Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0610
Respond appropriately to all alleged violations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to immediately investigate an injury of unknown origin for 1 of
3 residents (R1) reviewed for abuse in the sample of 7.
Residents Affected - Few
The findings include:
R1's face sheet printed on 11/9/23 showed diagnosis including but not limited to cerebrovascular disease,
ataxia (muscle movement impairment), aphasia (speech impairment), and vascular dementia without
behavioral disturbance. R1's facility assessment dated [DATE] showed severe cognitive impairment. The
assessment showed total staff assistance required for bed mobility, transfers, locomotion, dressing, toilet
use, and personal hygiene. The same assessment showed R1 is always incontinent of urine and bowel.
R1's care plan showed a focus area related to incontinence. Interventions included check pads or briefs
every two hours and report any red areas to the nurse.
R1's progress note dated 11/7/23 (Tuesday) showed around 6:30 AM a CNA reported a bruise to R1's
lower abdomen/pubic area. The writer checked on R1 and was noted with purplish discoloration to the
pubic/lower abdomen area measuring approximately 10 x 6 centimeters. The nurse practitioner and director
of nursing checked on resident. No complaints of pain or discomfort made known, resident is alert,
non-verbal, contracted to both upper and lower extremities. Appears comfortable and smiling.
On 11/9/23 at 11:45 AM, V5 (CNA-Certified Nurse Aide) stated she was providing incontinence care for R1
about one week ago and found a bruise on R1's pelvic/pubic area. It was dark purple and approximately the
size of a grapefruit. V5 said she found it after breakfast on 11/3/23 (Friday). V5 said she reported the bruise
to the floor nurse (V4), the CNA supervisor (V6), and the wound care nurse (V7). V5 said she went to the
room with V6 and V7 and all three of them viewed the pelvic area together. V5 said they were next to the
bed and the brief was open for V7 to examine the bruising. V5 said she continued to care for R1 over the
weekend and saw the same bruise on Saturday and Sunday. At 1:15 PM, V5 was interviewed again and
was certain she saw and reported the bruising on 11/3/23.
On 11/9/23 at 12:50 PM, V6 (CNA Supervisor) was interviewed regarding V5's report of bruising on
11/3/23. V6 said he did not remember any report or see any bruising. V6 said he did see V7 (WCN-wound
care nurse) and V5 (CNA) in R1's room that Friday. They were at R1's bedside while looking at her arm and
discussing a bruise. V6 said he remembered they were having a conversation about something in the room,
at the bedside.
On 11/9/23 at 12:55 PM, V7 (Wound Care Nurse) stated she did not know anything about a bruise to R1's
body until 11/7/23 (Tuesday). V7 said she did not remember being in R1's room with V5 on that Friday, four
days prior.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
145621
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145621
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pavilion of Waukegan
2217 Washington Street
Waukegan, IL 60085
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0610
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 11/9/23 at 1:09 PM, V4 (Licensed Practical Nurse) stated she did not know anything about R1's bruised
pelvic area until 11/7/23 (Tuesday).
On 11/14/23 at 10:18 AM, V2 (Director of Nurses) stated she was notified of a bruise to R1's lower
abdomen/pelvic area on 11/7/23 in the morning. V2 said the night CNA (V9) reported it to the floor nurse.
V2 said she went and looked at the area with V10 (Nurse Practitioner). The pelvic bruise was palm-size and
a yellowish, purplish, greenish color. V2 said she could not determine how many days old the bruise was.
V2 said an investigation was begun that day. V2 said during staff interviews, V5 stated she had found the
bruise four days earlier and reported it to the floor nurse, wound care nurse, and CNA supervisor. V2 said
V5 was uncertain of the exact reporting date until she looked at her cell phone calendar for verification.
On 11/15/23 at 7:12 AM, V10 (Nurse Practitioner) stated she assessed R1's bruising with V2 on 11/7/23
(Tuesday). The pelvic area was light purple and appeared to have been there a few days. V10 said it was
fading in color and not a new bruise. V10 said new bruises are a dark purple-reddish color. R1's bruise was
lighter and spreading in a manner that indicated it was older. V10 estimated the bruise was approximately 3
days old.
On 11/15/23 at 6:45 AM, V9 (CNA) stated she cared for R1 overnight 11/6 to 11/7. V9 said she did check
R1's for incontinence during the night. V9 said she used the hallway light to limit the activity and not disturb
resident sleep. V9 said she saw the pelvic bruising for the first time in the morning and reported it. V9 said
the pelvic bruise was light purple and not super dark like new ones. V9 said the bruise looked old and was
starting to fade away.
On 11/15/23 at 10:25 AM, V2 (DON) stated new resident bruises should be investigated immediately after
being discovered. It is a team effort to determine why and how it happened. V2 said R1's bruise was
absolutely an injury of unknown origin based on the unusual location and size. It is important to investigate
immediately to determine if abuse is occurring. The investigation determines if other residents or staff are
involved and protects the residents.
