South Elgin Living & Rehab Center

In the surveyor’s words

From the most serious findings on record at South Elgin Living & Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, patternF584Feb 1, 2024

  Based on observation interview and record review, the facility failed to maintain a safe, clean, comfortable homelike environment following the disruption of water services due to broken pipes in the facility. The failure resulted in a lack of available handwashing facilities and the accumulation of human feces/urine in the toilets. The lack of response caused a risk for psychosocial harm to residents as evidenced by their disgust for having to eliminate in toilets full of urine/feces and subsequently not have hand washing facilities available to wash hands. […]

• Actual harm, patternF692Sep 26, 2022

  Based on observation, interview, and record review, the facility failed to address residents' nutritional status and implement pertinent interventions to ensure residents did not experience significant weight loss. This failure resulted in R1, R2, R3, and R4 experiencing significant weight loss. This applies to 4 of 4 residents (R1-R4) reviewed for improper nursing in the sample of 4. The findings include: 1. On September 20, 2022 at 9:58 AM, R1 was lying in his bed, wearing a hospital gown. R1 appeared thin/emaciated, with protruding collarbones, and a gaunt appearance to his face, with protruding cheekbones. R1 could not answer questions due to his cognitive status. The facility's undated face sheet shows R1 was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF600Jul 8, 2025

  Based on observation, interview, and record review, the facility failed to prevent resident-to-resident physical abuse. This applies to 2 of 3 residents (R1, R2) reviewed for abuse in the sample of 3. This failure resulted in R2 striking R1 on the nose, resulting in R1 being transferred to the hospital and found to have a fractured nose.Findings include:R1's Face Sheet shows R1 admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, mild intellectual disability, and bipolar disorder. R2's Face Sheet shows R2 admitted to the facility on [DATE] with diagnoses including diabetes, seizures, and depression. The facility's 6/19/25 Final Incident Investigation Report shows an incident between R1 and R2 occurred on 6/15/2025 (Sunday) at approximately 5:15 PM. […]

• Actual harm, isolatedF758May 31, 2024

  Based on observation, interview and record review, the facility failed to follow physician's orders for psychotropic medication administration (R36). The facility failed to follow its psychotropic medication policy by failing to monitor residents (R1, R14, R36) for Extrapyramidal Symptoms due to antipsychotic medication use and failing to attempt/request a Gradual Dose Reduction of a Benzodiazepine medication for a resident (R14) no longer exhibiting anxiety behaviors. These failures resulted in the R36 receiving the wrong psychotropic medications and at excessive dosages. R36 experienced side effects of increased abnormal involuntary movements. This applies to 3 of 5 residents (R1, R14, and R36) reviewed for psychotropics in a sample of 19. The findings include: 1. […]

• Actual harm, isolatedF825Apr 25, 2024

  Based on interview and record review, the facility failed to obtain orders and provide physical therapy services to residents. This failure resulted in a resident with a functional decline (R103) having a delay in receiving physical therapy and taking longer to return to his baseline function. This applies to 3 of 3 residents (R101, R102, and R103) reviewed for therapy services in the sample of 9. The findings include: 1. R103's Medical Record showed R103 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart disease, epilepsy, dementia, and nontraumatic subarachnoid hemorrhage. R103's MDS (Minimum Data Set) dated January 28, 2024, showed R103 had moderate cognitive impairment. […]