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 Elgin Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, depression, anxiety, impulse disorder, and prior behavioral issues was struck in the face twice by another resident while seated in a wheelchair. Nursing staff assessed the resident, documented stable VS and low pain, and reassured the resident, but the incident report did not specify changes to the plan of care. The existing care plan focused on longstanding behavioral and sexual issues and was revised only to add a general intervention to monitor for concerns related to peer contact under an unrelated behavior problem. The ADON, DON, and ADM acknowledged that the care plan did not include a distinct problem or specific interventions related to the altercation or psychosocial monitoring, contrary to facility policy requiring comprehensive, person-centered care plans with measurable objectives and timeframes.
Two residents experienced misappropriation of their controlled medications when significant quantities of Amphetamine-Dextroamphetamine and Hydrocodone-Acetaminophen went missing. Medication count sheets and narcotic records were found to be tampered with, and the discrepancies were linked to a nurse who had access to the medication carts during both incidents. Despite the missing medications, both residents continued to receive their prescribed doses without interruption.
A resident did not receive scheduled hydrocodone for three days due to communication lapses and failure to follow medication administration policies. The resident experienced discomfort and potential withdrawal symptoms, and the facility's system for monitoring medication availability over the weekend was inadequate.
The facility failed to develop comprehensive care plans for residents, including one with significant weight loss and others with PTSD. A resident's refusal to be weighed was not addressed in his care plan, and PTSD triggers were not documented for two residents, potentially impacting their well-being.
The facility failed to provide trauma-informed care for three residents with PTSD, as their care plans lacked identified triggers and interventions. Despite staff acknowledging known triggers, such as loud noises for one resident, this information was not documented, potentially leading to re-traumatization.
The facility failed to provide palatable and attractive food, with residents reporting issues with texture, taste, and appearance. Observations revealed non-adherence to recipes, resulting in unappetizing meals. A test tray confirmed the poor quality, with items being overly seasoned and unappealing.
The facility failed to meet food safety standards, with issues in labeling, sealing, and discarding food items, as well as improper hand hygiene and lack of hair restraints by staff. These deficiencies could lead to food contamination and illness.
A facility failed to update the activity plan for a resident with Alzheimer's and dementia who was admitted to hospice care. The resident, who became bedfast, did not receive an activity assessment or revised care plan for in-room activities. Observations showed the resident was often left in a dark room without stimulation, and the Activity Director admitted to missing the update. The facility's policy requires regular visits for bedfast residents, which was not followed.
A resident with Alzheimer's and contractures in a LTC facility was not provided with appropriate treatment to prevent a decline in range of motion. Despite needing hand rolls in both hands, the resident was often found without one in her right hand. Staff were unclear about the necessity and responsibility for the hand roll placement, and the facility lacked a specific policy for contracture management.
A medication aide failed to sanitize hands between residents and improperly handled medication and drinking cups, risking cross-contamination. The DON confirmed the expectation for proper hand hygiene, aligning with the facility's policy on medication administration.
Failure to Update Care Plan After Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes that reflected a resident’s needs following a resident-to-resident altercation. A male resident with diagnoses including unspecified dementia, major depressive disorder, generalized anxiety disorder, impulse disorder, and cerebral infarction had a comprehensive MDS showing moderate cognitive impairment (BIMS score of 11) and no documented behaviors in Section E. His existing care plan, initiated in 2019 and last revised in March 2026, focused on behavior problems such as tearing diapers, chewing briefs, inserting fingers into the rectum and mouth, laughing when falling, sexual behaviors in public, inappropriate sexual comments, exposing genitals, entering others’ rooms uninvited, and a history of inappropriate touching of female residents. On a date in March 2026, an incident report documented that a CNA observed another resident hit this resident in the face twice while he was sitting in his wheelchair in the hallway next to the other resident. The CNA moved him to the dining room, and a nurse assessed him, finding no injuries and documenting vital signs, a low pain score, and the resident’s denial of pain, fear, or feeling unsafe. The nurse reassured him that the other resident would be kept separate and noted that he remained in the dining room watching TV with wheelchair brakes locked, with the notation that the plan of care was ongoing. The incident report did not include further details about changes or additions to the plan of care. Despite this altercation, the resident’s care plan revision only added an intervention under the pre-existing behavior problem, stating to continue to monitor for areas of concern related to contact with a peer. The ADON acknowledged that the problem statement used for the revision did not relate to the incident and that the care plan was not updated with a problem specific to the resident-to-resident altercation or psychosocial monitoring needs. The DON and the administrator both stated that care plans are used by floor staff to guide care and that the care plan for this resident did not reflect the interventions put in place after the altercation, nor did it include a problem related to monitoring for psychosocial harm. This was inconsistent with the facility’s Comprehensive Care Plans policy, which requires a comprehensive, person-centered care plan with measurable objectives and timeframes to address medical, nursing, mental, and psychosocial needs identified in the assessment.
Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to ensure the right to be free from misappropriation of resident property for two residents, resulting in the diversion and loss of controlled medications. For one resident with multiple sclerosis, ADHD, PTSD, and anxiety disorder, approximately 25 tablets of Amphetamine-Dextroamphetamine were reported missing. The medication count sheets and narcotic substance records were found to be tampered with, including scratched-out and overwritten numbers, and the corresponding blister packs could not be located. Staff interviews and record reviews confirmed that the medication was present and accounted for at the end of one shift, but discrepancies were discovered after the subsequent shift, during which a specific nurse had access to the medication cart and documentation. A second incident involved another resident with chronic pain syndrome, osteoarthritis, and hemiplegia, for whom 57 tablets of Hydrocodone-Acetaminophen (Norco) were reported missing. The narcotic count sheet for this medication was also found to be altered, with evidence of white-out and overmarking to make the count appear correct. The pharmacy confirmed the delivery of the correct quantity of medication, but the facility discovered the discrepancy when a refill was requested earlier than scheduled. The missing medication and altered documentation were linked to the same nurse who had access to the medication cart during both incidents. In both cases, the residents did not miss any doses of their prescribed medications, and there were no reports of unrelieved pain or missed treatments. However, the facility's failure to prevent the misappropriation of controlled substances and the tampering of medication records constituted a violation of residents' rights and facility policy. The investigation did not identify eyewitnesses to the theft, but the documentation and timing of the discrepancies pointed to a single staff member who had access during the relevant periods.
Failure to Provide Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure that a resident received scheduled hydrocodone as ordered from 03/29/24 to 03/31/24. This failure was identified through observation, interview, and record review, and it placed the resident at risk of increased pain and decreased quality of life. The resident, a cognitively intact female with a history of chronic pain and rheumatoid arthritis, did not receive her scheduled hydrocodone doses for three days, despite it being part of her pain management regimen. The resident reported feeling poorly, experiencing irritation in her legs, and sweating during this period, although she did not initially communicate her discomfort to the nursing staff, assuming they were aware of the medication issue. The medication administration records indicated that the hydrocodone doses were marked as unavailable, and the progress notes reflected attempts to reorder the medication. However, the medication was not administered from the emergency kit after the initial dose on 03/28/24. Interviews with the nursing staff revealed a lack of communication and follow-up regarding the medication's unavailability. The charge nurse and medication aide did not ensure the medication was reordered in a timely manner, and the resident's pain assessments during this period did not indicate any reported pain, leading to further delays in addressing the issue. The facility's policies on pain management, medication administration, and ordering and receiving medications were not followed, resulting in the resident going without her prescribed pain medication for an extended period. The ADON and DON acknowledged the communication lapses and the failure to monitor medication availability over the weekend. The facility relied on staff to report missing medications verbally, but this system failed, leading to the resident's discomfort and potential withdrawal symptoms due to the lack of hydrocodone.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in meeting their individualized needs. Resident #54, who has a history of significant weight loss and multiple health conditions, regularly refused to be weighed, which was not addressed in his care plan. Despite documentation of his refusals and the importance of monitoring his weight, the care plan was not updated to reflect these issues, potentially impacting his nutritional status and overall health. Additionally, the facility did not adequately address the needs of residents with PTSD. Resident #58, who has a diagnosis of PTSD, did not have his condition or potential triggers documented in his care plan. This oversight could lead to re-traumatization or psychosocial harm, as his care plan only included medication management for depression and anxiety without specific interventions for PTSD. Similarly, Residents #61 and #63, both diagnosed with PTSD, had care plans that lacked identification of triggers and appropriate interventions. The care plans primarily focused on medication management without addressing the specific needs related to their PTSD. This lack of comprehensive planning could result in adverse effects on their mental and psychosocial well-being, as the facility's policy requires individualized interventions for trauma survivors.