Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Waukegan Health And Rehab during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of behavioral issues attempted to enter his room while his roommate, who had dementia, depression with psychotic features, cognitive deficits, and conflictual relationships with others, was sitting in the doorway. The roommate swung and struck the cognitively impaired resident multiple times in the face and head while both were in wheelchairs, causing visible redness to the face and hand. Care plans for both residents identified behavioral and cognitive problems and included interventions such as redirection, limit-setting, and separating the resident from others when aggressive, and the facility’s abuse policy defined resident-to-resident altercations as abuse; however, a physical assault still occurred, demonstrating a failure to protect a resident from abuse by another resident.
Two residents with cognitive and neurological impairments were seated next to each other, resulting in one being struck in the face by the other's involuntary arm movement. Staff were aware of the need to keep the resident with movement disorder separated from others, but this intervention was not followed, leading to the incident.
A resident who is mentally intact and physically able to bathe independently was provided unwanted assistance by a CNA who was unaware of the resident's preferences. The resident expressed discomfort and distress due to the lack of privacy and respect for her wishes. Staff interviews and record review confirmed that the resident's bathing preferences were not documented in the care plan until after the incident, leading to care that did not align with the resident's choices.
Staff failed to follow safe food handling practices, including using a towel that had fallen on the floor to clean food prep surfaces and reusing contaminated scoops between different food items without cleaning or sanitizing them. These actions created a risk of cross-contamination for all residents receiving food or nourishment.
Multiple residents reported that a bathroom/shower room had visible ceiling damage, including discoloration and peeling paint, which had not been repaired for an extended period due to the absence of maintenance staff. The administrator confirmed ongoing staffing issues and acknowledged the damage was caused by a plumbing leak, with no maintenance logs or repair policy provided when requested.
A resident with dementia and other medical conditions received PRN Risperdal, an antipsychotic, without a required 14-day stop date. Despite pharmacy notification and facility policy aligning with CMS guidelines, the medication was administered multiple times over two months without evidence of a prescriber evaluation or renewal, resulting in a deficiency.
A resident with a contracted left hand and a physician's order for a palm protector was repeatedly observed without the device in place. Staff interviews revealed a lack of awareness about the resident's splint needs, and the care plan interventions for application, monitoring, and documentation were not followed.
A resident with dementia and documented weight loss did not consistently receive ordered dietary supplements, specifically yogurt with meals, despite care plan and physician orders. Observations showed the supplement was missing from meal trays on multiple occasions, and staff did not provide it, even though it was available and expected to be given per dietary recommendations.
A resident receiving IV antibiotics for osteomyelitis did not have required numerical values documented for PICC line length and arm circumference measurements. Instead, staff recorded only check marks in the MAR and progress notes, despite orders and facility policy requiring weekly numerical documentation to monitor for catheter displacement or swelling.
A resident with memory impairment and cognitive deficits was found with a cup of pills left on the bedside table, which the resident was unaware of and had not taken. Staff confirmed that medications were sometimes left at the bedside, despite facility policy requiring observation of medication consumption and no authorization for self-administration in the care plan.
Surveyors found that insulin pens for two residents were not properly labeled with names or open dates, and an unopened insulin pen was not refrigerated as required. Both a registered nurse and the DON confirmed that facility policy mandates labeling and refrigeration, but these procedures were not followed.
Staff did not consistently wear required PPE, including gowns, when providing high-contact care to two residents with indwelling medical devices, despite physician orders and facility policy mandating enhanced barrier precautions. In both cases, either the proper PPE was not used or signage indicating the need for precautions was missing.
A resident was found soaked in urine due to delayed incontinence care. A CNA admitted the resident had not been changed yet because she was busy, despite the facility's policy requiring checks every two hours.
The facility failed to apply necessary mobility devices for two residents with limited range of motion. One resident, with hemiplegia due to a stroke, was observed without a prescribed hand splint and sling, while another resident with similar mobility issues was not provided a required sling during transfers. Staff acknowledged the absence of these devices, which were essential to prevent further decline.
