Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elevate Care Waukegan during CMS and state inspections, most recent first.
A resident who required supervision or touching assistance with eating, as documented on the MDS, was observed eating alone in their room using a small, child-sized plastic spoon without any supervision, cueing, or touch assist. Due to vision loss and difficulty straightening fingers, the resident gripped the flexible plastic spoon with a loose fist, causing food to repeatedly fall off the spoon without being noticed, leading to frustration and only partial meal consumption. An LPN reported that only plastic spoons were available and did not know why, while the Dietary Manager stated plastic was used when there was not enough metal flatware. Resident council minutes also showed that two residents had complained about receiving plastic ware.
A resident receiving anticoagulation therapy for an upper extremity thrombosis had multiple physician orders for INR testing, and blood was reportedly drawn, but PT/INR tests were not completed and no lab results were documented for several ordered test dates. The DON acknowledged that although lab orders were placed correctly, the anticoagulation testing was not performed, and the physician reported frequently ordering INRs without receiving any results. The resident was later hospitalized with a supratherapeutic INR of 12.0 and a markedly prolonged PT, while the facility was unable to provide a relevant policy during the survey.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with ALS reported that a CNA attempted to damage and then turned off his oxygen concentrator and disabled his call light. The incident was reported internally to nursing supervisors and the Administrator, and the CNA was suspended during the investigation. However, the Administrator did not report the abuse allegation to the State Agency as required by facility policy.
Two residents who were dependent on staff for ADLs did not receive required oral care as ordered and outlined in their care plans. Both had visible debris and poor oral hygiene observed during the survey, despite staff statements that oral care is performed daily and facility policy requiring regular oral hygiene.
A resident with a history of stroke and on tube feeding experienced significant weight loss due to the facility's failure to monitor their weight as recommended. Despite being on a specific feeding regimen, the resident's weight was not recorded in December, leading to a 9.36% weight loss by January. The facility's policy required monthly weights and more frequent monitoring for those at nutritional risk, which was not followed.
The facility failed to provide palatable food, as observed during a lunch service where chicken was found to be hard, tough, and dry. Several residents reported dissatisfaction with the meal, and a test tray confirmed the chicken was overcooked. The Assistant Food Service Manager acknowledged the issue, stating that the chicken should be juicy.
A resident with chronic respiratory issues was observed self-administering a nebulizer treatment without the required assessment or physician's order. The facility's policy mandates an assessment and physician order for self-administration, but the resident's records lacked both. The Respiratory Therapy Manager provided the medication without knowing the requirement, and the resident's care plan did not address self-administration.
A resident was involved in a physical altercation with another resident, resulting in the resident being knocked out of her wheelchair. Both residents were alert and oriented, and the incident was witnessed by a CNA who intervened. The resident reported pain but refused further assessment. The facility's Administrator substantiated the abuse, and the involved resident was arrested and not allowed to return to the facility.
A facility failed to follow its abuse policy for a resident with a criminal history, leading to a deficiency. The resident's background check was delayed due to an error in recording race, and a HIT for domestic battery was not acted upon. The facility's policy required immediate fingerprinting, but this was not done, resulting in an incident with another resident. The admissions staff admitted to the error, and the necessary follow-up actions were not executed.
The facility failed to provide meaningful activities for two residents with dementia, leading to deficiencies in meeting their needs. One resident, who enjoys puzzles and arts, was left in bed without engagement, while another, who benefits from sensory activities, was not offered any activities and was repeatedly redirected to sit down. The lack of personalized activity offerings and insufficient staffing contributed to the residents' inactivity and dissatisfaction.
A resident with limited ROM was not evaluated for a brace and did not receive prescribed ROM exercises. Despite an order for evaluation dated in November, the resident had not been assessed for a splint by January, and documentation showed inconsistent delivery of ROM exercises.
The facility failed to supervise medication administration for two residents. One resident was found with an unconsumed Adderall pill, and another had multiple medications left at their bedside. Both instances lacked physician orders for self-administration, contrary to facility policy requiring nurse supervision during medication ingestion.
