Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Libertyville Manor Ext Care during CMS and state inspections, most recent first.
A resident with dementia sustained a distal femur fracture during a transfer using a mechanical sit-to-stand lift. The incident occurred when a CNA attempted to lower the resident into a wheelchair, but the resident began slipping off the seat. Despite assistance from other staff, they were unable to reposition the resident safely, and she was lowered to the ground, potentially causing the fracture. The facility's policy required proper use of leg straps and foot support, which were not adhered to during the incident.
A facility failed to monitor residents' weight and nutritional intake, leading to significant weight loss in a resident with a G-Tube. The resident was not weighed upon admission, and their poor oral intake was not documented or communicated to the physician or dietician. Other residents also experienced delays in weight monitoring. These failures resulted in an Immediate Jeopardy situation.
The facility failed to have an RN on duty for 8 hours a day, 7 days a week, affecting all 35 residents. A violation notice indicated non-compliance with staffing requirements from July to September. On two specific days, there were no RNs available, confirmed by the DON. The facility's staffing requirements stated an RN was needed for two shifts per day.
The facility failed to monitor food temperatures and improperly stored scoops in food bins, affecting all residents. Meals were served without temperature checks, and scoops were found inside bins, violating facility policies.
The facility failed to ensure safety and supervision for four residents, including a dementia resident who was not assessed for safe smoking, a resident at risk for aspiration left with un-thickened liquids, a high fall-risk resident transferred without a gait belt, and another resident without a reachable call light. These actions were contrary to care plans and facility policies.
A facility failed to provide a vegetarian resident with protein substitutes and did not serve residents on pureed diets the same menu items as those on regular diets. A vegetarian resident received meals without protein substitutes, and residents on pureed diets did not receive pureed versions of all menu items, contrary to facility policy.
The facility failed to follow infection control protocols, including improper medication handling by an LPN and inadequate glove use and hand hygiene by a CNA. Additionally, Enhanced Barrier Precautions were not implemented for residents with indwelling medical devices or wounds, as required by facility policy.
The facility failed to maintain the confidentiality of two residents' health information. A sign indicating a COVID-19 quarantine was placed on one resident's door, and a letter detailing another resident's Clostridium Difficile diagnosis was hung outside their room. A CNA confirmed that such information should remain private, as per the facility's policy on residents' rights.
The facility failed to provide adequate ADL assistance for two residents requiring care. A resident with traumatic brain injury was found with a saturated incontinence brief and long fingernails, indicating neglect in personal hygiene. Another resident with chronic kidney disease was left in an uncomfortable position after incontinence care, contrary to facility policy requiring regular repositioning and hygiene care.
A resident with a history of urinary tract infection and chronic kidney disease did not receive thorough incontinence care, as a CNA failed to clean stool from the resident's buttocks before applying a clean brief. This was against the facility's policy, which aims to prevent infection and ensure comfort.
A facility failed to ensure medications were administered uncrushed, resulting in a 12% error rate. A resident with multiple diagnoses, including fractures and a staph infection, was given crushed extended-release medications, contrary to physician orders and facility policy. An LPN crushed and administered these medications, believing they were crushable, despite the facility's list indicating otherwise.
A resident in an LTC facility experienced mental abuse when a CNA instructed her not to use her call light for two hours after a disagreement over changing her brief. The resident, who is alert and oriented, felt intimidated and refrained from calling for assistance. The CNA admitted to the behavior, which was confirmed by staff interviews, highlighting a failure to protect the resident from mental abuse as per the facility's policy.
The facility failed to follow its abuse policy by not investigating an allegation of theft involving a resident. Despite the resident reporting missing money to the Acting Administrator, no investigation was conducted, which is a violation of the facility's elder abuse policy that mandates investigation and reporting of such allegations.
The facility failed to investigate an allegation of theft reported by a resident, who stated that approximately $1,100 was missing from his possession. The Acting Administrator did not interview staff or other residents regarding the missing money, and the facility only provided an unusual occurrence report and a State of Illinois long-term care facility report.
