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 Thrive Of Lake County during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, osteoporosis, abnormal gait, and high fall risk, who required extensive assistance for bed mobility, fell from bed while a CNA was changing an incontinent brief with the bed in an elevated position. The CNA stood on the opposite side of the bed from the direction the resident was instructed to roll and reported the resident rolled off before she could intervene. A restorative nurse later stated staff should stand on the side toward which a resident is being turned to act as a barrier. The resident was sent to the hospital, where imaging showed a fracture deformity of a toe of indeterminate age.
Unsafe Turning and Positioning During Incontinence Care: A resident with morbid obesity, cognitive impairment, limited lower-extremity ROM, and a history of falls was being turned for incontinence care when she slid toward the edge of the bed and fell to the floor. The CNA attempted to stop the slide with the draw sheet but could not prevent the fall; staff later described the resident as heavy and a two-assist for turning in bed.
A resident with severe cognitive impairment did not receive a lidocaine patch as ordered, with conflicting documentation and observation regarding its application and removal. Additionally, a nurse pre-poured medications for five residents into cups ahead of scheduled administration times, contrary to facility policy, increasing the risk of medication errors.
A resident with multiple medical conditions was found to have a new left hip fracture requiring surgery after being sent to the hospital. The DON assumed the fracture was old without confirming with hospital staff, did not interview all relevant staff or therapists, and the facility's incident report inaccurately described the injury. The facility did not follow its own abuse investigation policy, which requires interviewing all staff present during the period in question.
A resident's overpayment resulting from a change in Medicaid liability was not refunded in a timely manner. Despite the facility's policy requiring prompt processing, the refund process was not completed, and the resident's family did not receive the identified overpayment for nearly two years.
A resident with a history of falls and cognitive impairment fell and sustained pelvic fractures due to inadequate supervision in the dining room. The LPN and CNAs were occupied with other tasks, leaving the resident unsupervised despite her high fall risk. The fall was unwitnessed, and the resident's care plan had identified her as needing close monitoring.
A resident experienced unrelieved pain and sleep disturbances for three days due to the facility's failure to provide her prescribed muscle relaxer, tizanidine, despite multiple requests. The medication was eventually received and administered after a delay, with discrepancies noted between the resident's account and medication administration records. Staff interviews revealed issues with medication reordering and dispensing, contrary to the facility's policies on pain management.
The facility failed to properly store food items and maintain sanitary conditions in the kitchen, affecting all residents. Thickener was left uncovered, and sanitization levels were inadequate, increasing the risk of contamination. A cook was observed using contaminated gloves without changing them or performing hand hygiene, leading to potential cross-contamination. The facility lacked specific policies for glove use and hand hygiene in the kitchen.
The facility failed to serve food at an appetizing temperature, as meals were often delayed and served cold, leading to resident complaints. The Dietary Manager was aware of the issue but had not attended Resident Council meetings to address it. Logistical issues with food carts were cited as a reason for the lack of insulated covers on trays. CNAs, responsible for distributing trays, often had to reheat food, impacting their ability to provide other resident care.
The facility failed to implement proper infection control measures, including incorrect isolation signage for a resident with MRSA, inadequate PPE use by staff during high-contact care for residents under enhanced barrier precautions, and improper glove use during pericare. These deficiencies were confirmed by the facility's infection control staff.
A resident with severe cognitive impairment and other medical conditions was not provided with appropriate toileting assistance, as a CNA instructed her to relieve herself in her brief instead of offering a bedpan. The facility's policy emphasizes maintaining residents' dignity, which was not upheld in this instance.
A resident with severe cognitive impairment and hemiplegia was not safely transferred using a mechanical lift, as only one staff member was actively involved in the process, contrary to the facility's policy requiring two staff members. This deficiency was observed during a survey, highlighting a failure to adhere to safety protocols.
A resident with multiple health conditions, including severe malnutrition and chronic kidney disease, did not receive timely PICC line dressing changes and measurements as required. The facility's records showed the last dressing change was on 2/28, but by 3/13, the dressing was not intact and lacked a date or signature. The facility's policy mandates weekly dressing changes and proper labeling, which were not followed, as confirmed by the DON.
A facility was found to have a 6% medication error rate during a medication pass involving two residents. An LPN administered an incorrect dose of Zinc to a resident and failed to provide a prescribed Thiamine tablet. The facility lacked the prescribed Zinc 220 mg capsules, and there was no documentation of the discrepancy or communication with the provider. The DON confirmed that nurses should follow physician orders and document any issues.