The facility failed to ensure proper PPE use and isolation signage for residents on isolation. A CNA entered a resident's room on contact isolation for ESBL without wearing required PPE. Additionally, two residents who tested positive for COVID-19 lacked isolation signs and PPE outside their rooms, as confirmed by an LPN and the Infection Preventionist. These actions violated the facility's infection control policies.
The facility failed to assess and administer influenza and pneumonia vaccinations to three residents, leading to a deficiency in their immunization practices. A resident received an influenza vaccine late, and two residents did not receive timely pneumonia vaccinations. The Infection Control Preventionist Nurse acknowledged the oversight and lack of documentation regarding communication attempts with a resident's POA.
A resident with a hand contracture suffered a foul odor and an open wound due to inadequate hand and nail care. Despite being dependent on staff for personal hygiene, the resident's fingernails were excessively long, causing a cut to the palm. Facility staff failed to follow policies for nail care and bathing, resulting in the resident's injury and requiring intervention by the wound care team.
A resident with a history of chronic conditions experienced a fall and subsequent pain, but the facility delayed X-ray reporting and treatment. The X-ray, revealing a fracture, was not reviewed until over 20 hours later, delaying hospital transfer. Staff interviews highlighted communication and procedural issues.
A resident at high risk for falls experienced an unwitnessed fall resulting in a right hip fracture due to inadequate supervision. Despite a care plan indicating high fall risk, the facility failed to continuously monitor and document the resident's condition post-fall, delaying hospital evaluation. The resident, previously ambulatory with assistance, required a total lift and non-weight bearing status after the incident.
A resident in a long-term care facility, who was a Full Code, did not receive immediate CPR due to staff's inability to quickly verify the code status. The resident was found unresponsive and pulseless, but the CNA and RN involved were unsure of the code status and had to check the electronic medical record, causing a delay. This delay contributed to the resident's death, highlighting a deficiency in the facility's process for identifying code status.
A resident experienced verbal abuse from a staff member, V12, who used profanity and inappropriate language during an altercation about an oxygen concentrator. Despite attempts by other staff to de-escalate the situation, V12 continued the confrontation at the nurses' station, witnessed by multiple staff members. The facility's investigation confirmed the incident as a violation of the resident's right to be free from abuse.
A resident was physically abused by another resident after wandering into their room and taking food. The incident resulted in a fall and injuries, including a laceration and bruising. A housekeeper witnessed the altercation and confirmed the push. The facility's policy requires such incidents to be reviewed as potential abuse.
A facility failed to monitor a resident for 72 hours after a fall where she hit her head. The resident was observed with discoloration on her forehead, and the DON confirmed that required post-fall procedures, including vital signs and neuro checks, were not completed. Initial vital signs were recorded, but further monitoring was not conducted as per policy.
The facility failed to ensure a resident room was free from cockroaches, despite multiple reports and observations of the pests. The Maintenance Director was aware of the issue but had not taken steps to seal the room or repair the hole in the bathroom wall where the pests were entering. The facility's Pest Control policy was not followed, and the problem persisted for weeks without resolution.
Failure to Provide Required Eating Assistance and Appropriate Utensils
Penalty
Summary
The deficiency involves the facility’s failure to provide required supervision and appropriate assistance with eating for a resident who needed supervision or touching assistance, resulting in the resident being left alone in the bedroom to eat with inadequate utensils. The resident’s MDS documented a need for supervision or touching assistance with eating, including verbal cueing and/or steadying/contact guard assistance throughout or intermittently during the activity. During a noon meal observation, the resident was seated alone in a wheelchair at an overbed table with the meal tray and was given a small, child-sized plastic spoon. The resident, who reported losing vision and being unable to straighten their fingers, gripped the tiny handle with a loose fist; when the resident attempted to scoop food, the flexible plastic spoon bent downward and the food repeatedly fell off without the resident noticing, leading to visible frustration and intake of only about 50% of the meal. Staff interviews revealed that only plastic flatware was being used on the unit, with an LPN stating there were no metal spoons and not knowing why plastic was used, and the Dietary Manager stating plastic was used when there was not enough metal flatware. Resident council minutes also documented that two residents had previously complained about receiving plastic ware. These observations, interviews, and record reviews show that the resident who required supervision and assistance with eating was not provided with the necessary supervision, cueing, or appropriate utensils during the meal, and that the facility’s practice of substituting plastic flatware when metal flatware was insufficient contributed to the deficiency.
