated that since moving to that room from the second floor, she was missing a gray comforter and a green bath towel. R11 said her Guardian Angel, a staff member assigned to round on her, had spoken with her that morning and she had told the staff member about the missing items. On 03/10/2026, R11 stated she had not heard anything about her missing items and no one had spoken with her after she told her Guardian Angel. She also said she had forgotten to mention missing slippers and her wallet and planned to tell the staff member when she returned to round. On 03/11/2026, R11 said her Guardian Angel had come in on Monday and she told her about the missing items, and that the staff member rounded again the previous day, wrote down a list, and said she would turn it in to the Administrator. The Administrator stated on 03/09/2026 that there were no grievances reported for March 2026. The Social Services Director stated that when a resident has a grievance, the information is taken down, a grievance form is completed and sent to the Administrator, and she would expect the staff receiving the grievance to submit it the same day. The facility could not provide a Concern/Compliment form for R11 until the morning of 03/11/2026, and the form was dated 03/10/2026. The facility's grievance policy states it is to ensure prompt resolution of all grievances regarding care and treatment furnished or not furnished.
Failure to Document Behaviors Before Starting Seroquel
Penalty
Summary
The facility failed to document medical symptoms and failed to ensure non-pharmacological interventions were implemented before starting a resident on Seroquel for anxiety. The resident, who had vascular dementia, depression/anxiety, and insomnia, was seen by psychiatry and was documented as alert, able to answer some questions appropriately, denying depression and anxiety, sleeping well at night, and having no reported agitation, outbursts, hallucinations, suicidal ideation, or homicidal ideation. Staff also reported no concerns, no changes in appetite, and no overt signs of sadness or loneliness. A phone order was received for Seroquel 50 mg twice daily for anxiety, and a nurse practitioner later documented that the resident had been trying to get out of bed more on his own and that the Seroquel would be reinstated at a lower dose. However, the resident’s EMR did not contain behavior notes from the prior psychiatry visit through the date of the order, did not show that the resident had been seen by psychiatry again before the order, and did not document why Seroquel was initiated. The DON stated that behavior monitoring should be documented in the EMR and that there should be documentation of behaviors and non-pharmacological interventions before starting a psychotropic medication.
Failure to Report Injury of Unknown Origin and Abuse Allegation
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident with severe cognitive impairment and extensive assistance needs. On 03/09/2026, R31 was observed lying in bed with a left frontal hematoma and abrasion to the head and did not respond to verbal stimulation. Staff gave conflicting accounts about when the head injury was first noticed, with one CNA stating the bruising was present when she started work on 03/05/2026 and an RN stating she saw the bruise on 03/08/2026 but did not report it because she believed it was not new and was healing. The administrator stated she did not know about the injury until the surveyor asked, and no initial injury investigation documents were provided at survey exit. R31’s recent assessments showed no injury, and the wound rounds record showed no active wounds. The facility also failed to report an allegation of abuse involving another resident. R133’s sister reported that a CNA was rude, abrupt, and grabbed R133 harshly while rolling him, causing his leg to go over the bed and upsetting the resident. The human resources director stated she believed the concern was abuse and notified the administrator, who said she took statements from the resident’s mother and sister and spoke with the CNA and nurse, but did not treat it as an abuse investigation or report it because she considered it a customer service issue. The administrator also stated she had no abuse investigations pending for March 2026, despite the facility’s file containing statements, resident interviews, and a grievance form related to the incident. The facility policy stated that any allegation of abuse, retaliation, mistreatment, or misappropriation of resident property must be reported immediately, but not more than two hours after the allegation.
Failure to Refer Resident for PASARR Level II Review After New Psychosis Diagnosis
Penalty
Summary
The facility failed to refer a resident for a PASARR Level II evaluation after the resident received a new diagnosis of psychosis during the stay. R17 was admitted with diagnoses of generalized anxiety disorder and major depression, and the Face Sheet later documented a diagnosis of psychosis not due to substance or known physiological condition on 1/30/24. The resident’s PASARR Level 1 Screening, dated 10/3/22, indicated no serious mental illness diagnoses and that a Level 2 screen was not indicated. During interview, the Social Service Coordinator stated corporate completes PASARR screening prior to admission, that she was not sure who checks the screenings for accuracy, and that a new severe mental illness diagnosis would require a PASARR Level II evaluation. She also stated corporate contacted her in February and told her to do a PASARR for R17, but she was having issues with the system, and she was not sure how corporate was notified of new diagnoses. The facility policy stated that residents with newly evident or possible serious mental illness, intellectual disability, or related condition are to be referred for a Level II review upon significant change in status assessment.