A resident did not receive their prescribed Depakote 500 mg medication due to it being out of stock, resulting in two missed doses. An LPN failed to reorder the medication in time, and the DON confirmed that the medication was not available in the convenience box. The facility's policy requires contacting the pharmacy or using the emergency kit if medications are unavailable.
The facility failed to follow infection control protocols for two residents. A CNA did not change gloves or wash hands during incontinence care, violating hand hygiene policy. Additionally, two CNAs did not wear gowns while caring for a resident on enhanced barrier precautions, despite policy requirements for PPE use during high-contact activities.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident (R1), with diagnoses including senile degeneration of the brain, dementia, muscle weakness, and atrial fibrillation, had a facility assessment indicating severe cognitive impairment and a care plan noting impaired memory, poor decision-making, and a history of behavior problems such as hitting staff. Another resident (R2), with diagnoses including chronic congestive heart failure, UTI, dysphagia, dementia, major depressive disorder, and low back pain, had an assessment indicating no cognitive impairment but a care plan identifying potential situational and coping problems, cognitive deficits, conflictual relationships with staff and peers, and behaviors that may leave him susceptible to abuse. R2’s care plan also included interventions such as setting limits, staying calm during agitated behaviors, and separating him from other residents if he showed aggression. On the date of the incident, documentation and staff interviews showed that R2 was sitting in the doorway of his room when R1 attempted to gain access to the room. A CNA reported that R2 swung and struck R1 in the face and on the top of the head while both residents were in their wheelchairs, with a third punch blocked by R1. Staff noted redness on the left side of R1’s face and on the back of his right hand. An RN confirmed that the only noted injuries were redness to R1’s cheek and hand, and another RN reported hearing a CNA yell and then observing that one resident had been hitting the other before they were separated. The facility’s abuse, neglect, and exploitation policy states that abuse includes willful infliction of injury and encompasses certain resident-to-resident altercations, and that the facility will develop and implement policies and procedures to prohibit and prevent abuse. Despite existing care plans and policies, a resident-to-resident physical altercation occurred, resulting in physical abuse of R1 by R2.
Failure to Maintain Safety Interventions for Residents with Involuntary Movements
Penalty
Summary
The facility failed to implement safety interventions for two residents with significant cognitive and neurological impairments, resulting in one resident being struck in the face by another's involuntary movements. One resident, diagnosed with Alzheimer's disease, non-traumatic brain dysfunction, and severe cognitive impairment, was seated near the nurses' station in a wheelchair. Another resident, with Parkinson's disease, dementia, legal blindness, and an extrapyramidal movement disorder, also in a wheelchair, was seated next to the first resident. The second resident exhibited uncontrollable arm, head, and hand movements due to his medical condition. Staff interviews and records confirmed that the second resident's involuntary arm movement caused his hand to strike the first resident's face. Both residents were assessed and transported to the emergency room, returning the same day without injury. Staff interviews revealed that the second resident had a known history of involuntary, spastic body movements since admission, and interventions were in place to keep him seated at least three feet away from others to prevent accidental contact. However, on the day of the incident, staff failed to maintain this separation, and the two residents were placed next to each other by the nurses' station. Multiple staff members acknowledged awareness of the second resident's movement disorder and the need to keep him apart from others, but the intervention was not followed, leading to the incident.
Failure to Honor Resident's Bathing Preferences and Provide Person-Centered Care
Penalty
Summary
The facility failed to honor a resident's preferences and provide necessary care and services to maintain the highest practicable physical and psychosocial well-being. The resident, who has been in the facility for five years and is mentally intact with no upper or lower extremity impairment, reported that a CNA attempted to assist with a shower despite the resident's clear preference and ability to bathe independently. The resident expressed discomfort with the CNA's actions, stating that previous staff had respected her wishes by only assisting with her back and providing privacy. The resident reported feeling uncomfortable and stated that she no longer wanted staff to touch her, preferring to use a back brush and complete bathing tasks independently. Interviews with staff confirmed that the resident is capable of washing independently and often refuses assistance, including skin checks. The CNA involved was not aware of the resident's showering preferences at the time of the incident. Review of the care plan revealed that the resident's bathing and shower preferences were not documented until after the incident, despite a long-standing history of independence in this area. The lack of awareness and documentation of the resident's preferences led to the provision of care that did not align with her wishes, resulting in psychosocial distress.