Failure to Monitor Anticoagulation Lab Results Leading to Supratherapeutic INR
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and complete laboratory monitoring of a resident’s anticoagulation therapy. The resident had a diagnosis of thrombosis of the right upper extremity and was receiving anti-clotting medication regulated by INR (International Normalized Ratio) testing. A physician’s order dated 03/02/2026 directed that an INR blood test be drawn, and the DON stated that the blood was drawn on 03/03/2026. However, the resident’s medical record contained no results for this INR order, and the DON reported that although the laboratory orders were placed correctly, the PT (Prothrombin Time) and INR tests were not completed. The resident’s prior INR result in the record was from 01/16/2026, with an INR of 1.2, and no subsequent INR results were documented for the ordered tests. According to the DON, additional INR tests were scheduled on 03/13/2026, 03/14/2026, 03/16/2026, 03/17/2026, and 03/18/2026, but no INR results were obtained for any of those dates. The resident was later discharged from the facility and admitted to the hospital, where hospital laboratory results on 03/19/2026 showed a PT of 96.6 seconds (normal 12.3–15.1) and an INR of 12.0 (normal 0.8–1.2). The attending physician explained that a supratherapeutic INR indicates too much Coumadin, that the resident’s therapeutic INR range should have been 2–3, and that INR levels are used to regulate the resident’s anti-clotting medication. The physician stated that INR tests were ordered frequently at the facility but that no laboratory results were received. The facility did not provide a policy related to this issue at the time of the survey.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Report Abuse Allegation Involving Resident's Oxygen and Call Light
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency as required by its own policy and regulatory standards. A male resident with Amyotrophic Lateral Sclerosis (ALS), who was alert and oriented, reported that a Certified Nursing Assistant (CNA) attempted to break his oxygen concentrator by hitting it, then turned it off, and also disabled his call light by pulling it out of the wall. The resident stated he informed a nurse about the incident, and an internal investigation was conducted. Multiple staff members, including the Administrator, DON, and nursing supervisors, were made aware of the allegations. The CNA involved was suspended during the investigation. Despite the seriousness of the allegations, including purposeful interference with life-sustaining equipment and communication devices, the Administrator decided not to report the incident to the Illinois Department of Public Health (IDPH), stating it was not considered a major abuse case. The facility's Abuse Prevention and Reporting Policy requires immediate reporting of any abuse allegations to the Department of Public Health, but this protocol was not followed in this case.
Failure to Provide Oral Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate oral care to two residents who were dependent on staff for activities of daily living. For one resident with a history of poor oral hygiene and dental problems, physician orders and the care plan required oral care every eight hours. Despite this, observations revealed that the resident had visible white/yellow debris and a film on her teeth, and she confirmed that her teeth had not been brushed that morning. The resident's family also reported ongoing concerns about plaque and poor oral hygiene during recent visits. Staff interviews indicated that oral care should be performed daily, but the resident continued to have visible debris in her mouth during multiple observations. Another resident, who was nonverbal and had significant physical impairments including quadriplegia and a persistent vegetative state, also had physician orders for oral care every eight hours. A dental consult had previously documented poor general oral hygiene. During the survey, this resident was observed with yellowish debris between his teeth. The DON confirmed that morning care should include brushing teeth or using a sponge to remove debris, in accordance with the facility's oral hygiene policy. Despite these requirements, both residents did not receive the necessary oral care as ordered and outlined in their care plans.
