Below average — CMS composite of the measures below.
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 South Elgin Living & Rehab Center during CMS and state inspections, most recent first.
Two residents with complex medical and psychiatric histories engaged in a physical altercation over room temperature, resulting in one resident sustaining a fractured nose that required hospital treatment. Staff and facility records confirmed the incident, which was not prevented despite an abuse prevention policy.
The facility failed to manage a Strep A outbreak effectively, not adhering to health department instructions for testing and treatment, and failing to enforce a masking mandate. A resident with a positive Strep A wound infection was not under proper precautions, and staff and residents were observed unmasked. The facility's infection control policies were not effectively implemented, contributing to ongoing transmission concerns.
A facility failed to repair an exposed ceiling area with exposed pipes outside the rooms of three residents. The issue stemmed from a pipe leak fixed by an outside plumbing company, but the ceiling remained open with a loose plastic covering and debris. The Housekeeper Supervisor and Administrator confirmed the lack of maintenance staff to address the repair, despite requests to corporate management. The facility's maintenance guidelines emphasize prompt repair of such damage.
A registered nurse in an LTC facility demonstrated a lack of competency in administering medications and transcribing orders, affecting four residents. One resident reported receiving incorrect dosages, while another had to correct the nurse on missing evening medications. A third resident refused a pill that did not match her usual regimen, and a physician order was transcribed incorrectly. The nurse's personnel file lacked competency evaluations, and concerns were raised about her skills. The facility did not have a policy on nurse competencies.
The facility failed to maintain a full-time Director of Nursing (DON), affecting all 60 residents. The previous DON resigned, and the subsequent DON worked briefly. The facility relied on a Regional Director of Clinical and an Acting DON from a sister facility, neither present full-time. The Acting DON was instructed to work 20 hours focusing on infection control, but lacked structured job duties. The Regional Director had limited availability due to personal commitments. Concerns were raised about the Acting DON dividing her time between two facilities.
The facility failed to provide structured activities for residents during weekends, affecting several individuals with various diagnoses. Observations and interviews revealed that residents were left without activities, leading to boredom. Staff indicated that activities should be available seven days a week, but there was no policy in place to ensure this.
The facility failed to follow physician's orders for psychotropic medication administration and did not adhere to its psychotropic medication policy by failing to monitor residents for Extrapyramidal Symptoms (EPS) and not attempting a Gradual Dose Reduction (GDR) for a resident who no longer exhibited anxiety behaviors. These failures resulted in a resident receiving the wrong psychotropic medications and at excessive dosages, leading to side effects of increased abnormal involuntary movements.
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting 53 residents who receive oral nutrition. Various food items were found to be improperly labeled or not labeled at all, violating the facility's food storage policies. The Dietary Manager and Dietician acknowledged the risks of serving expired food, which could lead to food poisoning.
The facility failed to follow a physician's laboratory order for a resident receiving phenobarbital for seizure disorder. Despite an order for a phenobarbital trough level lab draw, the lab was not conducted, and the resident's medication blood levels were not monitored as required. The DON confirmed that nurses are expected to follow such orders, but a review of the resident's lab results showed no phenobarbital trough level for the past six months.
The facility failed to follow its policy on behavior monitoring for residents with known behaviors and receiving psychotropic medications. Despite care plans specifying the need for behavior monitoring and documentation, the RN admitted to not documenting behaviors for any of his assigned residents. This lapse in protocol compromised the ability to manage and adjust psychiatric care effectively for the residents involved.
The facility failed to ensure that Ascorbic Acid 500 mg was available for administration to residents with physician's orders. The medication had been unavailable since May 27, 2024, affecting at least five residents. The issue was observed during medication passes and confirmed through interviews and record reviews.
The facility failed to administer medications as ordered by the physician, resulting in a 10.81% medication error rate. A registered nurse was unable to provide specific medications to three residents due to unavailability and oversight, contrary to the facility's medication administration policy.
The facility failed to adhere to proper infection prevention and control protocols, particularly in the use of PPE in rooms requiring Enhanced Barrier Precautions (EBP). Staff did not wear gowns and gloves while providing care to residents with open wounds, gastrostomy tubes, and catheters, despite the presence of signs indicating the need for EBP. The facility's failure to implement and enforce proper infection control measures put residents at risk of infection and compromised their safety.