Improper Use of Sit-to-Stand Lift Leads to Resident Injury
Penalty
Summary
The facility failed to ensure safe care during the use of a mechanical sit-to-stand lift, resulting in a resident sustaining a distal femur fracture. The incident involved a resident with dementia who was wheelchair-bound and had a history of falls due to weakness and an unsteady gait. During a transfer from her bed, the sit-to-stand lift reportedly malfunctioned, causing the resident to fall and sustain a fracture. The resident was subsequently taken to the emergency department, where imaging confirmed a displaced and angulated comminuted fracture of the distal femur, necessitating surgical intervention. The incident occurred when a CNA was using the mechanical sit-to-stand lift to provide incontinence care to the resident in the shower room. As the CNA attempted to lower the resident back into her wheelchair, the resident began slipping off the seat. The CNA sought assistance from other staff members, but they were unable to reposition the resident safely into the chair. The resident was eventually lowered to the ground, during which time her right leg was noted to be in an awkward position, potentially contributing to the fracture. Interviews with staff revealed that the resident's legs were not properly secured with the lower leg straps, and the staff did not consider using the lift to reposition the resident once she began to slip. The facility's policy required that the resident's feet remain in contact with the foot support and that the lower leg straps be used to maintain the resident's position. The Director of Nursing acknowledged that the fracture might have occurred during the lowering process and emphasized the need for two staff members to be present during sit-to-stand transfers, despite the policy stating only one was necessary.
Failure to Monitor Resident Weight and Nutritional Intake
Penalty
Summary
The facility failed to implement a system to monitor residents for weight loss, particularly affecting four residents, including one with a gastrostomy tube (G-Tube). Resident R183 was not weighed upon admission and did not have any weights recorded from December 5, 2024, to January 14, 2025. Despite having a G-Tube for supplemental feeding due to poor oral intake, R183 experienced a 3.3% weight loss over 41 days. The facility also failed to report R183's decreased oral intake to the physician before discontinuing enteral feeding and did not notify the dietician of the discontinuation. The facility's inaction led to R183 not being weighed as per physician orders, and the resident's poor oral intake was not documented or communicated effectively. The dietician was unaware of the discontinuation of enteral feedings and the resident's weight loss, which hindered the ability to provide appropriate nutritional interventions. The physician discontinued the enteral feeding based on the family's request without being informed of the resident's poor appetite and lack of weight monitoring. Additionally, other residents, R135, R10, and R86, were not weighed upon admission, with significant delays in obtaining their initial weights. R135 experienced a 13-pound weight loss over 23 days without being weighed upon admission due to being on contact isolation. These failures in monitoring and communication resulted in an Immediate Jeopardy situation, highlighting the facility's noncompliance with weight monitoring protocols.
Removal Plan
- An order for daily weights on the day shift was obtained and implemented by the V3 nurse supervisor for R183.
- V24, Dietician, will assess the resident, provide recommendations and documentation.
- V4, Director of Nursing, spoke to the R183's POA and the POA is in agreement to start the tube feedings again.
- The nursing staff will monitor all resident's oral intake and notify physician and dietician with any complications.
- V3, Nurse Supervisor, has contacted V12, R183's physician and he will be in contact with the facility.
- V5, QAPI had an emergency meeting with V25, Medical Director, V1, Administrator, V4, DON, and V3, Nurse Supervisor. The problem was discussed, identified, and a system will be put into place for monitoring the compliance with the facility weight protocol.
- The facility will follow the recommendations from the Dietician as well as any orders from V12, R183's physician, and these will be implemented.
- The staff will be in serviced by V4, DON, V3, Nurse Supervisor, and V7, Unit Manager, on the facility policy for obtaining weights on admission on all residents and the facility policy on obtaining weights for medicare and skilled residents. This will involve all nursing staff and CNA's.
- The facility will weigh all residents. Any significant weight gain or loss of 5 percent or more, the physician will be contacted and the Dietician will be consulted for an assessment.
- The Dietician currently visits twice a month, 4 hours each visit, and as needed.
- V3, Nurse Supervisor, and V7, Unit Manager, will audit all weights on their units for new admissions, weekly weights, and monthly weights, and provide the weights daily to the Director of Nursing.
- Any weights that are missing will be obtained immediately, the employee responsible for the missed weight will be in serviced to ensure compliance in the future.
- The audit will be provided to V5, QAPI, at the weekly management meeting to ensure compliance.
- The QAPI committee will be updated quarterly.
RN Staffing Deficiency in LTC Facility
Penalty
Summary
The facility failed to comply with the requirement of having a Registered Nurse (RN) on duty for 8 hours a day, 7 days a week, affecting all 35 residents. This deficiency was identified through observation, interview, and record review. The CMS-671 application dated January 14, 2025, confirmed the presence of 35 residents in the facility. A violation notice was posted on the facility's entrance, indicating non-compliance with staffing requirements from the Illinois Department of Public Health for the period of July 1, 2024, to September 30, 2024. Specifically, on July 4, 2024, and September 2, 2024, there were no RNs available in the facility. The Director of Nursing confirmed the absence of RN coverage on these two days. The facility's minimum staffing requirements indicated that an RN was needed for two shifts per day, 24 hours per day.