Failure to Prevent Cross-Contamination During Food Handling
Penalty
Summary
The facility failed to ensure safe food handling practices were followed in the kitchen, resulting in potential cross-contamination affecting all residents who receive food or nourishment. During meal preparation, a cook dropped a cleaning towel onto the floor, then used it to wipe down food prep surfaces and equipment without replacing it or washing hands. The same towel was used to clean areas where food was later prepared, and no additional cleaning was performed on these surfaces before food contact. Additionally, scoops used to serve food were placed on potentially contaminated surfaces and then returned to food pans without being cleaned or replaced. Further, during the preparation of pureed foods, a staff member used a scoop to add food thickener to different food items. The scoop became contaminated with food residue when drops of creamed corn and pureed chicken fell onto it, but the same scoop was reused to access the bulk food thickener without being cleaned or sanitized. The contaminated scoop was then returned to the bulk bin, creating a risk of cross-contamination between food items. All residents, including those on tube feedings with pleasure feedings, were potentially affected as they received food from the kitchen.
Failure to Maintain Clean and Homelike Bathroom Environment Due to Maintenance Staffing Issues
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the first floor bathroom/shower room, as evidenced by observations of brown/yellowish discoloration, dried water rings, and pieces of peeled paint and drywall hanging from the ceiling above the toilet. Four residents reported during a council meeting that the bathroom appeared to have mold on the ceiling and that the issue had persisted for some time without repair. The administrator confirmed that there had been no maintenance staff available for over a month due to staffing turnover, and that the ceiling damage was caused by a leaky toilet on the floor above. The facility was unable to provide maintenance logs for the past three months or a policy on maintenance repairs when requested.
Failure to Limit PRN Antipsychotic Medication to 14 Days
Penalty
Summary
A deficiency was identified when a resident with diagnoses including cerebral infarction, unspecified dementia with psychotic disturbance, and hemiplegia/hemiparesis was administered PRN Risperdal (an antipsychotic medication) without a required 14-day stop date. The resident, who was under hospice care, had a physician's order for PRN Risperdal entered into the electronic medical record with instructions not to discontinue without consulting hospice, but no stop date was specified. The facility's policy, consistent with CMS guidelines, requires all PRN antipsychotic orders to be limited to 14 days unless a prescriber evaluation is conducted and a new order is written. Despite pharmacy notification to the facility regarding the 14-day limitation and the need for prescriber evaluation, the PRN Risperdal order remained active and was administered on multiple occasions over a two-month period. The Director of Nursing was unable to obtain documentation of a prescriber evaluation after 14 days and confirmed that neither the hospice provider nor the facility nurse practitioner had added a stop date for the PRN Risperdal. This failure to ensure compliance with the 14-day stop date requirement for PRN antipsychotic medication resulted in the cited deficiency.
Failure to Ensure Application of Ordered Palm Protector for Resident with Contracture
Penalty
Summary
A deficiency occurred when a resident with a physician's order and care plan for a left hand palm protector was repeatedly observed without the device in place while in bed. The resident's left hand was contracted in a closed fist position, with fingers pressing into the palm, and the palm protector was not applied as ordered during multiple observations. Staff interviews revealed a lack of awareness regarding the resident's need for the splint, with one agency CNA stating she was unaware of the device and the restorative nurse indicating she did not know the resident was without it and was unsure of its location. The resident's care plan and physician's order specified the palm protector should be on during AM cares and removed for hygiene and bathing, with monitoring for compliance and documentation of refusals or unscheduled removal, but these interventions were not followed as observed.
