Waukegan Health and Rehab

In the surveyor’s words

From the most serious findings on record at Waukegan Health and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 22, 2023

  Based on observation, interview, and record review the facility failed to safely transfer a resident (R1). This failure resulted in R1 being hit in the head with the arm of the mechanical lift, resulting in a large skin tear, being admitted to the hospital, and requirng sutures to her head. This applies to one of three residents (R1) reviewed for safety in the sample of five. The findings include: The facility assessment dated [DATE] shows R1 to be cognitively intact, requires maximum assistance for her activities of daily living and uses a mechanical lift for her transfers. On 12/21/23 at 11:15 AM, R1 said she was being lifted from her bed to her wheelchair using the mechanical lift. R1 said as she was being lowered to her wheelchair, the arm bar on the lift hit her in the head. […]

• Actual harm, isolatedF689Nov 30, 2023

  Based on interview and record review the facility failed to ensure a resident was assisted in safe manner to prevent injury for 1 of 3 residents (R1) reviewed for safety in the sample of 4. This failure resulted in (R1) sustaining a fall and receiving a right ankle fracture. The findings include: R1's face sheet shows she has diagnoses including: Parkinsonism, anxiety disorder, auditory and visual hallucinations, and a history of falls. R1's current care plan shows on 10/6/23 Impaired Memory care plan was initiated which says R1 is having impaired memory and problems with decision-making, insight, logic, calculation, reasoning, planning and judgement. R1's active Fall Risk care plan initiated 3/9/17 shows R1 is at risk for falls and she requires a one person assist for transfers. […]

• Actual harm, isolatedF686Oct 26, 2022

  Based on observation, interview and record review, the facility failed to identify and assess prior to developing unstageable and stage 3 pressure injuries. These failures resulted in R49 developing multiple unstageable pressure injuries. The failure also resulted in R49 developing a [CONDITION(S)] infection in R49's sacral wound. This applies to 2 of 5 residents (R49 & R58) reviewed for pressure injuries in the sample of 18. The findings include: 1. R49's face sheet lists his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R49's face sheet shows, he was admitted to the facility on [DATE]. R49's skin observation tool dated June 2, 2022 on admission shows, he had a stage two pressure injury to his coccyx. There were no other pressure injuries documented on the initial skin assessment. […]

• No harm, potential for more than minimal, widespreadF812Aug 12, 2026

  Based on observation, interview, and record review the facility failed to ensure kitchen cookware was adequately cleaned and sanitized prior to using them for food preparation, failed to ensure food preparation equipment was properly sanitized before use, and failed to ensure food temperatures were taken after final cooking and prior to serving lunch. This has the potential to affect all residents that receive food from the kitchen. The findings include: Centers for Medicare and Medicaid Services form 671 shows there are 82 residents residing in the facility. Facility provided list of residents receiving tube feedings as nutrition shows three residents have orders for tube feeding (R16, R54, R5). R16's meal ticket shows R16 also receives a puree diet.1. […]

• No harm, potential for more than minimal, widespreadF812May 21, 2025

  Based on observation, interview, and record review the facility failed to ensure safe food handling practices were followed to prevent cross-contamination. This has the potential to affect all residents that receive food and nourishments from the kitchen. The findings include: Centers for Medicare and Medicaid form 671 dated 5/19/25, shows there are 88 residents that reside in the facility. On 5/21/25 at 10:40 AM, V10 (Director of Culinary Services) said at this time, all residents residing in the facility receive food, beverage, or nourishment from the kitchen at this time; even those receiving a tube feeding because they are ordered pleasure feeding. 1. On 5/19/25 at 11:25 AM, V11 (Cook) dropped a white cleaning towel onto the floor. […]