A facility failed to complete prescribed treatments for a resident with an unstageable sacral pressure ulcer. The resident's treatment orders were changed to include cleansing with normal saline and applying Iodosorb/Calcium alginate and foam dressing three times a week. However, the Treatment Administration Record showed that 2 out of 11 treatments were not documented as completed. The wound nurse confirmed that treatments should be changed as ordered and documented.
A facility failed to notify a resident's POA about the initiation of treatment for a pressure injury. The resident was admitted with a pressure injury, and treatment orders were obtained the following day. However, the POA was not informed until the resident was in the emergency room. The facility's policy did not specify the need to notify a POA, contributing to the communication lapse.
Resident Falls From Bed During Incontinent Care Due to Improper Positioning and Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe provision of care and adequate supervision to prevent an accident for one resident identified as high risk for falls. The resident had Alzheimer’s disease, osteoarthritis, osteoporosis, abnormal gait and mobility, cognitive deficit, incontinence, and required extensive assistance for bed mobility. A fall risk evaluation completed on 12/9/25 identified the resident as high risk for falls. On 3/15/26 at 7:00 PM, while a CNA was changing the resident’s incontinent brief, the resident slid or rolled off the side of the bed and fell to the floor. The CNA reported that the bed was elevated to facilitate care, the brief was partially undone, and the resident was instructed to roll to the right side and grab the bed bar, at which point the resident rolled off the bed. The CNA stated she was positioned on the resident’s left side and did not have time to grab the resident as she fell to the right side. The LPN’s incident report and interview confirmed that only one staff member was present during the turning and changing, and that the resident fell off the right side of the bed while the CNA was working on the left side and pulling on lumpy sheets. The restorative nurse stated that staff should stand on the side of the bed toward which the resident is being turned to act as a barrier and help prevent rolling off the bed, and indicated that in this case the CNA should have been on the right side of the bed when the resident was turning. The resident’s daughter reported being told that the CNA pulled the sheet and the resident rolled off the bed, and stated that the CNA should have been standing in front of the resident rather than behind her. The resident was sent to the hospital for evaluation, and an X-ray of the left foot showed a fracture deformity of the second proximal phalanx of indeterminate age, with the physician unable to definitively link the fracture to this fall. The facility’s fall prevention policy states that each resident will receive services and care to ensure the environment remains as free from accident hazards as possible.
Unsafe Turning and Positioning During Incontinence Care
Penalty
Summary
The facility failed to ensure a resident was safely turned and positioned during incontinence care. The resident had diagnoses including type 2 diabetes, morbid obesity, a cardiac pacemaker, hypertension, polyneuropathy, restless and agitation, and a history of falling. Her MDS showed impaired functional range of motion in one lower extremity, moderate cognitive impairment, and dependence on staff for toileting hygiene and for rolling left and right. Her care plan identified ADL deficits, limitations in physical mobility, resistance to care, and high fall risk due to debility and need for assistance with ADLs. During incontinence care, a CNA had the resident turned on her side in bed when the resident began sliding toward the edge of the bed. The CNA told the resident not to move, attempted to stop the slide by grabbing the draw sheet, and then guided the resident down to the floor when she could not prevent the fall. The resident landed on her left side and later reported that she was being rolled onto her right side when she fell out of bed onto her knees. Staff interviews described the resident as heavy and a two-assist for turning in bed, and the CNA stated that two people in the room would have prevented the fall.
Failure to Administer and Store Medications According to Physician Orders and Facility Policy
Penalty
Summary
The facility failed to administer medication as ordered by a physician for one resident and did not ensure medications were stored in their original packaging prior to administration for five other residents. One resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, was found with a lidocaine patch stuck to her bed linens, dated from the previous day. The nurse responsible had not yet applied the new patch as scheduled, despite documentation indicating otherwise. The medication administration record specified the patch should be applied in the morning and removed at night, but this was not followed, and the nurse's statements conflicted with the documented times. Additionally, during a medication pass, a registered nurse was found to have pre-poured medications for five residents into cups labeled with room numbers, storing them in the medication cart drawer. The nurse stated this was done to expedite the medication pass due to a high resident load. The medications in the cups were scheduled for administration at later times, and the Director of Nursing confirmed that pre-pouring medications is against policy as it could lead to medication errors. Facility policy requires medications to be prepared and administered immediately, with proper documentation at each step, which was not adhered to in these instances.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident who was readmitted with multiple diagnoses, including acute respiratory failure, kidney failure, hypertension, and diabetes. The resident was sent to the hospital after refusing food and fluids and was found to have a new left femoral neck fracture, which required surgical intervention. The resident's family requested an investigation into the cause of the fracture, as there was no documentation of a fall or incident at the facility, and it was unclear if the injury occurred during care or another activity. The Director of Nursing (DON) assumed the fracture was old, referencing a four-year-old record of a different fracture, and did not contact hospital staff to clarify the nature of the injury. The DON also did not interview all staff or therapists who had cared for the resident during the relevant period. The facility's incident report inaccurately described the fracture as old, despite hospital records indicating it was new. The facility's abuse investigation policy requires interviews with all staff present during the period of the allegation, but this was not followed.