Unsupservised meal service for resident with dysphagia
Penalty
Summary
The facility failed to ensure a resident with dysphagia was supervised during meals. R141’s face sheet listed diagnoses including dysphagia, hemiplegia and hemiparesis following a non traumatic subarachnoid hemorrhage affecting the right dominant side, type 2 diabetes, and left upper limb carpal tunnel syndrome. Physician orders dated March 2026 directed a mechanical soft diet and nectar thick liquids. During observation on 03/09/2026 at 12:17 PM, R141 was eating the noon meal in his room while seated in his wheelchair with the meal tray on his bedside table; he was served beef stew and green beans, was drinking water that was not thickened, and was coughing after drinking water and taking bites of food. On 03/10/2026 at 1:00 PM, a CNA stated that R141 was on the list to be supervised and assisted during meals for safety, that he was on a mechanical altered diet and nectar thickened liquids, and that he should not have been eating in his room unsupervised. R141’s current care plan did not include his dysphagia diagnosis or the interventions implemented.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident's indwelling urinary catheter was secured to prevent pain and/or injury. During observation on 03/09/2026, the resident's urinary drainage bag tubing was hanging off the bed and the tubing was fully supported by the indwelling urinary catheter inside the resident's bladder. The resident did not have an external securing device in place for the catheter. A CNA stated that the resident's catheter securing device may have fallen off, and an LPN stated that catheter securing devices are used to prevent yanking on the catheter that may cause it to come out of the urinary urethra and cause damage or pain. The facility's Urinary Catheter Care policy states that indwelling catheters may be secured to prevent trauma and tension.
Failure to Provide Ordered Nutritional Supplements
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was cited after surveyors observed that R141, who had diagnoses including dysphagia, hemiplegia and hemiparesis following a non traumatic subarachnoid hemorrhage affecting the right dominant side, type 2 diabetes, and left upper limb carpal tunnel syndrome, did not receive the nutritional supplements ordered for weight loss risk. During the noon meal on 03/09/2026, R141 was eating in his room, appeared thin and underweight, and was served beef stew and green beans without the frozen nutritional supplement that was supposed to accompany the meal. The resident's dietary note dated 1/10/26 documented that he was underweight at 103 lb and should continue frozen nutritional treats and a nutritional shake twice daily, and the current care plan identified him as at risk for compromised nutritional status with interventions to provide dietary supplements. On 03/10/2026, a CNA stated the frozen nutritional treats should come on the resident's meal tray from the kitchen.
Failure to Obtain Required Weights for Resident With G-Tube
Penalty
Summary
The facility failed to obtain weights for a resident with a gastrostomy tube, identified as R191, who was reviewed for gastrostomy tube care. On 03/09/2026 at 10:06 AM, R191 was observed in bed sleeping with the gastrostomy tube connected to a feeding pump and Osmolite 1.2 running at 70 cc/hour. On 03/10/2026 at 1:19 PM, the DON stated that resident weights are checked on admission, weekly for 4 weeks to establish a baseline, and then monthly, and that weights are needed for residents on gastrostomy tube feedings so the Dietician can determine whether the tube feeding is meeting caloric needs. R191’s weight record showed only one weight obtained on 03/10/2026, and the physician orders included weigh upon admission, weekly x4, and monthly, along with NPO status and enteral feed orders for Osmolite 1.2 at 70 ml/hr. The facility’s Enteral Nutrition-Tube Feeding Policy stated that monitoring includes weight and that enteral feed should be delivered as ordered by the physician.
Oxygen Flow Set Above Physician Order
Penalty
Summary
The facility failed to ensure a resident's oxygen was administered according to physician orders for R162, who was observed sleeping in bed with a nasal cannula on 03/09/2026 and later watching TV in bed with a nasal cannula on 03/10/2026. During both observations, the resident's oxygen concentrator was set at 5 liters, while the physician order dated 6/18/2025 specified oxygen at 3 L/min via nasal cannula. The DON stated that nurses should follow the oxygen order in the physician orders when setting the oxygen level and noted that residents can have respiratory issues if oxygen is set too high. The facility's Oxygen Therapy Policy states that oxygen should be used in a safe and effective manner and that the flow meter should be turned to the ordered flow rate.
Failure to Stop Antibiotic as Ordered
Penalty
Summary
The facility failed to discontinue cephalexin as ordered for one resident, R57, who was reviewed for unnecessary medication use. R57 was admitted with diagnoses including acquired absence of the right great toe, right toes, left great toe, and osteomyelitis. His hospital discharge medication order dated 2/8/26 directed cephalexin 500 mg, 1 capsule four times a day for 7 days, but the February and March MAR showed he received cephalexin 500 mg four times a day from 2/8/26 to 3/11/26. An Infectious Disease Nurse Practitioner note dated 2/23/26 documented that the resident was on cephalexin 500 mg by mouth four times a day with no end date, while the hospital record indicated it was supposed to be only for 7 days. The note stated clarification was needed with nursing staff about whether the antibiotic had been extended. On 3/11/2026, the Infection Preventionist stated that when a resident admits with antibiotic orders, the nurse should enter the medication into the system with the appropriate stop date, and said she did not notice a duration on the discharge papers. She also stated the resident should have stopped cephalexin after 7 days and that no one had spoken to her previously about the antibiotic.