The facility failed to use a standardized tool to determine the necessity of antibiotic therapy for five residents, leading to undocumented and potentially unnecessary antibiotic use. Staff interviews revealed a lack of awareness and adherence to McGeer's criteria, and the facility could not provide an Antibiotic/Antimicrobial Stewardship Program-Mission Statement and Guidelines.
The facility failed to provide appropriate written notices to two residents that their Medicare coverage was ending. The Business Office Manager, who was new to the role, was unaware of the requirement to issue the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) forms. Both residents confirmed they did not receive any written notice, and their medical records lacked the necessary documentation.
The facility failed to provide privacy during pressure ulcer dressing changes for two residents. One resident had his dressing changed with the door open and privacy curtain partially drawn, while another had the blinds open, allowing visibility from outside. Staff did not wear gowns during the procedures, violating standard protocol.
The facility failed to maintain good personal hygiene for a resident who was unable to perform activities of daily living. The resident was observed with a crusty mouth, dry lips, and a strong foul odor. Despite the CNA's efforts and reporting the issue, the condition persisted. The RN attributed the odor to a periodontal issue, but the DON was unaware of any such condition and attributed it to poor oral hygiene. Medical records did not show any related diagnosis.
The facility failed to safely transfer a resident with multiple diagnoses and to properly position another resident during feeding in bed. A CNA transferred a resident without using a gait belt and while the resident was barefoot, and another CNA fed a resident who was in a slouched position. The DON confirmed the need for proper use of gait belts and safe positioning during feeding.
A facility failed to ensure a resident received a prescribed double protein diet, resulting in a significant weight loss. The resident's care plan was not updated, and there was no consistent monitoring of weekly weights as required by facility policy.
The facility failed to ensure a supply of gastrostomy tube feeding formula, did not label and date feedings, and did not follow physician's orders for three residents. One resident's g-tube machine was running at an incorrect rate, and another's bag lacked necessary labeling. The DON was unaware of the shortage and emphasized the importance of following orders and labeling.
The facility failed to store narcotic medications under double-lock and improperly stored an inhaler. An unlocked medication refrigerator contained an opened bottle of Lorazepam, and a resident's Albuterol inhaler was found on their bedside table without a doctor's order to self-medicate.
The facility failed to properly store and monitor food items brought in by residents' families or visitors. One resident had opened food items requiring refrigeration stored on a dresser without a refrigerator, while another resident's refrigerator contained expired food items and lacked a thermometer and temperature log. Staff confirmed that these procedures were not followed.
The facility failed to provide timely physical therapy services to three residents, resulting in delays in care and functional decline. The delays were due to the absence of a therapy company, leading to gaps in therapy services for the residents.
The facility failed to have a full-time DON, affecting all 57 residents. Observations and interviews confirmed the absence of a DON since early April, with no interim DON appointed and no waiver from the Illinois Department of Public Health. Nurses reported difficulties due to the lack of clinical management support.
The facility failed to employ a licensed administrator, lacked a DON and IP, and did not provide therapy services between February 5, 2024, and March 22, 2024. Additionally, the facility did not document evidence for plans of correction or report to the QAPI committee, and failed to implement adequate PPE during a COVID outbreak.
The facility failed to have a designated Infection Preventionist (IP) at least part-time, affecting all 57 residents. The acting IP nurse, who lives three hours away, has had difficulty visiting weekly due to health issues. The infection control log for March 2024 was incomplete, contrary to the facility's stated adherence to CDC best practices.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse, resulting in one resident sustaining a fractured nose after being struck by his roommate. Both residents involved had significant medical and psychiatric histories, including paranoid schizophrenia, mild intellectual disability, bipolar disorder, diabetes, seizures, and depression. The incident occurred following a disagreement over the room's thermostat settings, escalating to physical violence when one resident punched the other on the bridge of the nose. The injured resident required hospital transfer and was diagnosed with a closed nasal fracture. Staff interviews and facility records confirmed that the altercation was witnessed shortly after it occurred, with blood observed on the injured resident and both residents providing statements about the argument and subsequent physical contact. The facility's abuse prevention policy affirms residents' rights to be free from abuse, defining physical abuse as the infliction of injury requiring medical attention. Despite this policy, the facility did not prevent the altercation, resulting in harm to a resident.