Failure to Monitor Weight in Tube-Fed Resident
Penalty
Summary
The facility failed to ensure that a resident receiving tube feedings had their weight monitored, resulting in significant weight loss. The resident, identified as R112, had a history of difficulty swallowing due to a stroke and was on a gastrostomy tube feeding regimen. The Physician Order Sheet indicated that R112 was to receive Glucerna 1.5 at 60 ml per hour for 10 hours daily, supplemented by a general diet of mechanical soft with nectar thick fluids. Despite recommendations from the dietitian to monitor the resident's weight weekly, no weights were recorded for December 2024, and the resident experienced a weight loss from 173 pounds in November 2024 to 156.6 pounds in January 2025, a 9.36% decrease. The dietitian, V13, noted that R112's food intake was poor in November 2024 and had reinstated the tube feeding order with an increased rate of 75 ml per hour. However, the resident's weight was not monitored as recommended, and the December weight was not recorded. The facility's policy required monthly weights and more frequent monitoring for residents at nutritional risk, but this was not adhered to. The physician, V25, confirmed that weight monitoring should be done at least monthly for tube-fed residents, and weekly if weight loss is detected. The lack of timely weight monitoring led to the resident's significant weight loss, highlighting a deficiency in the facility's adherence to its weight monitoring policy.
Facility Fails to Ensure Palatable Food for Residents
Penalty
Summary
The facility failed to ensure that food was palatable for resident consumption, affecting four residents in the sample. During a lunch service, the cooked chicken was observed on the steam table and required reheating in the oven before being served. Several residents reported that the chicken was hard, tough, dry, and overdone, with one resident unable to eat it and another only consuming half of the portion. A test tray provided to surveyors confirmed that the chicken appeared dry and overcooked, with a tough texture. The Assistant Food Service Manager acknowledged that the food should not be hard or dry, indicating that chicken should be juicy on the inside.
Failure to Assess and Approve Self-Administration of Medications
Penalty
Summary
The facility failed to assess and approve a resident for self-administration of medications, specifically nebulizer treatments. A male resident, who was admitted with chronic respiratory failure, tracheotomy, and chronic obstructive pulmonary disease, was observed self-administering a nebulizer treatment without an assessment or physician's order. The resident reported that the respiratory therapist provided him with the medication ampule, and he initiated the treatment himself. The Director of Nursing confirmed that an assessment and physician order are required for residents to self-administer any medication, including nebulizer treatments. The Respiratory Therapy Manager, who provided the medication to the resident, was unaware of this requirement. The resident's medical records lacked an assessment for self-administration and did not include a physician's order for the nebulizer treatment. Additionally, the resident's care plan did not address self-administration of medications, contrary to the facility's policy, which mandates an assessment and physician order for self-administration requests.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical and verbal abuse by another resident. An incident occurred where a resident, identified as R84, was involved in a physical altercation with another resident, R166. Both residents were described as alert and oriented with no cognitive impairments. The altercation began as a verbal disagreement in R166's room, which escalated to R84 being knocked out of her wheelchair onto the floor. A Certified Nursing Assistant (CNA), V15, witnessed the incident and intervened to prevent further harm. R84 reported pain in her left lower extremity and right arm but refused a full body assessment and any diagnostic tests. Following the incident, R84 expressed a desire to press charges against R166, leading to police involvement and R166's arrest. The facility's Administrator, V1, substantiated the abuse after an investigation, noting that R166 had a clenched fist directed at R84, although no further physical harm was inflicted. R84 was granted an order of protection against R166, who was not allowed to return to the facility. The facility's Abuse Prevention and Reporting policy, last revised in 2022, emphasizes that residents should be free from all forms of abuse, including physical and verbal abuse.