Medication administration errors exceeded the acceptable rate
Penalty
Summary
Medication administration errors occurred for 2 of 3 residents reviewed for medication administration, resulting in 6 errors out of 30 opportunities and a 20% medication error rate. For one resident, the March 2026 MAR directed Metoprolol Succinate ER 50 mg once daily and to hold the medication if the resident’s pulse was less than 60 beats per minute. On 3/9/26 at 10:02 AM, an RN administered the Metoprolol without assessing the resident’s pulse immediately before giving the medication. The RN stated the last pulse assessment had been around 8:00 AM that morning, and the DON later stated the pulse should be checked immediately prior to administering the medication. For another resident, the March 2026 MAR listed multiple scheduled medications, including Duloxetine, Metoprolol Tartrate, Mucinex ER, Buprenorphine, and Topamax at specific morning, afternoon, and evening times. On 3/9/26 at 10:30 AM, an LPN administered these medications to the resident, including doses scheduled for 9:00 AM and 9:00 PM. The DON stated medications should be administered as ordered and that medication administration is considered late if given more than one hour after the scheduled time. The facility’s medication administration policy required the five rights of medication administration and stated medications are to be given in accordance with prescriber orders and within 60 minutes of the scheduled time.
Missed psychotropic medication doses due to delayed reordering
Penalty
Summary
The facility failed to ensure psychotropic medications were reordered before they ran out, resulting in missed doses of lithium and lorazepam for one resident. The resident, who had schizoaffective disorder, was observed lying in bed with a calm demeanor and stated there had been a few occasions when doses of lorazepam were missed. The resident’s February 2026 MAR showed one missed dose of lorazepam on 2/5/26, two missed doses on 2/26/26, one missed dose on 2/27/26, and two missed doses of lithium on 2/1/26. The eMAR progress notes for the missed doses stated the reason was awaiting delivery. During interview, an LPN said that when a resident runs low on medication, nursing staff call the pharmacy, and if the resident is already out, staff may obtain the medication from the locked medication dispensing machine if available or request a STAT delivery if it is not. The LPN also stated the pharmacy does not automatically send medications before they run out and that nursing staff must call or fax for refills. The physician stated the resident received lithium and lorazepam to manage symptoms associated with schizoaffective disorder, and the psych NP stated the resident was dependent on lithium and lorazepam to stabilize mood and was not a candidate for gradual dose reduction. The facility policy stated medications are to be reordered four days in advance of need to assure an adequate supply is on hand.
Therapeutic Diets Not Followed for Two Residents
Penalty
Summary
The facility failed to ensure staff provided prescribed therapeutic diets for 2 of 34 residents reviewed for therapeutic diets. One resident had diagnoses including dysphagia, hemiplegia and hemiparesis following a non traumatic subarachnoid hemorrhage affecting the right dominant side, type 2 diabetes, and left upper limb carpal tunnel syndrome. During the noon meal, the resident was served beef stew, green beans, and two cups of thin liquids. The resident took a sip of water and started coughing, then continued drinking the water and requested more. A CNA later poured water from the drink cart and delivered it without thickener, and there was no thickener solution on the cart. The resident’s March 2026 physician orders specified a mechanical soft diet with nectar thick liquids, and a CNA confirmed the resident was on nectar thick liquids. A second resident’s speech therapy notes stated the recommended food and liquid consistency was pureed foods with slightly thickened drinks. The resident said the lunch tray arrived and was sent back because it was cold, and the resident confirmed it was puree food. Later, the resident was observed eating a can of chili that a CNA had heated up. The RD and FSD stated the resident had been downgraded to puree after requesting a change from mechanical soft because swallowing difficulties continued, but the facility’s diet order report still listed the resident as mechanical soft. A CNA stated the resident’s puree status was not known when the soup was heated and said the last time the CNA worked with the resident, the resident was not on a pureed diet.
Failure to Implement EBP for Resident With Heel Pressure Ulcer
Penalty
Summary
The facility failed to ensure enhanced barrier precautions (EBP) were implemented for a resident with an open wound. R170 had a right heel pressure ulcer documented as unstageable, measuring 1.0 cm by 1.0 cm, with a date identified of 2/19/26 and noted as present on admission. On 03/09/2026 and again on 03/10/2026, R170’s room did not have an EBP sign or isolation cart outside the room, and the resident stated he had a sore on his right heel with a protective foam dressing in place. R170’s Physician Order Sheets for March 2026 showed there was no order for EBP until 3/10/26. On 03/11/2026, the Infection Control Preventionist stated residents with open wounds should be placed on EBP and confirmed that R170 should have been on EBP. The facility’s revised 2024 EBP policy did not include residents with open wounds are placed on EBP.