Food Temperature Monitoring and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper food temperature monitoring and storage practices, affecting all 35 residents. On January 13, 2025, a Dietary Aide did not place food in the steam table, and the Nurse Manager served meals without checking food temperatures. The Cook admitted to not logging food temperatures, and the facility could not provide any temperature logs. The facility's policy requires food temperatures to be checked and logged at various stages, but this was not adhered to. Additionally, on January 13, 2025, scoops were found lying inside bins of sugar, flour, and oatmeal, contrary to the facility's policy that requires scoops to be stored with handles extending out of the food to avoid manual contact. The facility's policies on food safety and scoop storage were not followed, leading to potential contamination risks.
Safety and Supervision Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure the safety and supervision of four residents, leading to multiple deficiencies. A resident with dementia, who was a smoker, was not assessed for safe smoking practices, despite being on supplemental oxygen and having difficulty holding cigarettes. The facility's policy did not require safe smoking assessments, and staff were unaware of the resident's dementia diagnosis. Another resident, also with dementia and at risk for aspiration, was not provided with the appropriate consistency of fluids as per her care plan. The resident was left unsupervised with un-thickened coffee, contrary to her dietary requirements for thickened liquids due to dysphagia. Additionally, a resident at high risk for falls was transferred without the use of a gait belt, contrary to her care plan instructions. The staff member used improper techniques, increasing the risk of injury. Another resident, with a history of falls and fractures, was found without her call light within reach, despite her care plan indicating the need for it to be accessible. The facility's fall prevention policy was not adhered to, as interventions to reduce fall risk were not implemented effectively.
Failure to Provide Adequate Dietary Substitutes and Pureed Menu Items
Penalty
Summary
The facility failed to meet the nutritional needs of a resident who follows a vegetarian diet and residents on pureed diets. A resident on a vegetarian diet was not provided with any protein substitutes during meals on January 13 and 14, 2025. The Nurse Manager and Cook confirmed that the resident received meals without meat but did not receive any alternative protein sources. The Dietician was unaware of what protein substitutes were being provided, indicating a lack of communication and planning for the resident's dietary needs. Additionally, the facility did not ensure that residents on pureed diets received the same menu items as those on regular diets. On January 14, 2025, four residents on pureed diets were served Salisbury steak and mashed potatoes but did not receive pureed corn, garden salad, or peaches, despite the facility's policy allowing for these items to be pureed. The Cook stated he did not puree these items, mistakenly believing that corn could not be pureed. The Dietician confirmed that corn can be pureed, highlighting a gap in the implementation of the facility's puree policy.
Infection Control Deficiencies in Medication Handling and Barrier Precautions
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, leading to multiple deficiencies. A Licensed Practical Nurse (LPN) was observed preparing a resident's medications by pressing them out of bingo cards directly into her hand, contrary to the facility's policy of not touching medications when opening the bottle or unit dose. Additionally, a Certified Nursing Assistant (CNA) provided incontinence care to a resident without changing gloves or performing hand hygiene after contact with bodily fluids, which is against the facility's handwashing policy. Furthermore, the facility did not implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices or wounds. Two residents with a gastrostomy tube and a stage 3 pressure injury, respectively, did not have EBP isolation signs or carts with personal protective equipment outside their rooms, as required by the facility's policy. The Director of Nursing confirmed that residents with such conditions should be on EBP, indicating a lapse in adherence to infection control protocols.
Failure to Maintain Resident Privacy
Penalty
Summary
The facility failed to maintain the confidentiality of residents' protected health information for two residents. For one resident, a red stop sign indicating 'STOP COVID 19' was visibly placed on the outside of the resident's door, making it visible to anyone walking in the hallway. This resident was on a COVID-19 quarantine as per physician orders. For another resident, a typed letter was hung outside the room, detailing the resident's diagnosis of Clostridium Difficile and providing information on the infection and handwashing instructions. This information was visible to anyone passing by. A Certified Nursing Assistant acknowledged that residents' information should not be visible, as it is private. The facility's policy on residents' rights assures confidential treatment of personal and medical records, which was not adhered to in these instances.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) assistance for two residents, R15 and R9, who required such care. R15, who was admitted with diagnoses including traumatic brain injury and major depressive disorder, was found with a completely saturated incontinence brief and a strong urine odor, indicating that he had not been changed since the night shift at 5:00 AM. Additionally, R15's right ring fingernail was excessively long, suggesting neglect in personal hygiene care. R9, who has diagnoses including urinary tract infection and chronic kidney disease, was observed to require substantial assistance with personal hygiene. During an observation, R9 was found laying crooked in bed after incontinence care was provided, and the CNA did not reposition him to ensure comfort. The facility's policy mandates that residents receive regular personal hygiene care, including repositioning and incontinence care every two hours, which was not adhered to in these instances.