Failure to Follow Abuse Policy for Resident with Criminal History
Penalty
Summary
The facility failed to adhere to its abuse policy for a resident, identified as R166, who was admitted with a criminal history that included a HIT for domestic battery. The initial criminal history background check was initiated on 5/28/24, but due to an error in recording the resident's race, the process was delayed. A second report dated 6/27/24 confirmed the HIT, but the facility did not act on this information. The administrator and assistant administrator were unaware of the HIT until after an incident on 11/1/24, when R166 was involved in a physical altercation with another resident, R84. The facility's policy required immediate fingerprinting upon identifying a HIT, but this step was not taken. The admissions staff, V28, admitted to the error in recording the resident's race and the subsequent delay in processing the background check. V28 was not present when the final background check results were received, and the necessary follow-up actions, such as notifying social services for fingerprinting, were not executed. The facility's abuse policy mandates requesting background checks within 24 hours of admission and taking all necessary steps to ensure resident safety while awaiting fingerprint results. However, these procedures were not followed, leading to the deficiency identified in the report.
Failure to Provide Meaningful Activities for Dementia Residents
Penalty
Summary
The facility failed to provide meaningful activities to two residents with dementia, leading to deficiencies in meeting their needs. Resident R70, who enjoys activities such as bingo, puzzles, and arts and crafts, was observed in bed multiple times without any activities being offered. Despite being part of the Activity on Wheels (AOW) program, R70 expressed boredom and a lack of engagement. The Activity Assistant, V8, was unaware of R70's preferences and only offered activities that R70 did not enjoy, such as music. This lack of personalized activity offerings contributed to R70's inactivity and dissatisfaction. Similarly, Resident R111, who benefits from sensory activities and enjoys watching movies and TV shows, was observed in her wheelchair without any activities being offered. Staff repeatedly redirected her to sit down without providing engaging activities. The Activity Assistant, V8, admitted to not seeing R111 due to leaving early and noted that R111 was often asleep. The facility's policy requires activities to meet the interests and preferences of each resident, but the lack of available sensory items and insufficient staffing on the dementia unit contributed to the failure to provide appropriate activities for R111.
Failure to Evaluate and Provide ROM Exercises for Resident
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) was properly evaluated for a brace and received the necessary ROM exercises. The resident's care plan, initiated in October 2022, indicated the need for an active assisted ROM program 3-7 days a week. However, an order for restorative nursing to evaluate the resident's left wrist and finger contractures for a splint was not acted upon. This order was dated November 26, 2024, but by January 14, 2025, the resident had not been evaluated for a possible splint, and the resident reported not receiving routine ROM exercises. Observations and interviews revealed that the resident's left wrist was contracted at about 90 degrees, and the resident was unable to move the wrist and index finger. The resident mentioned requesting a brace from a doctor over a month ago, but no action had been taken. The restorative nurse was unaware of the evaluation order and confirmed that the resident had not been evaluated for a splint. Documentation showed that the resident did not receive ROM exercises 3-7 days a week for several weeks, with multiple instances of missing documentation or notes indicating that ROM was not applicable, meaning it was not done.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to ensure proper supervision during medication administration for two residents. In the first instance, a resident was found with an orange pill, identified as Adderall, on their bedside stand. The resident admitted to not taking the medication because they did not want to stimulate their system further. The resident's Physician Order Summary (POS) indicated an active order for Adderall to be administered twice daily, but there was no order permitting self-administration. The nurse responsible for administering the medication believed the resident had taken it, highlighting a lapse in supervision. In the second instance, another resident was found with two plastic medication cups containing approximately 18 medications. The resident stated that the medications were left with them to take later with food. The Director of Nursing confirmed that no residents had orders to self-administer medications, and nurses were required to supervise medication ingestion. The resident's POS did not include an order for self-administration, and the Medication Administration Summary showed a scheduled administration of 16 pills that morning. The facility's policy mandates supervision during medication administration, which was not adhered to in these cases.