Failure to Screen, Offer, and Administer Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to screen, educate, and offer the influenza immunization to one resident upon admission, and failed to administer a pneumococcal immunization after the resident consented to receive it. R163 was admitted to the facility on [DATE], and the immunization record printed 3/10/26 showed the resident was not screened for, educated on, or offered the influenza immunization until 3/10/26. The record also showed the resident had never received a pneumococcal immunization in the facility. An Authorization and Release for Pneumococcal form dated 9/22/25 showed R163 consented to the pneumococcal vaccine after being screened for and educated on the immunization, but the vaccine was not administered. The Infection Preventionist stated residents should be screened for, educated on, and offered influenza and pneumococcal immunizations upon admission, and stated R163's immunizations must have gotten missed.
Failure to Screen, Educate, and Offer COVID-19 Immunization on Admission
Penalty
Summary
The facility failed to screen, educate, and offer the COVID-19 immunization upon admission for 2 of 5 residents reviewed for immunizations in a sample of 34. R123's admission record showed the resident was admitted to the facility on [DATE], but the immunization record printed on 3/10/26 showed R123 was not screened for, educated on, or offered a COVID immunization until 3/10/26. R163's admission record showed the resident was admitted to the facility on [DATE], and the immunization record printed on 3/10/26 showed R163 was not screened for, educated on, or offered a COVID immunization until 3/10/26. On 3/10/26 at 1:14 PM, the Infection Preventionist stated residents should be screened for, educated on, and offered the COVID immunization upon admission to the facility, and stated R123 and R163 were not offered the immunization until 3/10/26.
Ceiling Light Fixture Caught Fire and Burned a Resident
Penalty
Summary
The facility failed to ensure a light fixture was in safe operating order. During the incident, a ceiling light fixture in a resident room overheated, caught fire, and melted plastic pieces fell onto the resident while he was in bed. The resident, who had diagnoses including peripheral vascular disease, a left leg amputation, and hypertension, had no cognitive impairment noted on his facility assessment and was alert and pleasant when later observed in bed with a dressing on his right upper arm. The resident stated that while eating breakfast, the light fixture above him exploded, the plastic covering fell on him, and his blankets and gown caught fire. He reported yelling for help and described pain from the burn to his right upper arm. The emergency department documented second degree burns to the right upper arm and a superficial partial thickness burn to the distal palmar aspect of the left middle finger, with the injury caused by melted plastic from the light fixture. He was treated in the ER and discharged with topical antibiotic ointment and pain medication. Staff described responding to the fire in the resident’s room, pulling the resident away from the ceiling and bed area, and calling 911. The maintenance director stated the cause was a loose contact in the original light fixture that overheated and caused the fire. The facility reported that the light fixture malfunctioned and melted onto the resident’s bed, and an electrician later noted the plastic covering on the LED bulb was melted and the end of the lamp was burnt. The report also states that prior preventive maintenance consisted of looking for broken bulbs and replacing them.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Report Abuse Allegation Involving Resident's Oxygen and Call Light
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency as required by its own policy and regulatory standards. A male resident with Amyotrophic Lateral Sclerosis (ALS), who was alert and oriented, reported that a Certified Nursing Assistant (CNA) attempted to break his oxygen concentrator by hitting it, then turned it off, and also disabled his call light by pulling it out of the wall. The resident stated he informed a nurse about the incident, and an internal investigation was conducted. Multiple staff members, including the Administrator, DON, and nursing supervisors, were made aware of the allegations. The CNA involved was suspended during the investigation. Despite the seriousness of the allegations, including purposeful interference with life-sustaining equipment and communication devices, the Administrator decided not to report the incident to the Illinois Department of Public Health (IDPH), stating it was not considered a major abuse case. The facility's Abuse Prevention and Reporting Policy requires immediate reporting of any abuse allegations to the Department of Public Health, but this protocol was not followed in this case.
Failure to Provide Oral Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate oral care to two residents who were dependent on staff for activities of daily living. For one resident with a history of poor oral hygiene and dental problems, physician orders and the care plan required oral care every eight hours. Despite this, observations revealed that the resident had visible white/yellow debris and a film on her teeth, and she confirmed that her teeth had not been brushed that morning. The resident's family also reported ongoing concerns about plaque and poor oral hygiene during recent visits. Staff interviews indicated that oral care should be performed daily, but the resident continued to have visible debris in her mouth during multiple observations. Another resident, who was nonverbal and had significant physical impairments including quadriplegia and a persistent vegetative state, also had physician orders for oral care every eight hours. A dental consult had previously documented poor general oral hygiene. During the survey, this resident was observed with yellowish debris between his teeth. The DON confirmed that morning care should include brushing teeth or using a sponge to remove debris, in accordance with the facility's oral hygiene policy. Despite these requirements, both residents did not receive the necessary oral care as ordered and outlined in their care plans.