Failure to Provide Ordered Dietary Supplements for Weight Loss
Penalty
Summary
A resident with dementia experienced a significant weight loss over the course of a year, dropping from 116.4 lbs. to 108.3 lbs., which amounts to a 7.75% decrease. The resident's care plan and physician orders specified the provision of dietary supplements, including yogurt with meals, to address her nutritional needs and support weight maintenance. The dietician had recommended these supplements due to observed weight fluctuations and had recently added additional supplements to the resident's regimen. Despite these documented interventions, direct observations during meal services revealed that the resident did not receive the ordered yogurt supplement with her meals on multiple occasions. Staff present during meal times did not provide the yogurt, and the Director of Culinary Services confirmed that yogurt was available and should have been included on the meal tray per the order. The dietician also confirmed the expectation that the supplement be offered with meals, as it was beneficial for the resident's health.
Failure to Document PICC Line Measurements for Resident Receiving IV Therapy
Penalty
Summary
The facility failed to document numerical values for peripherally inserted central catheter (PICC) measurements for a resident receiving intravenous (IV) antibiotics for osteomyelitis. The resident's medical records, including the Medication Administration Records (MAR) and progress notes for multiple dates, showed only check marks instead of the required numerical values for both the catheter length and arm circumference measurements. Facility policy and physician orders required weekly documentation of these measurements to monitor for catheter displacement or arm swelling. During interviews, a registered nurse confirmed that numerical values should be documented to track changes in the PICC line and arm circumference. The resident reported that staff did not measure or record the catheter length or arm circumference as required. The facility's policy on central venous catheter care emphasized the importance of monitoring for risks such as infection, thrombosis, and dislodgement, but the required documentation was not completed.
Medications Left Unattended at Bedside for Cognitively Impaired Resident
Penalty
Summary
A resident with documented memory impairment and problems with decision-making, insight, logic, calculation, reasoning, planning, and judgment was found with a cup containing four pills on the bedside table during a morning observation. The resident stated he had not received his morning medications and was unaware of the pills on his bedside table, further indicating cognitive impairment. The resident also reported that staff sometimes leave his medications at the bedside for him to take later. The pills remained unattended for a period of time before being disposed of by a registered nurse, who confirmed that staff should not leave medications at the bedside and are required to observe residents consume their medications. The resident's care plan and order summary did not indicate that self-administration of medications was permitted. The facility's medication administration policy required staff to observe residents taking their medications.
Insulin Pens Not Properly Labeled or Stored
Penalty
Summary
Surveyors observed that insulin pens were not properly stored and labeled for two residents. During a review of the first-floor medication cart with a registered nurse, a partially used Lantus insulin pen was found without a resident name or open date, and a Humalog Kwik pen labeled for one resident was not opened but was stored outside the refrigerator despite packaging instructions to refrigerate until use. The nurse was unable to identify the owner of the unlabeled Lantus pen and confirmed that all insulin pens should be labeled with the resident's name and open date, and unopened pens should be refrigerated. The Director of Nursing also confirmed these requirements. Facility records showed that both residents had orders for Lantus insulin, and one had an order for Humalog. The facility's own policy requires insulin pens to be labeled with the resident's name and open date, and unopened pens to be refrigerated, which was not followed in these instances.
Failure to Adhere to Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Staff failed to follow required infection prevention and control protocols for residents on enhanced barrier precautions. For one resident with a gastrostomy tube, a registered nurse was observed connecting a syringe to the feeding tube while wearing gloves but not an isolation gown, despite signage on the resident's door and care plan instructions indicating that both gloves and gown were required for high-contact care activities. The facility's policy specified that enhanced barrier precautions, including gown and gloves, must be used during high-contact care such as device care. In another instance, an agency certified nursing assistant provided care to a resident with both a gastrostomy tube and an indwelling urinary catheter without wearing a protective gown. Additionally, there was no sign indicating enhanced barrier precautions on the resident's door, even though physician orders required such precautions. The assistant director of nursing/infection preventionist confirmed that staff are in-serviced to wear both gown and gloves for direct care of residents on enhanced barrier precautions and that appropriate signage should be present.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who required assistance with toileting. On June 11, 2024, at 9:36 AM, a resident was found lying in bed with a strong smell of urine present. The resident's gown, bed pad, and bed sheet were soaked with urine. The resident expressed that it takes a long time to receive help. At 9:47 AM, a Certified Nursing Assistant (CNA) entered the room to assist the resident to the bathroom and acknowledged the resident was soaking wet, apologizing for the delay. The CNA admitted that the resident had not been changed yet because she was busy and the resident was the last one needing to be changed. On June 12, 2024, at 9:15 AM, the same CNA stated that residents should be checked and changed every two hours. The facility's Activities of Daily Living Policy from 2021 mandates that residents unable to carry out activities of daily living should receive necessary services to maintain good hygiene, including regular checks and changes for incontinence.