Inadequate Infection Control During Strep A Outbreak
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols during an outbreak of Group A Streptococcus (Strep A) disease. The facility did not follow the State Department of Public Health and the Local County Health Department's instructions for facility-wide testing and treatment initiation for a resident with positive test results. Additionally, the facility did not comply with the mandated facility-wide masking requirement. The facility's management was unaware of the outbreak's start date, the number of cases, and the residents involved, despite being informed of the outbreak in May 2024. The facility's infection preventionist and other staff members were not adequately informed or trained on the necessary precautions and procedures. A resident with a positive Strep A wound infection was not placed under the correct contact precautions, and the resident frequently left the facility without completing the prescribed antibiotic treatment. The facility also failed to conduct proper testing and reassessment of staff and residents, as instructed by health authorities, leading to ongoing transmission concerns. Observations revealed that staff and residents were not consistently wearing masks, despite the masking mandate. The facility's infection control policies were not effectively implemented, and there was a lack of compliance with infection control practices. The facility's prior management did not conduct accurate employee assessments or perform necessary testing, contributing to the continued outbreak and the need for mandated masking.
Unrepaired Ceiling Hazard in Resident Hallway
Penalty
Summary
The facility failed to safely repair an exposed ceiling area located outside the rooms of three residents. During environmental rounds, an open ceiling area with exposed pipes was observed above the entrance of the housekeeping room, which is situated in the resident hall directly across from the rooms of three residents. The ceiling area had a loose plastic covering with drywall debris, inadequately secured with scattered pieces of blue painter's tape. The issue originated from a pipe leak that occurred approximately three weeks prior, and despite the leak being fixed by an outside plumbing company, the ceiling remained unrepaired. The Housekeeper Supervisor confirmed the lack of available maintenance staff to address the ceiling repair, and the Administrator acknowledged being informed of the leak about a month ago. Despite requests to corporate management for repair assistance, the ceiling remained in its compromised state. The facility's maintenance documentation emphasized the importance of repairing wall or ceiling damage promptly to maintain smoke barriers, highlighting the facility's failure to adhere to its own maintenance guidelines.
Medication Administration and Competency Deficiencies
Penalty
Summary
The facility failed to ensure that a registered nurse, identified as V3, was competent in administering medications and transcribing orders, affecting four residents. Resident R3 reported that V3 did not provide the correct dosage of her medications, including lamotrigine, aripiprazole, and gabapentin, during a morning medication pass. R3 had to inform V3 of the missing medications, which were then corrected. Similarly, Resident R4 experienced issues with V3 during evening medication passes, where V3 initially provided fewer pills than prescribed. R4 had to point out the discrepancy, and V3 corrected it after being shown the list of medications by R4. Resident R8 also encountered a medication error when V3 attempted to give her a pill that did not match her usual medication regimen. R8, who was aware of her medication, refused the pill and informed V3 of the mistake, which was subsequently rectified. Additionally, Resident R7's physician order for Haldol was transcribed incorrectly by V3, leading to a potential medication error. The physician expressed dissatisfaction with the transcription error, and V3 acknowledged the mistake. The facility's documentation revealed that V3's personnel file lacked any Nurse Competency Checklists, and V3 herself confirmed she had not undergone any competency evaluations. The previous Director of Nursing expressed concerns about V3's competency and thoroughness in providing care. The current Director of Nursing stated that all nurses should complete an orientation and competency form, but V3 did not appear to have completed this process. The facility did not have a policy on nurse competencies, and the Resident Council Minutes indicated that V3 needed improvement.
Deficiency in Full-Time Director of Nursing Coverage
Penalty
Summary
The facility failed to have a Director of Nursing (DON) on a full-time basis, which has the potential to affect all 60 residents residing in the facility. The deficiency was identified through observations, interviews, and record reviews. On multiple occasions, staff members confirmed the absence of a full-time DON. The facility's administrator and other staff members indicated that the previous DON resigned, and the subsequent DON only worked for a short period. Since then, the facility has relied on a Regional Director of Clinical and an Acting DON from a sister facility to cover the role, but neither was present full-time. The Acting DON, who is also the full-time DON at a sister facility, was instructed to work 20 hours at the facility in question, focusing on infection control. However, there was no structured clinical meeting to outline her job duties. The Regional Director of Clinical, who was also assisting, had personal commitments and other responsibilities, limiting her availability. The Health Department Communicable Disease Supervisor expressed concerns about the Acting DON dividing her time between two facilities, emphasizing the need for focused attention on infection control and outbreaks at the facility.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide structured activities for residents during weekends, affecting 7 out of 8 residents reviewed for activities. Observations on a Saturday revealed that residents were either in the day room or in their rooms without any activities. Several residents expressed their dissatisfaction with the lack of activities on weekends, stating that they had nothing to do and found it boring. The residents involved had various diagnoses, including anoxic brain damage, depression, paranoid schizophrenia, bipolar disorder, and major depressive disorder, with BIMS scores indicating varying levels of cognitive function. Interviews with staff members, including a CNA and the Administrator, revealed that there was an expectation for activities to be provided seven days a week. However, it was noted that if activity aides were not working on weekends, activities such as games and puzzles should have been left for residents to engage with. The facility was unable to provide a policy on activities for residents, indicating a lack of structured planning and oversight in ensuring that residents' needs for engagement and stimulation were met consistently throughout the week.
