Aspyre of Waukegan

In the surveyor’s words

From the most serious findings on record at Aspyre of Waukegan, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 13, 2026

  Based on interview and record review the facility failed to supervise a resident with dementia, poor safety awareness, and known exit seeking behaviors resulting in the resident eloping from the second floor of the facility through an alarmed door, walking down 14 interior steps, and going out a second alarmed door that led outside. R1 proceeded down 4 concrete steps, onto a wooden deck, turned right, and went down a wooden ramp, across the facility's parking lot, then crossed a busy 4 lane street. R1 then walked through another parking lot of an apartment complex and was found unresponsive (deceased ) near the back of the apartment building approximately 125 yards from the facility's emergency exit door on 4/8/26. […]

• Immediate jeopardy, isolatedF684Feb 25, 2026

  Based on interview and record review the facility failed to ensure a resident received a higher level of care for a resident experiencing respiratory distress. This delay in medical intervention resulted in R77's death. This applies to 1 of 21 residents (R77) reviewed for care and services in the sample of 21.The Immediate Jeopardy began on [DATE] when the resident (R77) was found having respiratory distress and died the same day.V1 (Administrator) was notified of Immediate Jeopardy on [DATE] at 2:45 PM. […]

• Immediate jeopardy, isolatedF600Sep 26, 2023

  Based on interview and record review the facility failed to ensure a resident (R1) was free from sexual abuse from a resident (R2) with known sexual behaviors. This failure resulted in R1 being sexually abused by R2. These failures apply to 1 of 9 residents (R1) reviewed for abuse in the sample of 9. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 9/6/23 when R2 with a known history of sexually inappropriate behaviors started displaying inappropriate sexual behaviors and the facility failed to put interventions in place, and to notify his physician or nurse practitioner of the behaviors. This led to R2 behaviors escalating and R2 sexually abusing R1. V2 (Director of Nursing/DON) was notified of the Immediate Jeopardy on 9/25/23 at 2:00 PM. […]

• Actual harm, isolatedF686Feb 25, 2026

  Based on observation, interview and record review the facility failed to identify and assess a pressure ulcer prior to developing a new unstageable pressure ulcer and failed to implement pressure relieving interventions for a resident at risk for developing pressure ulcers. This failure resulted in R59 developing an unstageable pressure ulcer to her right ischium. This applies to 1 of 6 residents (R59) in the sample of 21 reviewed for pressure injuries. The findings include: R59's face sheet shows she has diagnoses including type 2 diabetes, unspecified dementia, hypertensive heart disease, dysphagia and bilateral hearing loss. On 2/22/26 at 9:51 AM, V10 (Licensed Practical Nurse-LPN) said R59 has an open area to her right buttock with a foam dressing. […]

• Actual harm, isolatedF600Jan 13, 2023

  Based on observation, interview, and record review the facility deprived a resident of a STAT X-Ray for 40 hours, failed to notify the physician of the delay, and the facility deprived the resident of assessments after a transfer incident. The neglect began on 12/28/22 at 8:00 PM, when the facility was aware of a delay in imaging and ended on 12/30/22 at 4:30 AM (approximately 32 hours later) when the resident was transported to a local area hospital. This applies to 1 of 3 residents (R1) reviewed for nursing care in the sample of 4. […]