Infection Control Deficiencies in PPE Use and Isolation Signage
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and signage for residents on isolation, leading to deficiencies in infection control. In one instance, a Certified Nursing Assistant (CNA) entered the room of a resident on contact isolation for extended-spectrum beta-lactamases (ESBL) without wearing the required gown and gloves. The resident's care plan and the facility's contact precautions policy both indicated the necessity of these protective measures, yet they were not followed. This oversight was observed during a survey, highlighting a lapse in adherence to infection control protocols. Additionally, the facility did not display isolation signs or provide PPE outside the rooms of two residents who tested positive for COVID-19. A Licensed Practical Nurse (LPN) confirmed the absence of necessary signage and PPE, which should have been in place following the residents' positive test results. The Infection Preventionist acknowledged the oversight, noting that the signs were not moved after room changes. The facility's infection prevention manual mandates isolation with signage and PPE for residents testing positive for COVID-19, but these measures were not implemented as required.
Failure to Assess and Administer Vaccinations
Penalty
Summary
The facility failed to properly assess and administer vaccinations for influenza and pneumonia to three residents, leading to a deficiency in their immunization practices. Resident 27, who was over the age of 65, received an influenza vaccine on January 14, 2025, but it was noted that the vaccine should have been offered at the start of the flu season. The Infection Control Preventionist (ICP) Nurse, V24, attempted to contact the resident's Power of Attorney (POA) but was unsuccessful and did not document the communication attempt. Resident 23, also over the age of 65, had received a Prevnar 13 dose on April 21, 2024, but was due for another pneumonia vaccine dose, which had not been administered. Resident 17 had received a Pneumovax dose in 2018, but there was uncertainty about which dosage was administered, and no follow-up was conducted to verify this information. The facility's policy, revised on April 21, 2022, states that residents should be educated about the benefits and side effects of immunizations upon admission, and once consent is given, the influenza vaccine should be administered annually. Additionally, residents should be offered influenza immunizations from October 1 through March 31 annually and pneumococcal immunizations per CDC recommendations. However, the facility failed to adhere to these policies, as evidenced by the lack of timely vaccination and follow-up for the residents in question. The ICP Nurse acknowledged these oversights, indicating a lapse in the facility's vaccination assessment and administration processes.
Neglect in Hand and Nail Care Leads to Resident Injury
Penalty
Summary
The facility failed to provide adequate hand and nail care to a dependent resident with a hand contracture, resulting in a foul odor and an open wound on the resident's palm. The resident, who has a history of encephalopathy, traumatic subdural hemorrhage, and other significant medical conditions, was dependent on staff for activities of daily living, including personal hygiene. Despite the care plan indicating the need for active assistive range of motion and monitoring of skin integrity, the resident's hand care was neglected. Observations revealed that the resident's fingernails were excessively long, with one nail causing a cut to the palm of the contracted hand. The resident's room had a foul odor, and there was a noticeable build-up of debris on the resident's hand. Interviews with staff indicated that hand care should be performed daily for residents with contractures, but this was not done for the resident in question. The facility's policies for nail care, morning/nighttime care, and bed baths were not followed, as evidenced by the lack of documentation and the condition of the resident's hands. The Director of Nursing and other staff acknowledged the oversight, noting that the resident's nails should have been trimmed and hand care provided regularly. The wound care team had to intervene to treat the open wound caused by the long fingernail. The facility's failure to adhere to its own policies and procedures for resident care led to the resident's injury and the need for immediate medical attention.
Delayed X-ray Reporting and Treatment After Resident Fall
Penalty
Summary
The facility failed to ensure timely completion and reporting of an X-ray and delayed treatment for a resident who experienced a fall. The resident, who had a history of chronic kidney disease, hemiplegia, and vascular dementia, was found on the floor by a nursing supervisor. Despite the resident's complaints of pain and visible discomfort, the X-ray order was not marked as urgent, leading to a delay in obtaining and reviewing the results. The X-ray, which revealed an acute intertrochanteric fracture of the right femur, was completed and signed by the radiologist on the evening of the fall. However, the results were not reviewed by the facility's staff until the following afternoon, resulting in a delay of over 20 hours before the resident was transferred to the hospital for emergency care. During this time, the resident continued to experience pain, and there was a lack of documentation regarding ongoing monitoring of the resident's condition. Interviews with facility staff revealed communication breakdowns and procedural lapses. The Director of Nursing acknowledged that the X-ray should have been ordered as STAT and that the results should have been monitored more closely. The Nurse Practitioner, who ordered the X-ray, was not informed of the results until the next day, which contributed to the delay in the resident receiving appropriate medical attention.