Failure to Follow Psychotropic Medication Policies and Monitoring Protocols
Penalty
Summary
The facility failed to follow physician's orders for psychotropic medication administration for a resident (R36). The facility did not adhere to its psychotropic medication policy by failing to monitor residents (R1, R14, R36) for Extrapyramidal Symptoms (EPS) due to antipsychotic medication use and did not attempt or request a Gradual Dose Reduction (GDR) of a Benzodiazepine medication for a resident (R14) who no longer exhibited anxiety behaviors. These failures resulted in R36 receiving the wrong psychotropic medications and at excessive dosages, leading to side effects of increased abnormal involuntary movements. R36's medical record showed she was receiving psychiatric care for major depression, anxiety, and insomnia. Despite being cognitively impaired and not showing mood symptoms, R36 was observed displaying abnormal movements such as rocking, lip-smacking, and repetitive tongue movements. The facility's care plan for R36 included monitoring for antipsychotic side effects and performing AIMS assessments every six months. However, the facility failed to follow these protocols, resulting in R36 receiving incorrect dosages of Aripiprazole and Quetiapine, which were not aligned with the psychiatric nurse practitioner's orders. R1 and R14 also experienced deficiencies in their care. R1, who was receiving psychiatric care for schizoaffective disorder, bipolar disorder, depression, and psychosis, was observed displaying abnormal oral movements. Despite this, the facility did not adequately monitor or report these side effects. Similarly, R14, who was receiving psychiatric care for anxiety and adjustment disorder with depressed mood, was observed to be excessively sleepy and confused. The facility did not attempt a GDR for R14's Benzodiazepine medication, despite recommendations from the pharmacy consultation report. These failures highlight significant lapses in the facility's adherence to psychotropic medication policies and monitoring protocols.
Improper Food Labeling and Storage in Facility Kitchen
Penalty
Summary
The facility failed to properly label, date, seal, and store food items in the kitchen, affecting 53 residents who receive oral nutrition and foods prepared in the facility kitchen. During a tour of the facility kitchen, several food items were found to be improperly labeled or not labeled at all, including various types of pasta, bread, tomato soup, cranberry juice, orange juice, steak, sausage patties, breaded fish patties, minestrone soup, and bread dough. These items were either missing dates of receipt, expiration dates, or both, which is a violation of the facility's policies for food storage and handling. The Dietary Manager acknowledged that expired items should be discarded to prevent accidental consumption, which could potentially make residents sick. The Dietician also confirmed that serving expired food could lead to food poisoning. The facility's policies for food storage, both dry and refrigerated/frozen, require all items to be dated upon receipt and containers to be labeled with the name of the item and the date it was opened or prepared. The failure to adhere to these policies was observed and documented during the survey, indicating a significant lapse in food safety practices within the facility.
Failure to Follow Physician's Laboratory Order for Anticonvulsant Medication
Penalty
Summary
The facility failed to follow a physician's laboratory order for the management of anticonvulsant medication for a resident with multiple diagnoses, including general convulsant epilepsy, intractable seizure disorder, encephalomalacia, and encephalitis. The resident was receiving phenobarbital, and an order was placed for a phenobarbital trough level laboratory draw. However, upon review, it was found that the lab draw had not been conducted. The Registered Nurse confirmed that the resident's medication blood levels should be monitored as ordered but was unable to find the lab result. The Director of Nursing stated that nurses are expected to follow physician lab orders. A review of the resident's lab results for the past six months showed no phenobarbital trough level. A pharmacy consultation report also indicated that the resident's medical record did not have a phenobarbital trough level within the previous six months, and a recommendation to monitor the trough concentration was accepted by the physician but not followed through. The resident's care plan included interventions such as labs as ordered and monitoring for adverse reactions and medication toxicity, but these were not adhered to.
