Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 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.
Failure to Complete Required PASRR Level 2 Assessments: The facility did not ensure required Level 2 PASRRs were completed for multiple residents with mental health diagnoses, including residents on locked units and a resident whose PASRR Level I showed major depression and anxiety with a need for re-screening if the stay extended beyond the initial authorization. The DON/Admission Director stated several residents did not have Level 2 PASRRs, and one resident never had a repeat PASRR I or initial PASRR II completed.
Failure to Properly Explain Arbitration Agreements: The facility did not inform 4 of 4 reviewed residents or their representatives that signing an arbitration agreement was not required for admission or continued care, and did not explain the agreement in a way they could understand. Two residents had moderate cognitive impairment, one resident on the dementia unit later said she did not know what an arbitration agreement was, and another resident stated he did not understand the term and spoke a primary language other than English. A staff member said she briefly described the form as a litigation question and did not provide any other details.
A resident’s PRN psychotropic medication lacked a stop date. The resident was observed calm and relaxed on a locked unit, and the RN stated a stop date ensures the resident is re-evaluated by the physician for continued need. The MAR showed no documented behaviors during the review period, yet the lorazepam order remained indefinite.
A resident’s PASARR I screening was not current or accurate after the resident later had diagnoses of major depression, unspecified psychosis, and schizophrenia. The Director of Admission stated PASARR I screening should be completed before admission and that a PASARR II should be ordered when a resident has a serious mental illness diagnosis. The Administrator stated the facility did not have a PASARR policy.
Failure to provide nail care and hand hygiene for a resident with hemiplegia and ADL dependence. A resident who needed help with personal hygiene was observed with long, jagged, thickened fingernails and stained cuticles/undersides of the nails on repeated observations, despite a care plan directing nail care as needed and a facility policy stating nail care would be provided as needed.
The facility failed to ensure two residents with limited ROM had ordered orthotics in place for contracture management. One resident with a left-hand contracture was observed without the ordered hand splint, and the resident said it no longer fit and had not been worn for months. Another resident with hemiplegia and bilateral ankle contractures was repeatedly observed without ankle braces, with the braces stored in the wardrobe and no documented refusals despite staff stating the resident often declined to wear them.
Unsafe transfer and fall prevention failures: A resident assessed as high fall risk was lowered to the floor during a shower-to-bed transfer when the CNA could not maintain hold, despite a care plan requiring total x2 assist for transfers. Two other high-risk residents had fall interventions not in place as documented, including fall mats standing upright or moved away from the bed and a bed not kept in the lowest position.
Failure to Provide Ordered Nutritional Supplement: A resident with dementia and a history of significant weight loss continued to lose weight after Influenza A and was ordered a daily nutritional supplement at lunch. During observations, the supplement was not on the resident’s tray in the dining room or when lunch was served in her room, and staff did not provide encouragement or assistance while she ate very little of her meals.
A resident with a G-tube, NPO status, severe cognitive impairment, and quadriplegia received continuous Jevity 1.5 at 90 ml/hr instead of the ordered 70 ml/hr on two observed occasions. The care plan, physician order, and dietary note all directed staff to administer the enteral feeding at the prescribed rate, and the facility's tube feeding policy required the pump to be set to the ordered rate.
A resident receiving TPN through a PICC line had a soiled dressing that had not been changed for about 2 weeks. The RN confirmed PICC dressings are changed weekly, and the DON stated they should be changed weekly and as needed to keep the site clean, dry, and intact. Facility policy required central line dressing changes at least weekly or sooner if moist, loosened, or soiled.
Unlabeled opened meds and unsecured inhaler: An RN found an opened insulin pen and an opened inhaler on a med cart without open dates, and stated these items should be dated when opened. A resident’s Advair inhaler was also left on the bedside table even though the resident had only been assessed to self-administer vitamins, nasal spray, and eye drops, with no documentation allowing inhaler self-administration.
A resident ordered a pureed diet was served the noon meal with a regular dinner roll instead of the required pureed roll. The resident’s order sheet and meal ticket both showed a pureed diet, and the diet spreadsheet specified a pureed roll for that meal. During tray delivery, the regular roll remained on the tray, and a CNA began unwrapping it while serving the meal. The Dietary Mgr stated the kitchen should have served the diet type listed on the meal ticket.
Failure to Use Required PPE for EBP Resident Care: A CNA entered a resident’s room on EBP without donning a gown while providing high-contact care. The resident had a urinary catheter and a history of E. coli, and the room had an EBP sign and PPE cart available. The CNA later acknowledged she should have worn a gown, and the LPN and DON confirmed that gown and gloves are required for close contact and high-contact care such as hygiene and changing clothes.