Inadequate Supervision Leads to Resident Fall and Hip Fracture
Penalty
Summary
The facility failed to provide adequate supervision for a resident at high risk for falling, resulting in an unwitnessed fall and a right hip fracture. The resident, who had a history of moderate cognitive impairment, hemiplegia, and was at high risk for falls, was found on the floor by a nursing supervisor during rounds. The resident was unable to recall the details of the fall and complained of pain in the right leg. An X-ray confirmed an acute intertrochanteric fracture of the proximal right femur. The resident's care plan indicated a high risk for falls due to confusion and gait/balance problems, yet there was a lack of continuous monitoring and documentation of the resident's condition following the fall. The nursing staff did not document any progress notes from the time of the fall until the resident was sent to the hospital the next day. The resident was in pain and had decreased mobility, but the facility delayed sending her to the hospital for evaluation and treatment. Interviews with staff revealed that the resident was previously able to ambulate with a walker and minimal assistance but required a total lift and non-weight bearing status after the fall. The facility's fall prevention program aimed to ensure resident safety by assessing fall risks and implementing appropriate interventions, but these measures were not effectively executed in this case, leading to the resident's injury.
Failure to Quickly Identify Code Status Delays CPR
Penalty
Summary
The facility failed to have an effective process in place for staff to quickly identify a resident's code status, leading to a delay in providing cardiopulmonary resuscitation (CPR) to a resident who was found unresponsive and pulseless. The resident, who was a Full Code according to their POLST form and physician orders, did not receive immediate CPR due to staff's inability to quickly verify the code status. This delay contributed to the resident's death in the facility. The incident involved a cognitively impaired resident with diagnoses including dementia, cerebral infarction, dysphagia, and schizophrenia, who was dependent on staff for care. On the evening of the incident, a Certified Nursing Assistant (CNA) found the resident unresponsive in their room but did not check for a pulse or call for help immediately due to uncertainty about what to do. The CNA sought assistance from a Registered Nurse (RN), who also did not know the resident's code status and had to leave the room to check the electronic medical record, further delaying the initiation of CPR. Interviews with facility staff revealed that there was no quick method to verify a resident's code status, as it required checking the electronic medical record or DNR lists in binders on crash carts. The facility's CPR policy required immediate assessment and initiation of CPR for Full Code residents, but staff were not adequately prepared to follow this protocol, resulting in a critical delay in emergency response for the resident.
Removal Plan
- Social Services Director and Director of Nursing completed full facility audit of DNR status to ensure all POLST forms are in place and match code status in PCC.
- Facility staff were educated on where resident code status is available via PCC as well as POLST binders located at each crash cart on each unit to quickly identify a resident's CPR/code status.
- Staff educated on facility's Code Blue Policy and process on what to do should a resident be found unresponsive and pulseless to ensure no delay in CPR.
- Education on Code Blue policy and POLST binders location on each crash cart to quickly identify code status has been included in facility new hire orientation process and annually for all staff.
- Education has been provided to all RNs, LPNs, and CNAs staff currently present in the facility and all staff not present in the facility, have been in-serviced over the phone and will be re-inserviced before the start of their next shift.
- Emergency QA meeting conducted with facility Medical Director.
- The Director Of Nursing/DON will conduct random audits of 5 staff members, 4 times a week for 3 months, to ensure staff is able to state facility's Code Blue Policy, how to quickly identify a resident's code status, and immediately initiate CPR as/when indicated.
- The DON will conduct random audits of 5 staff members, 4 times a week for 3 months, to ensure they are aware of the POLST binders located on each crash cart in the facility for quick identification of code status.
