Crescent Care of Elgin

In the surveyor’s words

From the most serious findings on record at Crescent Care of Elgin, in the surveyor’s own words.

• Immediate jeopardy, patternF689Nov 16, 2023

  There are multiple deficient practice statements. A. Based on observation, interview and record review the facility failed to ensure water temperatures in resident bathrooms were maintained at a safe level to prevent potential resident injury. This failure resulted in the water in five residents' bathrooms measuring 150(+) degrees Fahrenheit, having the potential to cause third degree burns within 1-2 seconds, at 12:40 PM on 11/13/23. This applies to 5 of 5 residents (R16, R17, R38, R53 and R55) reviewed for safety in the sample of 22. B. Based on observation, interview and record review the facility failed to ensure a resident on a mechanically altered diet was safely assisted to eat for 1 of 22 residents (R39) reviewed for safety in the sample of 22. The findings include: A. […]

• Actual harm, isolatedF686Nov 16, 2023

  Based on observation, interview and record review the facility failed to have ordered pressure reducing interventions in place to prevent R72's stage 2 sacral pressure wound from deteriorating to a stage 3. R72's pressure wound increased in size and depth and worsened in condition. This applies to 1 of 3 residents (R72) reviewed for pressure wounds in the sample of 22. The findings include: R72's Minimum Data Set Assessment of 9/24/23 shows that R72 was admitted to the facility on [DATE] with diagnoses including Renal Insufficiency, Neurogenic Bladder and Paraplegia. This same assessment shows that R72 had a stage 2 pressure ulcer (wound) present upon admission. On 11/14/23 at 8:45 AM R72 was lying in bed awake. R72 was alert and oriented. […]

• Actual harm, isolatedF684Jul 24, 2023

  Based on interview and record review, the facility failed to provide and document post (after) fall nursing assessments for a resident who sustained an unwitnessed fall with injury in accordance with their policy. This failure resulted in a delay in obtaining medical treatment for a resident with a displaced fracture of the leg bone and contusion of the forehead and eye orbit. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 9. The findings include: R1's EMR (Electronic Health Record) showed R1 was readmitted to the facility on [DATE], and discharged to the local Hospital on July 11, 2023. […]

• Actual harm, isolatedF689Jul 24, 2023

  Based on observation, interview, and record review, the facility failed to provide the necessary supervision to a resident to prevent a fall that resulted in a serious injury. This failure resulted in R1 sustaining a leg fracture because of the fall, that required urgent surgery upon admission to the hospital on July 11, 2023. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 9. The findings include: R1's EMR (Electronic Health Record) showed R1 was readmitted to the facility on [DATE], and discharged to the local hospital on July 11, 2023. R1 had multiple diagnoses that including Dementia with psychotic disturbance, glaucoma, hypertension, atherosclerotic heart disease, repeated falls, and cognitive communication deficit. […]

• No harm, potential for more than minimal, widespreadF947Dec 4, 2025

  Based on interview and record review, the facility failed to provide the required twelve (12) hours per year of continuing competence training for Certified Nursing Assistant (CNAs), including dementia management training. This failure has the potential to affect all 68 residents, as indicated in the facility's Centers for Medicare and Medicaid Services (CMS) Form 671, Long-Term Care Facility Application for Medicare and Medicaid report of their current census. The findings include:On 12/2/2025 at 10:20 AM, review of the facility's Certified Nursing Assistant (CNA) orientation packet showed no evidence of dementia-related in-services. […]