Failure to Follow Behavior Monitoring Policy for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to follow its policy on behavior monitoring for residents with known behaviors and receiving psychotropic medications. This deficiency was observed in five residents (R1, R8, R14, R36, and R39) who had multiple diagnoses including schizoaffective disorder, bipolar disorder, depression, psychosis, autism, developmental delay, anxiety, and dementia. Despite the care plans specifying the need for behavior monitoring and documentation, the Registered Nurse (V3) admitted to not documenting behaviors for any of his assigned residents. This lack of documentation was confirmed through observations and interviews, where residents exhibited behaviors such as inappropriate sexual gestures, hallucinations, yelling, and refusing care, but these were not recorded as required by the facility's policy. The Director of Nursing (V2) and the Psychiatric Nurse Practitioner (V14) both emphasized the importance of behavior tracking for managing psychiatric services and medication effectiveness. However, the facility's social worker only sometimes provided behavior-tracking documentation sheets, and the nurses did not consistently use them. The facility's policy on the reduction of psychotropic medications, which includes the implementation of a Behavioral Tracking sheet, was not adhered to, leading to a failure in monitoring and documenting resident behaviors as mandated. This lapse in protocol compromised the ability to manage and adjust psychiatric care effectively for the residents involved.
Medication Unavailability for Residents
Penalty
Summary
The facility failed to ensure that medications were available for administration to residents with physician's orders. On multiple occasions, a registered nurse (RN) was unable to administer Ascorbic Acid 500 mg to residents due to the medication being unavailable. This issue was observed during medication passes and confirmed through interviews and record reviews. Specifically, the RN reported that Ascorbic Acid was not available in the medication cart, medication room, or the small closet where house stocks are kept. The medication had been unavailable since May 27, 2024, affecting at least five residents who had orders for Ascorbic Acid 500 mg, 1 tablet due at 8:00 AM. The Medication Administration Records (MAR) for these residents showed that the medication was marked as
Medication Administration Errors
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 10.81%. This deficiency was observed in three residents. On one occasion, a registered nurse (RN) was unable to administer Ascorbic Acid 500 mg to a resident because it was not available in the medication cart, medication room, or house stock. The RN confirmed that the medication had been unavailable since May 27, 2024. The resident's Physician Order Sheet (POS) indicated that Ascorbic Acid 500 mg was due at 8:00 AM, but it was not administered as required. In another instance, the same RN administered medications to a second resident but failed to provide Calcium 600 mg/Vitamin D3 400 mg and Ascorbic Acid 500 mg as ordered at 8:00 AM. Additionally, the RN did not administer Docusate Na 100 mg to a third resident as ordered at 8:00 AM. The facility's policy on medication administration, which includes verifying medications with the physician's orders and promptly recording the time and dose given, was not followed in these cases.
Failure to Adhere to Infection Control Protocols
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, particularly in the use of Personal Protective Equipment (PPE) in rooms requiring Enhanced Barrier Precautions (EBP). During the survey, it was observed that staff did not wear gowns and gloves while providing care to residents with open wounds, gastrostomy tubes, and catheters. For instance, a nurse and a wound doctor entered a resident's room and performed wound care without wearing gowns, despite the presence of signs indicating the need for EBP. The Director of Nursing (DON) acknowledged that staff should wear gowns and gloves for residents with wounds, gastrostomy tubes, and catheters, and noted that the staff had been recently in-serviced on this requirement. However, the staff failed to comply with these precautions during the survey observations. Additionally, the facility's policy on EBP was not consistently followed, as evidenced by the lack of appropriate signage and staff awareness of the precautions required for certain residents. The Assistant Director of Nursing (ADON) and the DON both confirmed that the staff should have known and adhered to the EBP protocols, but this was not the case during the survey. The facility's failure to implement and enforce proper infection control measures put residents at risk of infection and compromised their safety.