Failure to Timely Refund Resident Overpayment Due to Billing Error
Penalty
Summary
The facility failed to accurately bill and issue a timely refund for an overpayment to a resident who was under hospice Medicaid coverage from the beginning of 2023 until her passing in mid-2024. The resident's spouse experienced a financial change in 2023, which altered the Medicaid payment and the spouse's liability for the resident's bill. Despite this change, the facility continued to bill the spouse the same amount, resulting in an overpayment. Documentation in the resident's electronic medical record indicated that a business office employee identified the issue and began the process to correct the payment and initiate a refund, but there was no evidence that the process was completed or that the refund was issued. Interviews with facility staff revealed that the overpayment was recognized, and the refund amount was identified as $9,290.10. However, the process to issue the refund was not followed through, and the resident's power of attorney and family had not received the refund despite repeated attempts to resolve the matter, including involving an attorney. The facility's own policy required refunds to be processed and released within 10 business days, but this was not adhered to, resulting in a delay of nearly two years.
Resident Falls Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, resulting in the resident falling and sustaining fractures to her pelvis. On the day of the incident, the resident, who was known to frequently attempt to get up from her wheelchair, was left unsupervised in the dining room. The Licensed Practical Nurse (LPN) and Certified Nursing Assistants (CNAs) were occupied with other tasks, leaving the resident without the necessary one-on-one monitoring. The resident's fall was unwitnessed, and she was unable to describe the event due to her cognitive impairment. The resident had a history of falls and was identified as a high risk for falls due to impaired cognition and poor safety awareness. Her care plan highlighted her diagnoses, including vascular dementia and osteoporosis, which contributed to her fall risk. Despite these known risks, the facility's staff did not provide the required supervision, as outlined in the facility's fall prevention policy. The incident was reported by a hospice nurse who was present in the unit, and subsequent medical evaluations confirmed the resident sustained acute fractures from the fall.
Failure in Pain Management for Resident
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as R133, who experienced unrelieved pain and was unable to obtain restful sleep for three days. The resident reported not receiving her prescribed muscle relaxer, tizanidine, from the 8th to the 10th of March, despite requesting it multiple times. The staff informed her that the medication was ordered and would follow up with the pharmacy, but no follow-up was communicated to the resident. The medication was eventually received on the night of the 10th, and the resident was administered the medication on the morning of the 11th. The medication administration records for January, February, and March 2025 showed inconsistencies with the resident's account, as they indicated that tizanidine was administered on the 8th and 9th of March. However, the resident disputed this, stating she did not receive the medication during those days. Pain assessments during this period documented varying pain levels, with a peak pain level of 8 on the 10th of March. The resident's care plan included interventions to anticipate and respond immediately to any complaint of pain, which were not effectively implemented. Interviews with staff revealed that the medication was reordered on the 4th of March, but the facility's automated medication dispensing system did not include tizanidine. The Director of Nursing expected staff to reorder medications when a week's supply remained and to use the dispensing system if a medication was unavailable. The facility's policies on medication administration and pain management emphasized the importance of timely and effective pain management, which was not adhered to in this case.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and handling of food items, as well as maintaining sanitary conditions in the kitchen, which affected all residents. During a kitchen tour, it was observed that a pitcher containing thickener was left uncovered, and a large box of thickener in the dry storage room was also left open, exposing the contents to potential contamination. The Dietary Manager acknowledged that the thickener should be covered to prevent cross-contamination, yet the issue persisted throughout the day. Additionally, the facility did not maintain proper sanitization levels in the food preparation area. A red bucket used for sanitizing was found with dingy water and a stained rag, and when tested, the sanitization level was inadequate. The Dietary Manager confirmed that the sanitizing solution was not effective, which could increase the risk of foodborne illness. The facility's policy required proper sanitization to prevent outbreaks, but this was not adhered to during the survey. Furthermore, a cook was observed handling food with contaminated gloves, failing to change them or perform hand hygiene after touching his clothing. The cook continued to prepare meals and handle clean utensils with the same gloves, leading to potential cross-contamination. The facility lacked a specific policy for glove use and hand hygiene in the kitchen, and the existing handwashing policy did not adequately address the observed deficiencies.