Failure to Monitor Weight in Tube-Fed Resident
Penalty
Summary
The facility failed to ensure that a resident receiving tube feedings had their weight monitored, resulting in significant weight loss. The resident, identified as R112, had a history of difficulty swallowing due to a stroke and was on a gastrostomy tube feeding regimen. The Physician Order Sheet indicated that R112 was to receive Glucerna 1.5 at 60 ml per hour for 10 hours daily, supplemented by a general diet of mechanical soft with nectar thick fluids. Despite recommendations from the dietitian to monitor the resident's weight weekly, no weights were recorded for December 2024, and the resident experienced a weight loss from 173 pounds in November 2024 to 156.6 pounds in January 2025, a 9.36% decrease. The dietitian, V13, noted that R112's food intake was poor in November 2024 and had reinstated the tube feeding order with an increased rate of 75 ml per hour. However, the resident's weight was not monitored as recommended, and the December weight was not recorded. The facility's policy required monthly weights and more frequent monitoring for residents at nutritional risk, but this was not adhered to. The physician, V25, confirmed that weight monitoring should be done at least monthly for tube-fed residents, and weekly if weight loss is detected. The lack of timely weight monitoring led to the resident's significant weight loss, highlighting a deficiency in the facility's adherence to its weight monitoring policy.
Facility Fails to Ensure Palatable Food for Residents
Penalty
Summary
The facility failed to ensure that food was palatable for resident consumption, affecting four residents in the sample. During a lunch service, the cooked chicken was observed on the steam table and required reheating in the oven before being served. Several residents reported that the chicken was hard, tough, dry, and overdone, with one resident unable to eat it and another only consuming half of the portion. A test tray provided to surveyors confirmed that the chicken appeared dry and overcooked, with a tough texture. The Assistant Food Service Manager acknowledged that the food should not be hard or dry, indicating that chicken should be juicy on the inside.
Failure to Assess and Approve Self-Administration of Medications
Penalty
Summary
The facility failed to assess and approve a resident for self-administration of medications, specifically nebulizer treatments. A male resident, who was admitted with chronic respiratory failure, tracheotomy, and chronic obstructive pulmonary disease, was observed self-administering a nebulizer treatment without an assessment or physician's order. The resident reported that the respiratory therapist provided him with the medication ampule, and he initiated the treatment himself. The Director of Nursing confirmed that an assessment and physician order are required for residents to self-administer any medication, including nebulizer treatments. The Respiratory Therapy Manager, who provided the medication to the resident, was unaware of this requirement. The resident's medical records lacked an assessment for self-administration and did not include a physician's order for the nebulizer treatment. Additionally, the resident's care plan did not address self-administration of medications, contrary to the facility's policy, which mandates an assessment and physician order for self-administration requests.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident. An incident occurred where a resident, identified as R84, was involved in a physical altercation with another resident, R166. Both residents were described as alert and oriented with no cognitive impairments. The altercation began as a verbal disagreement in R166's room, which escalated to R84 being knocked out of her wheelchair onto the floor. A Certified Nursing Assistant (CNA), V15, witnessed the incident and intervened to prevent further harm. R84 reported pain in her left lower extremity and right arm but refused a full body assessment and any diagnostic tests. Following the incident, R84 expressed a desire to press charges against R166, leading to police involvement and R166's arrest. The facility's Administrator, V1, substantiated the abuse after an investigation, noting that R166 had a clenched fist directed at R84, although no further physical harm was inflicted. R84 was granted an order of protection against R166, who was not allowed to return to the facility. The facility's Abuse Prevention and Reporting policy, last revised in 2022, emphasizes that residents should be free from all forms of abuse, including physical and verbal abuse.
Failure to Follow Abuse Policy for Resident with Criminal History
Penalty
Summary
The facility failed to adhere to its abuse policy for a resident, identified as R166, who was admitted with a criminal history that included a HIT for domestic battery. The initial criminal history background check was initiated on 5/28/24, but due to an error in recording the resident's race, the process was delayed. A second report dated 6/27/24 confirmed the HIT, but the facility did not act on this information. The administrator and assistant administrator were unaware of the HIT until after an incident on 11/1/24, when R166 was involved in a physical altercation with another resident, R84. The facility's policy required immediate fingerprinting upon identifying a HIT, but this step was not taken. The admissions staff, V28, admitted to the error in recording the resident's race and the subsequent delay in processing the background check. V28 was not present when the final background check results were received, and the necessary follow-up actions, such as notifying social services for fingerprinting, were not executed. The facility's abuse policy mandates requesting background checks within 24 hours of admission and taking all necessary steps to ensure resident safety while awaiting fingerprint results. However, these procedures were not followed, leading to the deficiency identified in the report.