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for three residents diagnosed with Post-Traumatic Stress Disorder (PTSD). The care plans for these residents did not include identified triggers or interventions related to their PTSD, which is a requirement to prevent re-traumatization. Resident #58, a male with a history of military service and a traumatic childhood accident, was not aware of his PTSD diagnosis and had not been asked about potential triggers. Despite the Assistant Director of Nursing (ADON) acknowledging that loud noises were a known trigger for him, this information was not documented in his care plan. Resident #61, a female with chronic obstructive pulmonary disease, morbid obesity, and PTSD, also had a care plan that lacked specific PTSD triggers or interventions beyond medication. Although she was assessed to have mood indicators of depression and anxiety, her care plan did not address potential triggers for her PTSD. The MDS Coordinator confirmed that her care plan should have included more detailed information about her PTSD triggers. Resident #63, a female with dementia, bipolar disorder, and PTSD, had a care plan that included medication interventions and monitoring of behavior episodes but did not identify any specific PTSD triggers. Despite her history of paranoia and hallucinations, the care plan failed to document potential triggers that could exacerbate her condition. Interviews with facility staff, including the MDS Coordinators and Social Worker, revealed a consensus that PTSD triggers should be documented to ensure proper care and prevent negative outcomes, yet this was not reflected in the residents' care plans.
Deficiency in Food Quality and Preparation
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and at a safe and appetizing temperature. Multiple residents expressed dissatisfaction with the food's texture, quality, appearance, and taste. Resident #2, for instance, reported that the meat served was too hard to cut and that she consumed only a small portion of her meal due to its poor quality. Similarly, Resident #245 found the meal unappealing, with the gravy being too gelatinous and the mashed potatoes overly seasoned with garlic and pepper. Resident #4 also reported that the mushrooms in her meal were overcooked and slimy, making the entire dish unappetizing. The facility's failure to follow recipes when preparing meals contributed to the unpalatable food. During an observation, a staff member was seen not using measuring spoons to add seasonings, instead using an eating utensil to pour unmeasured amounts of seasoning into the food. This lack of adherence to recipes resulted in meals that did not meet the expected taste and nutritional standards. The Dietary Manager (DM) acknowledged the importance of following meal tickets and recipes to ensure food is appealing and meets residents' nutritional needs. The test tray sampled during the survey further highlighted the issues with food quality. The beef patty with gravy and mushrooms was described as gelatinous and unappealing, with the meat having a mushy texture. The mashed potatoes were inedible due to excessive seasoning, and the wheat roll was dry and hard. These observations, along with resident interviews, indicate a systemic issue with food preparation and presentation in the facility, potentially affecting residents' food intake and quality of life.
Food Safety and Hygiene Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Several deficiencies were noted, including improper labeling and dating of dry storage food, inadequate sealing of dry storage items, and uncovered beverages left in the freezer. Additionally, damaged or dented canned food items were not separated into a designated area, and expired food, such as a container of jelly, was not discarded. These lapses in food storage and handling could lead to food contamination and foodborne illness. During the survey, it was observed that kitchen staff did not consistently practice proper hand hygiene and glove use. One staff member was seen putting gloved hands in pockets to retrieve alcohol wipes during food preparation and temperature checks, without washing hands between glove changes. Another staff member was observed without a hairnet or beard guard while assembling meals, which could lead to cross-contamination. The facility's policies require hair restraints and proper handwashing, but these were not followed, increasing the risk of contamination. Interviews with staff and the Administrator revealed a lack of awareness and adherence to food safety protocols. Staff members were unsure about the correct procedures for labeling, sealing, and discarding food items. The Administrator and Dietary Manager expressed expectations for proper food storage, labeling, and hygiene practices, but these were not consistently implemented. The failure to follow these protocols could result in contamination and potential illness for residents.