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.
Failure to Complete Required PASRR Level 2 Assessments
Penalty
Summary
The facility failed to ensure that residents who needed a Level 2 PASRR assessment received one for 4 of 8 residents reviewed for Pre-admission Screening and Resident Review. R52 was observed on a locked unit, and the admission director stated that R52 did not have a Level 2 PASARR. R52’s record showed admission with a diagnosis of depression, and later diagnoses of restlessness/agitation, anxiety disorder, and insomnia; the PASARR dated April 25, 2023 indicated no Level 2 was required because there was no severe mental illness. R130 was also observed on a locked unit, and the admission director stated that R130 did not have a Level 2 PASARR. R130’s record showed admission with a diagnosis of anxiety disorder, and the PASARR dated 4/24/25 indicated no Level 2 was required because there was no severe mental illness. R134 was observed on a locked unit, and the admission director stated that R134 did not have a Level 2 PASARR. R134’s record showed multiple diagnoses, including psychosis on 02/27/2017, but the PASARR dated 11/20/25 indicated no Level 2 was required because there was no severe mental illness. R97’s electronic record showed admission to the facility, and the PASARR Level I screening report dated 7/18/22 showed mental health diagnoses including major depression and anxiety, with authorization for a 30 day or less stay and a requirement for re-screening by or before the 30th day if the resident remained beyond that timeframe. The Director of Admission stated that PASARR I screening should be completed before admission, that a PASARR II should be ordered and completed as soon as possible if needed, and that a repeat PASARR I and initial PASARR II were never completed for R97. The Administrator stated the facility did not have a policy on PASARR screenings.
Failure to Properly Explain Arbitration Agreements
Penalty
Summary
The facility failed to inform residents or their representatives of the right not to sign a binding arbitration agreement as a condition of admission or continued care, and failed to explain the agreement in a manner they could understand, including in a language they understood, for 4 of 4 residents reviewed. R25 was admitted to the dementia unit, had a Brief Interview for Mental Status showing a memory problem and moderate impairment in decision-making, and her arbitration contract was signed by her; however, when interviewed later she stated she did not know what an arbitration agreement was and said she never agreed to arbitration. R83 was also moderately cognitively impaired, had an arbitration contract signed by himself, and later stated he did not know what arbitration meant and that his primary language is Tajlogy (Philippines).
PRN Psychotropic Medication Lacked Stop Date
Penalty
Summary
The facility failed to ensure that R18’s as-needed psychoactive medication had a stop date for 1 of 5 residents reviewed for chemical restraints. On 06/08/2026 and 06/09/2026, R18 was observed on a locked unit sitting in a wheelchair, calm and relaxed. On 06/10/2026, an RN stated that a stop date on the medication ensures the resident is re-evaluated by the physician for the continued need of the medication. R18’s physician order for lorazepam oral concentrate, 2 mg/mL, 0.25 mL by mouth every 4 hours as needed for restlessness or agitation, had a start date of 02/03/2026 and an indefinite end date. R18’s Medication Administration Record for 06/01/2026 through 06/30/2026 showed no documented behaviors from 06/01/2026 through 06/08/2026.
Failure to Complete Current PASARR Screening for Resident With Serious Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure a current and accurate PASARR I screening was completed for one resident, R13, who was reviewed for PASARR I screenings. R13’s admission record showed diagnoses of major depression, unspecified psychosis, and schizophrenia, but the resident’s PASARR I screening dated 11/17/2018 indicated no serious mental health diagnoses at that time. The Director of Admission stated that PASARR I screening should be completed on all residents prior to admission and that a resident with a serious mental illness diagnosis should have a PASARR II screening ordered and completed as soon as possible. The Administrator stated the facility did not have a policy on PASARR screenings.
Failure to Provide Nail Care and Hand Hygiene
Penalty
Summary
The facility failed to provide hand hygiene and nail care for one resident who was unable to perform activities of daily living independently. R14’s facility assessment showed diagnoses including hemiplegia affecting the left side and indicated the resident needed assistance with personal hygiene and had no behaviors of refusing care. During observation, R14 was found in bed with the right hand fingernails approximately a half inch long and the cuticles stained brown with brown and tan stains under the nails; the left hand fingernails were half to three-fourths inch long, jagged, and had significant thickening. R14 stated she did everything with her right hand because she could not move her left hand. On a later observation, R14 was again in bed and the nails were in the same condition. The care plan directed staff to provide nail care as needed, and the DON stated resident fingernails should be clean and maintained. The facility ADL policy stated nail care would be provided as needed and that CNAs or nursing could reduce fingernails.