Failure to Provide Meaningful Activities for Dementia Residents
Penalty
Summary
The facility failed to provide meaningful activities to two residents with dementia, leading to deficiencies in meeting their needs. Resident R70, who enjoys activities such as bingo, puzzles, and arts and crafts, was observed in bed multiple times without any activities being offered. Despite being part of the Activity on Wheels (AOW) program, R70 expressed boredom and a lack of engagement. The Activity Assistant, V8, was unaware of R70's preferences and only offered activities that R70 did not enjoy, such as music. This lack of personalized activity offerings contributed to R70's inactivity and dissatisfaction. Similarly, Resident R111, who benefits from sensory activities and enjoys watching movies and TV shows, was observed in her wheelchair without any activities being offered. Staff repeatedly redirected her to sit down without providing engaging activities. The Activity Assistant, V8, admitted to not seeing R111 due to leaving early and noted that R111 was often asleep. The facility's policy requires activities to meet the interests and preferences of each resident, but the lack of available sensory items and insufficient staffing on the dementia unit contributed to the failure to provide appropriate activities for R111.
Failure to Evaluate and Provide ROM Exercises for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) was properly evaluated for a brace and received the necessary ROM exercises. The resident's care plan, initiated in October 2022, indicated the need for an active assisted ROM program 3-7 days a week. However, an order for restorative nursing to evaluate the resident's left wrist and finger contractures for a splint was not acted upon. This order was dated November 26, 2024, but by January 14, 2025, the resident had not been evaluated for a possible splint, and the resident reported not receiving routine ROM exercises. Observations and interviews revealed that the resident's left wrist was contracted at about 90 degrees, and the resident was unable to move the wrist and index finger. The resident mentioned requesting a brace from a doctor over a month ago, but no action had been taken. The restorative nurse was unaware of the evaluation order and confirmed that the resident had not been evaluated for a splint. Documentation showed that the resident did not receive ROM exercises 3-7 days a week for several weeks, with multiple instances of missing documentation or notes indicating that ROM was not applicable, meaning it was not done.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure proper supervision during medication administration for two residents. In the first instance, a resident was found with an orange pill, identified as Adderall, on their bedside stand. The resident admitted to not taking the medication because they did not want to stimulate their system further. The resident's Physician Order Summary (POS) indicated an active order for Adderall to be administered twice daily, but there was no order permitting self-administration. The nurse responsible for administering the medication believed the resident had taken it, highlighting a lapse in supervision. In the second instance, another resident was found with two plastic medication cups containing approximately 18 medications. The resident stated that the medications were left with them to take later with food. The Director of Nursing confirmed that no residents had orders to self-administer medications, and nurses were required to supervise medication ingestion. The resident's POS did not include an order for self-administration, and the Medication Administration Summary showed a scheduled administration of 16 pills that morning. The facility's policy mandates supervision during medication administration, which was not adhered to in these cases.
Infection Control Deficiencies in PPE Use and Isolation Signage
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and signage for residents on isolation, leading to deficiencies in infection control. In one instance, a Certified Nursing Assistant (CNA) entered the room of a resident on contact isolation for extended-spectrum beta-lactamases (ESBL) without wearing the required gown and gloves. The resident's care plan and the facility's contact precautions policy both indicated the necessity of these protective measures, yet they were not followed. This oversight was observed during a survey, highlighting a lapse in adherence to infection control protocols. Additionally, the facility did not display isolation signs or provide PPE outside the rooms of two residents who tested positive for COVID-19. A Licensed Practical Nurse (LPN) confirmed the absence of necessary signage and PPE, which should have been in place following the residents' positive test results. The Infection Preventionist acknowledged the oversight, noting that the signs were not moved after room changes. The facility's infection prevention manual mandates isolation with signage and PPE for residents testing positive for COVID-19, but these measures were not implemented as required.
Failure to Assess and Administer Vaccinations
Penalty
Summary
The facility failed to properly assess and administer vaccinations for influenza and pneumonia to three residents, leading to a deficiency in their immunization practices. Resident 27, who was over the age of 65, received an influenza vaccine on January 14, 2025, but it was noted that the vaccine should have been offered at the start of the flu season. The Infection Control Preventionist (ICP) Nurse, V24, attempted to contact the resident's Power of Attorney (POA) but was unsuccessful and did not document the communication attempt. Resident 23, also over the age of 65, had received a Prevnar 13 dose on April 21, 2024, but was due for another pneumonia vaccine dose, which had not been administered. Resident 17 had received a Pneumovax dose in 2018, but there was uncertainty about which dosage was administered, and no follow-up was conducted to verify this information. The facility's policy, revised on April 21, 2022, states that residents should be educated about the benefits and side effects of immunizations upon admission, and once consent is given, the influenza vaccine should be administered annually. Additionally, residents should be offered influenza immunizations from October 1 through March 31 annually and pneumococcal immunizations per CDC recommendations. However, the facility failed to adhere to these policies, as evidenced by the lack of timely vaccination and follow-up for the residents in question. The ICP Nurse acknowledged these oversights, indicating a lapse in the facility's vaccination assessment and administration processes.