Failure to Update Activity Plan for Resident on Hospice
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the needs and preferences of a resident who experienced a change in condition. The resident, an elderly female with Alzheimer's disease, dementia, and contractures, was admitted to hospice care, which resulted in her no longer getting out of bed. Despite these changes, the facility did not conduct an activity assessment or update her care plan to include in-room activities, as required by their policy. Observations revealed that the resident was often left in a dark room with the TV off, and her representative expressed concerns about the lack of stimulation. Interviews with the Activity Director (AD) and the Administrator confirmed that the resident's activity plan was not updated following her change in condition. The AD acknowledged the oversight and admitted that the resident's care plan should have been revised to ensure she received adequate stimulation, especially since she was no longer able to participate in group activities. The facility's policy mandates that residents, particularly those who are bedfast, should be visited by the AD, Activity Assistant, or volunteers at least three times a week, which was not adhered to in this case.
Failure to Prevent Decline in Range of Motion for Resident with Contractures
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent a decline in range of motion for a resident with limited mobility, specifically Resident #43, who had contractures in her right hand. The resident, an elderly female with Alzheimer's disease, dementia, and contractures, was observed without a hand roll in her right hand, which was necessary to prevent further decline in her range of motion. Despite being assessed as having functional limitations in range of motion for her bilateral upper and lower extremities, there were no physician orders or interventions in place for her right-hand contracture. Observations and interviews revealed that Resident #43 was often found in bed without a hand roll in her right hand, although one was present in her left hand. The resident's responsible party expressed concern about her long fingernails digging into her hand due to the contracture. Staff members, including CNAs and an LVN, were unsure about the necessity of the hand roll for the right hand and who was responsible for monitoring its placement. The Director of Nursing (DON) acknowledged the oversight and mentioned updating the task list to include hand rolls and nail checks, although the staff had not yet been informed. The physical therapist confirmed that Resident #43 should have hand rolls in both hands at all times to manage her contractures. The resident had been on physical therapy for contracture management but was discharged to restorative care for hand rolls after being admitted to hospice. The facility lacked a specific policy for contracture management, which contributed to the oversight in the resident's care plan and the failure to prevent a decline in her range of motion.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a medication pass, as observed with one of the medication aides (MA C). MA C did not sanitize her hands between residents and handled drinking and medication cups improperly by placing her fingers inside the cups. This occurred during the administration of medication to two residents, Resident #146 and Resident #85, which could potentially lead to cross-contamination and infections. During the observation, MA C was seen leaving one resident's room without sanitizing her hands and then proceeded to another room, where she continued to handle cups inappropriately. In an interview, MA C acknowledged the failure to sanitize hands and the improper handling of the cups. The Director of Nursing (DON) confirmed that the expectation was for medication aides to practice good hand hygiene and avoid touching the inside of cups to prevent cross-contamination. The facility's policy on medication administration emphasized the importance of handwashing and sanitization between handling medications and residents.
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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 Elgin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakcrest Nursing And Rehabilitation Center | 13.8 mi | ★★★★★ | 8 | 0 |
| Pflugerville Nursing And Rehabilitation Center | 15.4 mi | ★★★★★ | 1 | 0 |
| Falcon Ridge Rehabilitation | 15.5 mi | ★★★★★ | 2 | 0 |
| Spjst Rest Home 1 | 15.8 mi | ★★★★★ | 6 | 0 |
| Five Points Of Pflugerville | 16.1 mi | ★★★★★ | 2 | 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 July 2026) and official state health department websites.