Failure to Serve Food at Appetizing Temperature
Penalty
Summary
The facility failed to serve food at an appetizing temperature to residents, as observed during a survey. Residents reported that meals were often served late, with dinner being delayed by an hour on some occasions, resulting in cold food. This issue was a recurring complaint in Resident Council meetings, yet the Dietary Manager had not attended these meetings to address the concerns. The Dietary Manager admitted to being aware of the complaints but cited logistical issues with the current food carts as a reason for the lack of insulated covers on some trays. The facility had ordered new carts to resolve this issue, but they had not yet arrived. During the survey, it was observed that the process of preparing and delivering meals was disorganized and slow, with the final plate being prepared over an hour after the first. The CNAs were responsible for distributing the trays to residents, but they reported not having enough time to do so promptly, often needing to reheat food in microwaves. This task took away from their other resident care duties. The dietary staff did not assist in passing trays, and the lack of insulated covers on some trays contributed to the food being served cold, leading to daily complaints from residents.
Infection Control Deficiencies in PPE Use and Isolation Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place for several residents. For one resident, identified as R465, the facility did not post the correct isolation precautions. Initially, an enhanced barrier precautions (EBP) sign was posted, which was later changed to contact isolation, as the resident had a serious MRSA infection and surgical wounds. The error was acknowledged by the Director of Nurses/Infection Control Preventionist, who confirmed that contact isolation was necessary due to the severity of the infection. In another instance, two staff members, a Licensed Practical Nurse (LPN) and a Certified Nurse Aide (CNA), failed to wear gowns while providing care to a resident under enhanced barrier precautions. The resident, R157, had a history of infections and required gowns and gloves during high-contact care activities. Despite the posted precautions, the staff only wore gloves, which was against the facility's policy for EBP, as confirmed by the Director of Nurses/Infection Control Preventionist. Additionally, a Licensed Practical Nurse (LPN) did not adhere to the enhanced barrier precautions while providing g-tube care to another resident, R16. The LPN wore gloves but failed to don a gown, which was required due to the potential for contamination during the procedure. The Assistant Director of Nursing/Infection Control Nurse confirmed that the failure to wear a gown could lead to cross-contamination. Furthermore, a Certified Nursing Assistant (CNA) did not change gloves or perform hand hygiene appropriately during pericare for resident R80, leading to potential cross-contamination. The facility's policies on glove use and handwashing were not followed, as confirmed by the Assistant Director of Nursing.
Failure to Maintain Resident Dignity During Personal Care
Penalty
Summary
The facility failed to maintain a resident's dignity during personal care, specifically for a resident with severe cognitive impairment, dementia, hemiplegia, and chronic pain, who was dependent on staff for toileting. On March 11, 2025, the resident expressed the need to use the bathroom, and a CNA along with a social services staff member assisted her into bed using a mechanical lift. Instead of providing a bedpan or assisting the resident to the toilet, the CNA instructed the resident to relieve herself in her brief, promising to clean her up afterward. The resident was later heard calling for help. The CNA admitted uncertainty about the availability of bedpans on the unit and acknowledged the resident's need for a bowel movement. The Assistant Director of Nursing and the Director of Nursing both confirmed that residents should be offered a bedpan if they cannot use the toilet, emphasizing the importance of maintaining residents' dignity. The facility's policy on dignity, dated November 2011, states that care should be provided in a manner that maintains and enhances each resident's dignity and respect.
Failure to Safely Transfer Resident Using Mechanical Lift
Penalty
Summary
The facility failed to transfer a resident safely, which was observed during a survey. The resident, identified as R66, has severe cognitive impairment, dementia, hemiplegia, and chronic pain, and is dependent on staff for transfers. On the day of the incident, R66 requested to go to the bathroom, and a CNA and a Social Services staff member were involved in transferring her using a mechanical lift. However, the Social Services staff member was not near the resident during the transfer, contrary to the facility's policy requiring two staff members to be present and actively involved in the transfer process. Interviews with various staff members, including the Assistant Director of Nursing, a Restorative Nurse, and the Director of Nursing, confirmed that the facility's policy mandates two staff members to be present during mechanical lift transfers for safety reasons. The care plan for R66 also specifies that two staff members should assist with mechanical lift transfers. Despite this, the Social Services staff member was not actively involved in guiding the resident during the transfer, which is a deviation from the established protocol and contributed to the deficiency.