Neglect in Hand and Nail Care Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate hand and nail care to a dependent resident with a hand contracture, resulting in a foul odor and an open wound on the resident's palm. The resident, who has a history of encephalopathy, traumatic subdural hemorrhage, and other significant medical conditions, was dependent on staff for activities of daily living, including personal hygiene. Despite the care plan indicating the need for active assistive range of motion and monitoring of skin integrity, the resident's hand care was neglected. Observations revealed that the resident's fingernails were excessively long, with one nail causing a cut to the palm of the contracted hand. The resident's room had a foul odor, and there was a noticeable build-up of debris on the resident's hand. Interviews with staff indicated that hand care should be performed daily for residents with contractures, but this was not done for the resident in question. The facility's policies for nail care, morning/nighttime care, and bed baths were not followed, as evidenced by the lack of documentation and the condition of the resident's hands. The Director of Nursing and other staff acknowledged the oversight, noting that the resident's nails should have been trimmed and hand care provided regularly. The wound care team had to intervene to treat the open wound caused by the long fingernail. The facility's failure to adhere to its own policies and procedures for resident care led to the resident's injury and the need for immediate medical attention.
Delayed X-ray Reporting and Treatment After Resident Fall
Penalty
Summary
The facility failed to ensure timely completion and reporting of an X-ray and delayed treatment for a resident who experienced a fall. The resident, who had a history of chronic kidney disease, hemiplegia, and vascular dementia, was found on the floor by a nursing supervisor. Despite the resident's complaints of pain and visible discomfort, the X-ray order was not marked as urgent, leading to a delay in obtaining and reviewing the results. The X-ray, which revealed an acute intertrochanteric fracture of the right femur, was completed and signed by the radiologist on the evening of the fall. However, the results were not reviewed by the facility's staff until the following afternoon, resulting in a delay of over 20 hours before the resident was transferred to the hospital for emergency care. During this time, the resident continued to experience pain, and there was a lack of documentation regarding ongoing monitoring of the resident's condition. Interviews with facility staff revealed communication breakdowns and procedural lapses. The Director of Nursing acknowledged that the X-ray should have been ordered as STAT and that the results should have been monitored more closely. The Nurse Practitioner, who ordered the X-ray, was not informed of the results until the next day, which contributed to the delay in the resident receiving appropriate medical attention.
Inadequate Supervision Leads to Resident Fall and Hip Fracture
Penalty
Summary
The facility failed to provide adequate supervision for a resident at high risk for falling, resulting in an unwitnessed fall and a right hip fracture. The resident, who had a history of moderate cognitive impairment, hemiplegia, and was at high risk for falls, was found on the floor by a nursing supervisor during rounds. The resident was unable to recall the details of the fall and complained of pain in the right leg. An X-ray confirmed an acute intertrochanteric fracture of the proximal right femur. The resident's care plan indicated a high risk for falls due to confusion and gait/balance problems, yet there was a lack of continuous monitoring and documentation of the resident's condition following the fall. The nursing staff did not document any progress notes from the time of the fall until the resident was sent to the hospital the next day. The resident was in pain and had decreased mobility, but the facility delayed sending her to the hospital for evaluation and treatment. Interviews with staff revealed that the resident was previously able to ambulate with a walker and minimal assistance but required a total lift and non-weight bearing status after the fall. The facility's fall prevention program aimed to ensure resident safety by assessing fall risks and implementing appropriate interventions, but these measures were not effectively executed in this case, leading to the resident's injury.
Failure to Quickly Identify Code Status Delays CPR
Penalty
Summary
The facility failed to have an effective process in place for staff to quickly identify a resident's code status, leading to a delay in providing cardiopulmonary resuscitation (CPR) to a resident who was found unresponsive and pulseless. The resident, who was a Full Code according to their POLST form and physician orders, did not receive immediate CPR due to staff's inability to quickly verify the code status. This delay contributed to the resident's death in the facility. The incident involved a cognitively impaired resident with diagnoses including dementia, cerebral infarction, dysphagia, and schizophrenia, who was dependent on staff for care. On the evening of the incident, a Certified Nursing Assistant (CNA) found the resident unresponsive in their room but did not check for a pulse or call for help immediately due to uncertainty about what to do. The CNA sought assistance from a Registered Nurse (RN), who also did not know the resident's code status and had to leave the room to check the electronic medical record, further delaying the initiation of CPR. Interviews with facility staff revealed that there was no quick method to verify a resident's code status, as it required checking the electronic medical record or DNR lists in binders on crash carts. The facility's CPR policy required immediate assessment and initiation of CPR for Full Code residents, but staff were not adequately prepared to follow this protocol, resulting in a critical delay in emergency response for the resident.
Removal Plan
- Social Services Director and Director of Nursing completed full facility audit of DNR status to ensure all POLST forms are in place and match code status in PCC.
- Facility staff were educated on where resident code status is available via PCC as well as POLST binders located at each crash cart on each unit to quickly identify a resident's CPR/code status.
