Elgin Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Elgin Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF686Apr 25, 2025

  Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and once developed, failed to ensure necessary treatment and services to promote healing for two (Resident #249 and Resident #40) of five residents reviewed for pressure ulcers. A) The facility failed to ensure Resident #249 who was at risk for skin breakdown received weekly skin assessments to identify skin breakdown. Resident #249 did not have a skin assessment from 04/09/2024 through 04/20/2025. […]

• Actual harm, isolatedF689Aug 31, 2021

  Based on observation, interviews and record reviews it was determined the facility failed to ensure the facility remained free of accidents and hazards as possible for three of six residents (Resident #1, #3 and #4) and two of three housekeepers reviewed for accidents and hazards. A. The CNA A failed to ensure Resident #1 was provided the required level of assistance of two staff during incontinence care and repositioning, resulting in the resident falling and sustaining a mildly displaced fracture of the proximal fibula (right lower leg) and distal tibia (right ankle). B. […]

• No harm, potential for more than minimal, widespreadF812Feb 14, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and preparation for one of one kitchen. A) The facility failed to defrost one freezer in the dry storage room to prevent ice covering containers of food and the inside of the freezer. B) The facility failed to properly store and label food in the facility's open front refrigerator, open front freezer, open top freezer, food prep table and the dry storage room. […]

• No harm, potential for more than minimal, patternF609Jun 16, 2026

  Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but no less than two hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation did not involve abuse or did not result in bodily injury, to the facility administrator and to other officials in accordance with State law through established procedures for four (Resident #11, Resident #60, Resident #64, and Resident #98) of 10 residents reviewed for abuse. […]

• No harm, potential for more than minimal, patternF812Jun 16, 2026

  Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen. The facility failed to ensure meals were served in accordance with facility dining hours and endure residents were not brought into the dining room to wait for an extended period of time for their food to be served. This failure could place residents at risk of cold food, dehydration, weight loss, and quality of life. Findings included:Record review of Resident #86's face sheet, dated 06/16/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE]. […]