Failure to Apply Mobility Devices for Residents with Limited Range of Motion
Penalty
Summary
The facility failed to provide appropriate care for two residents, R37 and R61, who required devices to maintain or improve their range of motion due to physical limitations. R37, diagnosed with hemiplegia affecting the right side due to a stroke, had a physician's order for a right resting hand splint and a sling to support her right arm. However, during observations on two consecutive days, R37 was found without the prescribed splint or sling, despite the presence of a Certified Nursing Assistant (CNA) who acknowledged the absence of the splint and the need to locate it. The Restorative Nurse confirmed the necessity of these devices to prevent further decline in R37's condition. Similarly, R61, a male resident with hemiplegia and limited mobility on the left side following a cerebral infarction, was observed without the required sling while being transferred to a recliner chair and wheeled into the dining room by two CNAs. Despite the physician's order for a sling when up in a chair, and confirmation from both an LPN and the Restorative Nurse about the necessity of the sling, it was not applied. R61's restorative assessment indicated dependency on staff for mobility and personal care, highlighting the importance of adhering to the prescribed use of supportive devices.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident's prescribed medication, Depakote 500 mg, was available for administration. During a morning medication pass, an LPN did not administer the medication to a resident because it was out of stock and needed to be reordered. The LPN mentioned that medications are usually reordered when there are about five pills left and that the pharmacy can send medications immediately if needed. The resident's Medication Administration Record (MAR) indicated that Depakote was not administered on the specified date, resulting in two missed doses. The Director of Nursing (DON) stated that staff should check the medication convenience box if medications are unavailable and notify the physician to order the medication STAT through the pharmacy. However, the LPN did not inform the DON about the unavailability of Depakote, and it was confirmed that the medication was not in the convenience box. The facility's Medication Administration Guidelines Policy outlines that if a medication cannot be located, the pharmacy should be contacted or the medication should be removed from the night box/emergency kit.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices during the care of two residents. In the first instance, a Certified Nursing Assistant (CNA) provided incontinence care to a resident without changing gloves or washing hands between tasks. The CNA removed a soiled brief, applied barrier cream, and dressed the resident without performing hand hygiene, subsequently leaving the room with soiled gloves still on. This action was contrary to the facility's hand hygiene policy, which mandates handwashing after removing soiled gloves to prevent cross-contamination. In the second instance, two CNAs entered the room of a resident on enhanced barrier precautions without donning the required personal protective equipment (PPE), specifically gowns. They provided incontinence care and transferred the resident using a mechanical lift without wearing gowns, despite the presence of a sign indicating the need for enhanced barrier precautions due to the resident's gastric tube. The facility's policy requires the use of gowns and gloves during high-contact care activities to prevent the transmission of multidrug-resistant organisms.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waukegan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Elevate Care Waukegan | 0.1 mi | ★★★★★ | 25 | 0 |
| Aspyre Of Waukegan | 2.3 mi | ★★★★★ | 16 | 2 |
| Claridge Healthcare Center | 5.1 mi | ★★★★★ | 9 | 2 |
| Alpine Care Of Zion | 6.5 mi | ★★★★★ | 27 | 0 |
| Libertyville Manor Ext Care | 6.8 mi | — | 0 | 0 |
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