- Staff educated on facility's Code Blue Policy and process on what to do should a resident be found unresponsive and pulseless to ensure no delay in CPR.
- Education on Code Blue policy and POLST binders location on each crash cart to quickly identify code status has been included in facility new hire orientation process and annually for all staff.
- Education has been provided to all RNs, LPNs, and CNAs staff currently present in the facility and all staff not present in the facility, have been in-serviced over the phone and will be re-inserviced before the start of their next shift.
- Emergency QA meeting conducted with facility Medical Director.
- The Director Of Nursing/DON will conduct random audits of 5 staff members, 4 times a week for 3 months, to ensure staff is able to state facility's Code Blue Policy, how to quickly identify a resident's code status, and immediately initiate CPR as/when indicated.
- The DON will conduct random audits of 5 staff members, 4 times a week for 3 months, to ensure they are aware of the POLST binders located on each crash cart in the facility for quick identification of code status.
- Social Services will conduct audits of POLST binders, 2 times a week for 3 months, to ensure the binders are up to date with the latest POLST information.
Verbal Abuse Incident Involving Staff Member
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse, as evidenced by an incident involving a resident and a staff member. The incident began when a resident, concerned about their brother's oxygen concentrator, approached a staff member for assistance. The staff member, identified as V12, responded inappropriately by using profanity and expressing frustration. This interaction escalated when the resident reported the issue to other staff members at the nurses' station, and V12 continued to use inappropriate language and behavior towards the resident. Multiple staff members, including nurses and a CNA, witnessed the altercation at the nurses' station. Despite attempts by other staff to de-escalate the situation, V12 persisted in using profanity and refused to step back when instructed. The facility's camera footage corroborated the accounts of the staff, showing V12 approaching the resident and engaging in a verbal confrontation. The resident expressed feeling unsafe when V12 was present, indicating the impact of the verbal abuse on their sense of security. The facility's investigation concluded that V12's behavior was unprofessional and constituted verbal abuse. The facility's policy affirms the right of residents to be free from abuse, and this incident was a clear violation of that policy. The report includes interviews with the involved parties and witnesses, as well as a review of the facility's camera footage, which all supported the finding of verbal abuse by V12.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse, as evidenced by an incident involving two residents. Resident 1 (R1) wandered into another resident's room and began taking food from trays. During this interaction, Resident 2 (R2) pushed R1, causing her to fall and sustain a small laceration on her right eyebrow. The incident report did not initially identify R2 as the resident who pushed R1. The facility's preliminary investigation noted an allegation of physical abuse involving R1 and R2. Observations and interviews conducted on 5/20/24 revealed that R1 had a scabbed laceration on her right eyebrow and bruising on her forehead and shoulder. R1 reported being pushed by a man, which caused her to fall and injure her right leg. A housekeeper, V8, witnessed the incident and confirmed that R2 pushed R1 with significant force, resulting in R1 hitting her head on the floor. The facility's abuse prevention policy requires that resident-to-resident altercations be reviewed as potential abuse situations, especially when they result in physical injury.
Failure to Monitor Resident Post-Fall
Penalty
Summary
The facility failed to adequately assess and monitor a resident for 72 hours following a fall in which the resident hit her head. This deficiency was identified for one resident in a sample of eight reviewed for quality of care. On May 8, 2024, the resident experienced a fall in front of her bathroom door and reported hitting her head. The Director of Nursing confirmed that post-fall procedures, including vital signs and neurological checks, were not completed for the required 72-hour period following the incident. The resident's fall report documented initial vital signs, but subsequent monitoring and documentation were not conducted as per the facility's policy, which mandates 72 hours of documentation by all three shifts after an incident.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to ensure a resident room was free from pests, specifically cockroaches, for one of the residents reviewed. On multiple occasions, staff and residents reported the presence of cockroaches in the room, with one resident showing the surveyor a hole in the bathroom wall where the pests were entering. Despite claims of spraying, the infestation persisted, and no efforts were made to seal the room or repair the hole. The Maintenance Director acknowledged awareness of the issue but had not taken steps to address it or communicated the problem effectively with other staff members. The facility's Pest Control policy, last revised on 9/1/22, mandates that employees promptly report pest observations and ensure all building openings are tight-fitting and free of breaks. However, this policy was not followed, as the maintenance request book did not contain recent reports of the roach problem, and the issue remained unresolved for weeks. The resident affected by the infestation had not been offered relocation to another room, and the problem continued to impact their living conditions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 559 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Waukegan Health And Rehab | 0.1 mi | ★★★★★ | 3 | 0 |
| Aspyre Of Waukegan | 2.2 mi | ★★★★★ | 16 | 2 |
| Claridge Healthcare Center | 5.2 mi | ★★★★★ | 9 | 2 |
| Alpine Care Of Zion | 6.4 mi | ★★★★★ | 27 | 0 |
| Libertyville Manor Ext Care | 6.7 mi | — | 0 | 0 |
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.