Failure to Maintain PICC Line Dressing and Measurement
Penalty
Summary
The facility failed to ensure the proper administration and maintenance of a PICC line for a resident, identified as R15, who was part of a sample of 32 residents reviewed for PICC line care. R15 had multiple diagnoses, including severe protein-calorie malnutrition, Guillain-Barre Syndrome, and chronic kidney disease, and required TPN for nutrition and hydration. The facility's records indicated that the dressing for R15's PICC line was supposed to be changed every seven days, with the last recorded change on 2/28/25. However, during an observation on 3/13/25, it was found that the dressing was not intact, and there was no date or signature on it, indicating it had not been changed as required. Further investigation revealed that the facility's Treatment Administration Record (TAR) showed the dressing change and measurement of the external catheter length were due on 3/7/25, but no nurse had signed off on completing these tasks. The facility's policy required that PICC line dressings be changed weekly or when the dressing becomes moist, loosened, or soiled, and that the dressing be labeled with the date of change and the initials of the nurse. The Director of Nursing confirmed the importance of these procedures for infection control and proper PICC line placement, highlighting the facility's failure to adhere to its own policies and procedures.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility was found to have a medication error rate of 6%, exceeding the acceptable threshold of 5%. This was observed during a medication pass involving two residents, where one resident, identified as R264, did not receive their prescribed Thiamine 100 mg tablet. Additionally, the resident was administered an incorrect dose of Zinc, receiving 225 mg instead of the prescribed 220 mg. The LPN responsible for the medication pass, V7, failed to locate the correct Zinc dosage and did not check the medication room or consult a nursing manager for the correct medication. Instead, V7 improvised by administering four 50 mg tablets and half of a fifth tablet, resulting in an incorrect total dosage. Further investigation revealed that the facility did not have the prescribed Zinc 220 mg capsules in stock, and there was no documentation in the resident's progress notes regarding the medication discrepancy or any communication with the provider to address the issue. The Director of Nursing (DON) confirmed that nurses are expected to follow physician orders and document any deviations or issues in the progress notes. The facility's policy requires that any discrepancies between the Medication Administration Record (MAR) and the medication label be checked against orders before administration, and any unadministered medication should be recorded with a reason and the physician notified.
Failure to Complete Prescribed Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that treatments were completed as prescribed for a resident with an unstageable sacral pressure ulcer. The resident's wound physician progress note documented a reopened unstageable pressure ulcer with 100% necrotic eschar tissue. Treatment orders were changed to cleanse with normal saline and apply Iodosorb/Calcium alginate and foam dressing three times a week and as needed. However, the Treatment Administration Record (T.A.R.) showed that 2 out of 11 treatments were not documented as completed. The wound nurse confirmed that treatments should be changed as ordered and documented on the T.A.R. The facility's wound policy states that any resident with a wound should receive treatment and services consistent with their goals of treatment.
Failure to Notify POA of Pressure Injury Treatment
Penalty
Summary
The facility failed to immediately notify the power of attorney (POA) for a resident regarding the initiation of treatment for a pressure injury. The resident, identified as R1, was admitted to the facility with a pressure injury on the coccyx, which was noted as present on admission. The wound care nurse, V4, assessed the resident on the day following admission and obtained treatment orders for the pressure injury. However, V4 did not inform the POA, V5, about these treatment orders. V5 only became aware of the pressure injury and its treatment when the resident was in the emergency room several days later. The facility's policy on change in resident condition did not specify the requirement to notify a POA, which contributed to the communication lapse. Despite a care conference held three days after the treatment orders were obtained, where V5 participated, there was no clear documentation or recollection of informing V5 about the wound care. The registered nurse, V8, acknowledged that new wound care treatment orders should be treated as a change in condition, necessitating immediate notification of the POA, which was not done in this case.
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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.
Illustrative
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Illustrative
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Nursing homes near Mundelein
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Libertyville | 2.8 mi | ★★★★★ | 3 | 1 |
| Avantara Lake Zurich | 3.7 mi | ★★★★★ | 1 | 0 |
| Serenity Estates Of Lincolnshire | 3.8 mi | ★★★★★ | 17 | 2 |
| Alden Long Grove Rehab &hc Ctr | 4.7 mi | ★★★★★ | 10 | 2 |
| Libertyville Manor Ext Care | 5 mi | — | 0 | 0 |
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