- Social Services will conduct audits of POLST binders, 2 times a week for 3 months, to ensure the binders are up to date with the latest POLST information.
Verbal Abuse Incident Involving Staff Member
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse, as evidenced by an incident involving a resident and a staff member. The incident began when a resident, concerned about their brother's oxygen concentrator, approached a staff member for assistance. The staff member, identified as V12, responded inappropriately by using profanity and expressing frustration. This interaction escalated when the resident reported the issue to other staff members at the nurses' station, and V12 continued to use inappropriate language and behavior towards the resident. Multiple staff members, including nurses and a CNA, witnessed the altercation at the nurses' station. Despite attempts by other staff to de-escalate the situation, V12 persisted in using profanity and refused to step back when instructed. The facility's camera footage corroborated the accounts of the staff, showing V12 approaching the resident and engaging in a verbal confrontation. The resident expressed feeling unsafe when V12 was present, indicating the impact of the verbal abuse on their sense of security. The facility's investigation concluded that V12's behavior was unprofessional and constituted verbal abuse. The facility's policy affirms the right of residents to be free from abuse, and this incident was a clear violation of that policy. The report includes interviews with the involved parties and witnesses, as well as a review of the facility's camera footage, which all supported the finding of verbal abuse by V12.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse, as evidenced by an incident involving two residents. Resident 1 (R1) wandered into another resident's room and began taking food from trays. During this interaction, Resident 2 (R2) pushed R1, causing her to fall and sustain a small laceration on her right eyebrow. The incident report did not initially identify R2 as the resident who pushed R1. The facility's preliminary investigation noted an allegation of physical abuse involving R1 and R2. Observations and interviews conducted on 5/20/24 revealed that R1 had a scabbed laceration on her right eyebrow and bruising on her forehead and shoulder. R1 reported being pushed by a man, which caused her to fall and injure her right leg. A housekeeper, V8, witnessed the incident and confirmed that R2 pushed R1 with significant force, resulting in R1 hitting her head on the floor. The facility's abuse prevention policy requires that resident-to-resident altercations be reviewed as potential abuse situations, especially when they result in physical injury.
Failure to Monitor Resident Post-Fall
Penalty
Summary
The facility failed to adequately assess and monitor a resident for 72 hours following a fall in which the resident hit her head. This deficiency was identified for one resident in a sample of eight reviewed for quality of care. On May 8, 2024, the resident experienced a fall in front of her bathroom door and reported hitting her head. The Director of Nursing confirmed that post-fall procedures, including vital signs and neurological checks, were not completed for the required 72-hour period following the incident. The resident's fall report documented initial vital signs, but subsequent monitoring and documentation were not conducted as per the facility's policy, which mandates 72 hours of documentation by all three shifts after an incident.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to ensure a resident room was free from pests, specifically cockroaches, for one of the residents reviewed. On multiple occasions, staff and residents reported the presence of cockroaches in the room, with one resident showing the surveyor a hole in the bathroom wall where the pests were entering. Despite claims of spraying, the infestation persisted, and no efforts were made to seal the room or repair the hole. The Maintenance Director acknowledged awareness of the issue but had not taken steps to address it or communicated the problem effectively with other staff members. The facility's Pest Control policy, last revised on 9/1/22, mandates that employees promptly report pest observations and ensure all building openings are tight-fitting and free of breaks. However, this policy was not followed, as the maintenance request book did not contain recent reports of the roach problem, and the issue remained unresolved for weeks. The resident affected by the infestation had not been offered relocation to another room, and the problem continued to impact their living conditions.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Waukegan Health And Rehab | 0.1 mi | — | 3 | 0 |
| The Terrace | 2.2 mi | — | 2 | 1 |
| Claridge Healthcare Center | 5.2 mi | — | 5 | 2 |
| Alpine Care Of Zion | 6.4 mi | — | 6 | 0 |
| Libertyville Manor Ext Care | 6.7 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.