Failure to Utilize Standardized Tool for Antibiotic Therapy
Penalty
Summary
The facility failed to utilize a standardized tool to determine the necessity of antibiotic therapy prescribed to residents. This deficiency was identified in five residents who were prescribed various antibiotics without proper documentation or adherence to McGeer's criteria. For instance, one resident was prescribed Bactrim DS without a documented reason in the Physician Order Sheet or medication administration log. Another resident was prescribed Bacitracin and Keflex, but the infection control binder and medical records lacked the McGeer's criteria form, and the onset date for Bacitracin did not match the physician's order sheet. Similar issues were found with other residents who were prescribed Erythromycin, Doxycycline, Cefadroxil, and Augmentin, with missing or inconsistent documentation in the infection control and antimicrobial logs, and the absence of McGeer's criteria forms in their medical records. Interviews with facility staff revealed a lack of awareness and adherence to McGeer's criteria. The Director of Nursing/Infection Preventionist, who had been at the facility for only a few weeks, acknowledged that the facility should follow McGeer's criteria to ensure appropriate antibiotic use but was unsure why it was not done. The physician admitted to not following McGeer's criteria and refused to discuss it further. A registered nurse stated that they follow physician orders when signs of infection are observed but had never heard of McGeer's criteria. The facility's policy on Infection Control Surveillance and Monitoring required daily updates to the infection control log to analyze data and identify trends, but the facility could not provide an Antibiotic/Antimicrobial Stewardship Program-Mission Statement and Guidelines.
Failure to Provide Written Notices of Medicare Coverage Termination
Penalty
Summary
The facility failed to provide appropriate written notices to residents that their Medicare coverage was coming to an end. This deficiency was identified during an interview and record review, where it was found that two residents were not given the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) forms. The Business Office Manager, who was new to the position, admitted to not being aware of the requirement to provide these forms and only informed the residents verbally about their remaining Medicare days. The facility was unable to provide a policy regarding the issuance of these notices. One resident, who was cognitively intact with a BIMS score of 15, confirmed that she was not given any written notice about her Medicare coverage. Her medical record also lacked the required NOMNC and SNF-ABN forms. Another resident, who was moderately impaired in cognition with a BIMS score of 9, also confirmed that he did not receive any written notice. His medical record similarly lacked the necessary forms. The facility's failure to provide these written notices constitutes a deficiency in ensuring residents are informed about their Medicare coverage and potential liability for services not covered.
Failure to Provide Privacy During Wound Care
Penalty
Summary
The facility failed to provide privacy during pressure ulcer dressing changes for two residents. Resident R47, who has a stage 3 pressure ulcer on his right heel, had his dressing changed by an RN and a wound doctor without proper privacy measures. The door was left open, and the privacy curtain was only partially drawn, while the resident's roommate was present in the room. Additionally, the staff did not wear gowns during the procedure, which is against standard protocol for infection control and resident dignity. Similarly, Resident R50, who has a stage 4 pressure ulcer on his left heel, experienced a dressing change with the blinds open, allowing visibility from outside the facility. The RN and wound doctor did not wear gowns during the procedure, and the wound doctor applied pain medication and debrided the wound without ensuring the resident's privacy. The Director of Nursing acknowledged that privacy measures, such as closing doors and blinds, should be followed during such procedures. The facility's policy on AM care also emphasizes the importance of providing privacy by pulling window curtains and privacy curtains.
Failure to Maintain Resident's Oral Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for one resident (R11) who was unable to perform activities of daily living. On multiple occasions, R11 was observed with a crusty mouth, dry lips, and a very strong foul odor emanating from his mouth. Despite the CNA's (V10) efforts to provide mouth care and reporting the issue to the nurses, R11's condition persisted. The RN (V5) attributed the odor to a periodontal issue, but the DON (V2) was unaware of any such condition and attributed the foul odor to poor oral hygiene. A review of R11's medical records did not show any diagnosis related to his mouth, teeth, or gums.
Failure to Safely Transfer and Position Residents
Penalty
Summary
The facility failed to safely transfer a resident (R10) and safely position a resident (R14) when assisting with feeding in bed. R10, who has multiple diagnoses including epilepsy, hemiparesis, and degenerative joint disease, required substantial to maximal staff assistance with transfers. On the observed date, a CNA transferred R10 from the bed to a shower chair without using a gait belt and while R10 was barefoot, contrary to the resident's care plan and facility policy. The Director of Nursing confirmed that staff should use a gait belt and ensure proper footwear during transfers for safety. R14, who has diagnoses including cerebral infarction and muscle weakness, required partial to moderate staff assistance with bed mobility. During the observation, a CNA was feeding R14 in bed while R14 was in a slouched position, with his buttock lower than the bend of the bed. The Director of Nursing confirmed that residents being fed in bed should be in a safe position and not slouched. The facility did not have a policy for feeding or positioning in bed, although R14's care plan included interventions for bed mobility to maintain safety and increase independence.