Failure to Use Ordered Splints and Braces for Residents With Contractures
Penalty
Summary
The facility failed to ensure residents with limited range of motion had orthotics in place for treatment of and/or prevention of contractures for 2 of 12 residents reviewed for range of motion/restorative services. One resident had a care plan and restorative assessment showing a left-hand splint was required for contracture management, with instructions to wear it at night and remove it during the day. During observations, the resident was seated in a wheelchair without the splint, and all fingers except the thumb were contracted into the palm of the left hand. The resident stated the splint no longer fit because the fingers had become so bent, and said it had not been worn for months. The restorative nurse stated the splint was needed to prevent the contractures from worsening but had not assessed whether it still fit during the restorative assessment. A second resident had diagnoses including left-sided hemiplegia and bilateral ankle contractures, with an order for bilateral ankle brace skin checks before and after use every shift as tolerated in bed. Observations showed the resident in bed without ankle braces, with feet pointing toward the end of the bed and the braces stored in the wardrobe. The resident stated she did have ankle braces but did not remember the last time she wore them. Staff stated the resident often refused to wear the braces and that refusals should be documented, but the restorative history report showed no refusal entries for the prior 30 days and only one entry for wearing the braces for 15 minutes. The DON stated braces and splints should be placed as ordered and refusals documented.
Unsafe transfer and fall prevention failures
Penalty
Summary
The facility failed to transfer a resident in a safe manner. R141 was assessed as high risk for falls and had a care plan indicating total x2 assistance for transfers due to ADL self-care deficits and limited physical mobility related to heart failure and hypertension. After a shower, R141 was being transferred to bed when the CNA could not hold onto her as her knees gave out and she was lowered to the floor. R141 stated staff repeatedly told her to "just fall on your knees," and the incident report documented that she was lowered to the floor slowly with no complaints of pain or injury. The CNA stated R141 had previously been a mechanical lift transfer and needed 2 staff assist for transfers for safety. The facility also failed to ensure fall interventions were in place for residents identified as high risk for falls. R82 had diagnoses including dementia with behavioral disturbances, muscle weakness, and acquired absence of the right foot, and had repeated fall risk assessments showing high fall risk after falls. On observation, R82's fall mats were not positioned flat on the floor but were standing vertically or placed away from the bed with items on top of them, and R82 was alone in the room. R24 was also observed lying in bed with the bed frame not in the low position and the fall mat leaning against the wall by the entryway, despite the care plan calling for a floor mat and maintaining the bed at the lowest possible position while in bed.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to ensure a resident with a history of significant weight loss and ongoing insidious weight loss received a prescribed nutritional supplement. The resident’s care plan identified her as being at risk for weight loss due to prior significant weight loss and dementia. Her weights and vitals summary showed a significant weight loss after Influenza A and continued weight loss of 3.65% (4.9 pounds) over the following month. A nutrition assessment dated 2/22/26 identified increased nutritional risk secondary to weight loss, suboptimal oral intake, diuretics, labs, meds, and diagnoses, and directed that Magic Cup be added at lunch for additional nutrition. A physician order dated 2/22/26 directed that the resident receive Magic Cup every day at lunch, but during observations on 6/8/26 and 6/9/26, no Magic Cup was present on the resident’s lunch tray. On 6/8/26, the resident ate only a cup of juice, half a bowl of soup, and about 25% of lunch, while staff in the dining room did not offer encouragement to eat. On 6/9/26, the resident was served lunch in her room and again did not receive the ordered supplement; she ate only a small amount of mashed potatoes and none of the meatloaf, carrots, or brownie, and staff were not present in the room. The dietician stated the Magic Cup had been added to provide additional calories and nutrition because the resident was not eating enough, and that all residents should receive nutritional supplements as ordered.
Tube feeding administered at incorrect rate
Penalty
Summary
The facility failed to ensure a resident's enteral feeding was administered according to the physician order for 1 of 2 residents reviewed for tube feeding. The resident had a gastrostomy tube, was NPO, and received enteral feedings as the only source of nutritional support and intake. The resident was severely cognitively impaired and dependent on staff for all care due to anoxic brain injury and quadriplegia. The care plan directed nursing staff to administer the enteral feedings as ordered, and the physician order specified continuous Jevity 1.5 at 70 ml/hr during set time periods. During observation, the resident's feeding pump was found infusing at 90 ml/hr instead of the ordered 70 ml/hr on two separate occasions. The Dietary/Nutrition note also stated the enteral feedings were to be administered at 70 ml/hr as ordered. The dietician stated enteral feedings should be given per physician order and that a higher continuous rate could cause weight gain from overfeeding, elevated liver enzymes, and/or fluid overload. The facility's Tube Feeding policy stated the pump should be set to the prescribed rate and the feeding started.