Inadequate Incontinence Care for Resident
Penalty
Summary
The facility failed to ensure thorough incontinence care for a resident, identified as R9, who was frequently incontinent of bowel and bladder and required substantial assistance with personal hygiene. During an observation on January 13, 2025, a CNA, V10, provided incontinence care to R9 while he was in bed. Despite the presence of stool in R9's rectum and on his buttocks, V10 placed a clean incontinence brief on R9 without thoroughly cleaning the stool from his buttocks. This action was contrary to the facility's Incontinence Care policy, which mandates correct incontinence care when continence cannot be maintained. R9's medical records indicate a history of urinary tract infection, elevated white blood cell count, and chronic kidney disease. The facility's policy, revised in April 2023, emphasizes the importance of proper incontinence care to prevent infection and ensure resident comfort. An interview with another CNA, V11, confirmed that staff should ensure all bowel movements are cleaned off residents to prevent infection and odor.
Medication Administration Error Due to Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to ensure medications were administered uncrushed, resulting in a medication error rate of 12%, which exceeds the acceptable threshold of 5%. This deficiency was observed during a medication pass involving one resident, who had been admitted with diagnoses including humerus fracture, femur fracture, and methicillin-resistant staph infection. The resident had physician orders for potassium chloride and metoprolol succinate, both of which are extended-release medications that should not be crushed. However, on January 13, 2025, an LPN crushed all of the resident's medications and administered them mixed with pudding. The LPN later stated that she believed all medications were crushable except for potassium, despite the facility's policy and list indicating that these medications should not be crushed.
Resident Mental Abuse by CNA
Penalty
Summary
The facility failed to ensure a resident was free from mental abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident. The resident, an alert and oriented female, reported that the CNA instructed her not to use her call light for two hours after a disagreement over changing her incontinent brief. The resident felt intimidated and refrained from using the call light, which she found distressing. The CNA admitted to making the statement and justified it by claiming the resident was using the call light excessively and consuming too many diapers. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Unit Manager, confirmed the resident's account of the incident. The CNA's behavior was described as abrasive and indifferent, and the Unit Manager acknowledged that the CNA needed re-education on resident rights. The facility's abuse policy emphasizes the importance of a living environment that encourages reporting concerns and protects residents from mental abuse, which includes humiliation and threats of deprivation.
Failure to Investigate Allegation of Theft
Penalty
Summary
The facility failed to follow its abuse policy by not investigating an allegation of theft/misappropriation of funds involving a resident. On April 17, 2024, a resident reported missing money to the Acting Administrator, who admitted to not conducting an investigation into the matter. The facility's elder abuse policy, dated April 11, 2023, mandates that all allegations of abuse or theft be investigated and reported to the Illinois Department of Public Health (IDPH) within 5 days. Despite this policy, the Acting Administrator did not initiate an investigation, resulting in non-compliance with the facility's established procedures for handling such allegations.
Failure to Investigate Allegation of Theft
Penalty
Summary
The facility failed to ensure an allegation of theft was investigated for one resident. The resident reported that approximately $1,100 was missing from his possession. An unusual occurrence report dated April 7, 2024, indicated that $1,000 in $100 bills, which had staples, was missing from the resident's wallet in the bedside table top drawer. The Acting Administrator stated that no one was aware the resident had the money and that the resident was advised not to keep valuables or money in the facility. The Acting Administrator did not interview staff or other residents regarding the missing money. The facility only provided an unusual occurrence report and a State of Illinois long-term care facility report, which confirmed the resident was alert and oriented and had reported the misappropriation of funds.
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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 Libertyville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Libertyville | 3.5 mi | ★★★★★ | 3 | 1 |
| Thrive Of Lake County | 5 mi | ★★★★★ | 3 | 0 |
| Claridge Healthcare Center | 5 mi | ★★★★★ | 9 | 2 |
| Lake Forest Place | 6.2 mi | ★★★★★ | 3 | 0 |
| Elevate Care Waukegan | 6.7 mi | ★★★★★ | 25 | 0 |
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