Failure to Provide Prescribed Double Protein Diet
Penalty
Summary
The facility failed to monitor and ensure that a resident with orders for a double protein diet received the diet as ordered by the physician. This failure resulted in a -10.16% weight loss from November 2023 to May 2024. On 05/29/2024, the resident was observed in the dining room appearing emaciated and weak. The meal tray served to the resident did not include the double protein as prescribed. The resident's medical records showed significant weight loss over several months, and the dietary manager and cook acknowledged the oversight in meal preparation. The resident's care plan was not updated to reflect the significant weight loss and the need for double protein meals, and there was no evidence of weekly meetings or consistent monitoring of weekly weights as recommended. The facility's policies on weight committee meetings and resident weight monitoring were not followed, contributing to the resident's continued weight loss. The dietary manager and registered dietician confirmed the necessity of the double protein diet to prevent further weight loss, but the facility failed to implement and monitor this intervention effectively.
Failure to Ensure Proper Gastrostomy Tube Feeding Procedures
Penalty
Summary
The facility failed to ensure they had a supply of gastrostomy tube feeding formula for residents per order, failed to label and date gastrostomy tube feedings, and failed to follow physician's orders for feedings. This deficiency was observed in three residents. One resident with quadriplegia and dysphagia was found connected to a g-tube machine running at 70 ML/HR, but the bag was not labeled or dated. Another resident with cerebral infarction and gastrostomy status was connected to a g-tube machine running at 55 ML/HR, contrary to the physician's order of 60 ML/HR, and the bag was also not labeled or dated. The nurse admitted to using substitute feedings due to a shortage of the prescribed formula and acknowledged the need to label and date the bags. The Director of Nursing was unaware of the shortage and emphasized the importance of following doctor's orders and labeling the bags. A third resident was observed with a gastrostomy feed running at 80 ML/HR, but the bag lacked a label indicating the date, time, and quantity of the feed. The nurse confirmed that the bag should have been labeled with this information. The facility's policy requires that all tube feeding bags be labeled and replaced every 24 hours, and that physician orders be followed precisely. The Director of Nursing reiterated the necessity of labeling the bags with the resident's name, type of feed, rate, date, start time, and nurse's initials.
Improper Storage of Narcotic Medications and Inhaler
Penalty
Summary
The facility failed to store narcotic medications under double-lock and improperly stored an inhaler. During an inspection of the medication room, it was observed that the medication refrigerator was not locked, and an opened bottle of Lorazepam Concentrate 2mg/ml belonging to a resident was found inside. The RN confirmed that the refrigerator is never locked, and the ADON acknowledged that all narcotics should be double locked to prevent theft and diversion. The facility's policy on the procurement and storage of medication did not address the storage of Lorazepam. Additionally, an Albuterol inhaler was observed on a resident's bedside table, which the resident stated was used as needed for breathing difficulties. The DON confirmed that a doctor's order is required to keep medications at the bedside and that the resident did not have such an order. A review of the resident's Physician Order Sheet confirmed the absence of an order to self-medicate.
Failure to Properly Store and Monitor Resident Food Items
Penalty
Summary
The facility failed to properly store and monitor food items brought in by residents' families or visitors. In one instance, a resident (R51) had several opened food items that required refrigeration, such as ranch dip, Miracle Whip, and mustard, stored on top of his dresser without a refrigerator in the room. These items were observed on two separate occasions, indicating that they were not being properly stored. Additionally, a loaf of bread with an expired best-by date was also found in the room. The resident was not available for an interview during the surveyor's visits. In another instance, a resident (R28) had a refrigerator in his room containing various food items, including mayonnaise, peppers, butter, and potato salad with expired sell-by dates. The refrigerator lacked a thermometer, and there was no temperature log maintained. The resident confirmed that staff never checked his refrigerator. The facility's policies require that all resident refrigerators have thermometers and temperature logs, and that housekeeping staff or a designee monitor and document refrigerator temperatures daily. However, these procedures were not followed, as confirmed by the Administrator and the Assistant Director of Nursing.