Soiled PICC Dressing Not Changed Weekly
Penalty
Summary
The facility failed to ensure safe, appropriate administration of IV fluids when it did not change a resident’s PICC line dressing according to standard of care. R94 was observed in bed receiving ongoing TPN with multivitamins at 72.71 ml per hour through a PICC line in the left upper arm, and the PICC dressing was noted to be soiled with a dressing date of 5/21/26, approximately 2 weeks earlier. During interview, the RN confirmed the PICC dressing had last been changed on 5/21/26 and stated PICC line dressings are done weekly to prevent infection and keep the site clean and secure. The DON also stated PICC line dressings should be changed every week and as needed to assess the insertion site for signs of infection and to ensure the dressing was clean, dry, and intact. The facility policy for Central Line Care stated dressing changes are to be completed according to standard care, following the initial 24-hour dressing change at minimum weekly or anytime the dressing becomes moist, loosened, or soiled.
Unlabeled Opened Medications and Unsecured Inhaler
Penalty
Summary
The facility failed to ensure that an insulin pen and an inhaler were dated when opened. During medication cart review on 6/10/26, the RN found R48’s Lispro insulin pen opened but not dated, and also found R56’s Anoro Elipta inhaler opened but not dated. The RN stated insulin pens should be dated when opened because they are only good for 28 to 30 days after the open date, and said inhalers are only good for 30 to 40 days after they are opened. The DON later stated that all medication carts would be audited to ensure medications, including insulin and inhalers, were labeled with the date opened. The facility also failed to keep a resident’s inhaler secured when the resident had not been assessed or ordered to self-administer it. R161 had an order for Advair Diskus inhaler once daily, but the self-administration evaluation showed the resident was assessed to self-administer only vitamins, nasal spray, and eye drops, with no documentation allowing inhalers. Despite this, the inhaler was observed on R161’s bedside table on 6/8/26 and again on 6/9/26. The ADON stated R161 had never been assessed to self-administer any inhalers and that residents may only keep medications in their rooms if they have been assessed to do so and have a physician order.
Pureed Diet Meal Served in Incorrect Form
Penalty
Summary
The facility failed to ensure that one resident on a pureed diet received the noon meal in the ordered form. The resident’s Physician’s Order Sheet and Meal Ticket both showed a pureed diet, and the Diet Spreadsheet for the noon meal indicated that residents on a pureed diet should receive a pureed dinner roll. However, during meal preparation, the resident’s tray was placed in the transportation cart with a regular dinner roll on it, and a plate or pureed food was also placed on the tray. When the tray was served to the resident, the regular dinner roll was still on the tray, and the CNA began unwrapping it while telling the resident, “You have a roll here too.” The Dietary Manager stated that residents on a pureed diet should have received a pureed roll for the noon meal and not a regular roll, and that kitchen staff should serve the diet type listed on the meal ticket. The facility’s Diet Orders Policy states that if the diet received for the resident is different than the order, nursing staff will alert dietary and retrieve the correct diet.
Failure to Use Required PPE for EBP Resident Care
Penalty
Summary
The facility failed to ensure staff wore the correct PPE when caring for a resident on Enhanced Barrier Precaution (EBP) isolation. R14’s facility assessment, dated 3/1/26, showed the resident used a urinary catheter and had a diagnosis that included a history of E. coli. On 6/9/26 at 8:45 AM, an EBP sign was displayed on the room door frame and a PPE cart was placed nearby, but V14, a CNA, entered R14’s room without putting on a gown after gathering washcloths in the hallway. Later, V14 stated she had been changing R14’s gown and cleaning her up after she spilled breakfast and acknowledged she should have worn a gown. V13, an LPN, stated EBP is used for residents with devices such as a catheter and that PPE for EBP is a gown and gloves during care. V2, the DON, stated gown and gloves are required when coming in close contact with the resident, including during high-contact care such as changing clothes and providing hygiene. The facility’s EBP policy, dated 3/2024, stated that gown and gloves are to be worn when performing high-contact resident care.
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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What surveyors actually found near you
We read the 925 citations issued within 25 miles in the last 12 months — including the 21 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 1 | 1 |
| Avantara Lake Zurich | 3.7 mi | ★★★★★ | 10 | 0 |
| Serenity Estates Of Lincolnshire | 3.8 mi | ★★★★★ | 18 | 2 |
| Alden Long Grove Rehab &hc Ctr | 4.7 mi | ★★★★★ | 10 | 2 |
| Libertyville Manor Ext Care | 5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.