Failure to Provide Timely Physical Therapy Services
Penalty
Summary
The facility failed to obtain orders and provide physical therapy services to residents, resulting in a delay in care and functional decline. Resident R103, who had multiple diagnoses including hypertensive heart disease and dementia, was admitted to the facility and initially could walk independently. However, in February, R103 suddenly stopped walking and was sent to the hospital. Upon readmission, the facility did not obtain an order for physical therapy, and R103 did not start receiving therapy until nearly a month later, leading to a prolonged recovery period. The delay was attributed to the facility not having a therapy company to provide services at that time. Resident R102, with diagnoses including chronic obstructive pulmonary disease and anxiety, was also affected by the lack of therapy services. R102 had been receiving physical therapy but went a month without it when the previous therapy company stopped services. The facility did not send R102 to an outside company for therapy, resulting in a gap in care until the new therapy company started. This interruption in therapy services was not documented as being due to R102 meeting her highest practicable level of function. Similarly, Resident R101, who had chronic kidney disease and dementia, experienced a disruption in physical therapy services. R101 required maximal assistance for mobility and had a physician order for physical therapy five times a week. However, there was no documentation of therapy services being provided between February and March, and the physician confirmed that therapy should not have been stopped. The facility's failure to provide continuous therapy services was due to the absence of a therapy company, leading to a delay in care for R101 as well.
Facility Lacks Full-Time Director of Nursing
Penalty
Summary
The facility failed to have a full-time Director of Nursing (DON) on duty, affecting all 57 residents. The Facility Data Sheet dated April 17, 2024, showed no DON or Assistant Director of Nursing (ADON) listed. Observations on April 17, 18, 22, and 23, 2024, confirmed the absence of a DON. Interviews with the Interim Business Office Manager and the Administrator revealed that the facility has been without a DON since April 3, 2024, and no interim DON has been appointed. Additionally, the facility does not have a waiver from the Illinois Department of Public Health to waive the staffing requirement for a full-time DON. Nurses at the facility expressed difficulties due to the lack of a DON. One RN mentioned that the absence of a DON has resulted in less support during situations when a resident experiences a change in condition. Another RN stated that without a DON, there is no clinical management person to consult when a resident has an Activities of Daily Living (ADL) decline. The Facility Assessment Tool dated March 7, 2024, indicated that the staffing plan included one DON and one ADON, but these positions were not filled at the time of the survey.
Failure to Employ Licensed Administrator and Provide Therapy Services
Penalty
Summary
The facility failed to employ a licensed administrator to ensure the facility could meet resident needs. The administrator, V1, held a temporary nursing home administrator license for a different facility and did not have the necessary documentation to work at the current facility. Additionally, the facility lacked a Director of Nursing (DON) and an Infection Preventionist (IP), with the Regional Director of Clinical Operations, V9, attempting to fill the IP role despite living three hours away and having health issues that limited her availability. The facility also failed to provide therapy services to residents between February 5, 2024, and March 22, 2024, when transitioning between rehab companies, leaving residents without necessary rehab services during this period. The facility administration failed to document evidence for plans of correction and evidence of reporting to the Quality Assurance Performance Improvement (QAPI) committee. Specifically, there was no evidence that medication counts were reviewed daily for three months as mandated by the facility's plan of correction related to missing narcotic medication. The facility's plan required the Director of Nursing or designee and QA to review medication counts daily for one month and for the next three months through the QA process, but this was not documented. The facility's failure to implement adequate personal protection equipment (PPE) during a COVID outbreak was also noted, further highlighting deficiencies in infection control practices.
Lack of Designated Infection Preventionist
Penalty
Summary
The facility failed to have a designated Infection Preventionist (IP) at least part-time, affecting all 57 residents. The Regional Director of Clinical Operations, who is currently acting as the IP nurse, lives three hours away and has had difficulty visiting the facility weekly due to health issues. During her visits, she reviews and updates the infection control logs, but the log for March 2024 was found to be incomplete. The Facility Assessment Tool dated March 7, 2024, indicated that the facility follows CDC best practices and has an Infection Nurse overseeing the program, which was not the case at the time of the survey.
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 719 citations issued within 25 miles in the last 12 months — including the 11 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 South Elgin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tower Hill Healthcare Center | 0.2 mi | ★★★★★ | 9 | 0 |
| The Pearl Of Fox River Valley | 2.8 mi | ★★★★★ | 13 | 0 |
| Crescent Care Of Elgin | 2.8 mi | ★★★★★ | 5 | 0 |
| River View Rehab Center | 2.8 mi | ★★★★★ | 28 | 0 |
| Aperion Care Fox River | 2.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for South Elgin Living & Rehab Center.
100% money-back within 48 hours.
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.