The facility's initial incident report to the Illinois Department of Public Health and the start of the
investigation was dated 11/7/23 (four days after being discovered).
The facility's Abuse Prevention Program policy date 2/7/17 states under the Internal Investigation section: If
classified as an 'injury of unknown origin' the person gathering facts will document the injury, the location
and time it was observed, any treatment given and notification of the resident's physician, responsible party.
The Department of Public Health will be notified. Time frames for reporting and investigating the abuse will
be followed. The policy states under the reporting section: The nursing staff is responsible for reporting the
appearance of suspicious bruises, lacerations, or other abnormalities of an unknown origin as soon as it is
discovered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145621
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145621
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pavilion of Waukegan
2217 Washington Street
Waukegan, IL 60085
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to implement neurological assessments following an
unwitnessed fall. This applies to 1 of 5 residents (R2) reviewed for falls in the sample of 7.
Residents Affected - Few
The findings include:
R2's admission Record (Face Sheet) showed an original admission date of 8/29/23. The Face Sheet
showed diagnoses to include traumatic subarachnoid hemorrhage (a bleed in the space surrounding the
brain due to a traumatic event); injuries due to a motor vehicle accident; schizoaffective disorder; and
altered mental status.
R2's 9/5/23 admission Minimum Data Set (MDS) showed he had moderate cognitive impairment with a
brief interview for mental status score of 12 out of 15. The MDS showed he required limited assistance of
one person for walking in his room. The MDS showed he used a walker and wheelchair for mobility.
On 11/14/23 at 11:13 AM, V14 Speech Therapist stated R2 and the room next to his share a bathroom. V14
said she was working in the adjoining room when she heard a bang and R2 had opened the bathroom door
with his back as he fell to the ground. V14 said she notified the nurse immediately. V14 stated R2 was one
of her patient's and she had seen R2 prior to his fall. V14 said, R2 had complained of a headache the day
of his fall.
On 11/9/23 at 1:53 PM, V12 Registered Nurse stated she was R2's nurse on 9/28/23, the day of his fall.
V12 said the fall was not witnessed. V12 said the fall happened at around 1:00 PM. V12 said R2 stated he
had gotten up to the go to the bathroom and then fell in the bathroom. V12 said R2 was known to have
headaches. V12 said neurological checks (neurochecks) should be done on unwitnessed falls every 15
minutes for 2 hours. V12 said the neuro checks will continue for 72 hours at a tapered frequency. V12 said
she would have documented R2's neurochecks in the electronic charting system. V12 was unable to locate
any neurochecks for R2, other than her head to toe assessment on 9/28/23. (The assessment did not
specify neurochecks were completed and did not mention a headache.) V12 said she did not do
neurochecks at that time because she believed she only needed to do them once a shift. V12 said the
15-minute neurocheck interventions was not implemented for an unwitnessed fall until after R2's fall.
On 11/9/23 at 2:25 PM V13 Certified Nursing Assistant stated R2 fell about 5 minutes after she delivered
his lunch tray. V13 said this was between 12:30 PM and 1:00 PM. V13 said the fall was not witnessed.
On 11/9/23 at 2:36 PM, V8 Registered Nurse stated she has been a nurse at the facility for several months
and neurochecks are done every 15 minutes for 2 hours for an unwitnessed fall. V8 said this policy has
been in place since she began her employment at the facility.
On 11/9/23 at 1:09 PM, V11 Restorative Nurse/Falls Coordinator stated almost all unwitnessed falls are
sent to the emergency department for evaluation. V11 said this is a precaution. V11 said if the resident
remains in the facility after an unwitnessed fall the nurse should initiate neurochecks. V11 said neurochecks
should be done every 15 minutes for the first several hours. V11 said the purpose of neurochecks is
because certain problems like a brain blead can take a while to develop and show symptoms. V11 said the
neurocheck intervention for falls is not apart of the facility's policy;
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145621
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145621
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pavilion of Waukegan
2217 Washington Street
Waukegan, IL 60085
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
however, the nursing staff have been trained on it.
Level of Harm - Minimal harm
or potential for actual harm
On 11/14/23 at 11:39 AM, V11 stated neurochecks every 15 minutes for 2 hours has been in place for
months, for quite a while. V11 said R2 was at an elevated risk for another brain bleed due to his recent
history. V11 said given R2's recent history of brain bleed and the fall was unwitnessed; he would have done
neurochecks every 15 minutes for two hours then continue with them per the facility training. V11 said R2
was sent out to the hospital for evaluation the day of his fall because he was not able to sit unsupported at
the edge of his bed. V11 said this was a change for R2 who was expected to be discharged home in a few
days.
Residents Affected - Few
R2's 9/28/23 Nurses Note from 3:10 PM showed R2 was transported to the hospital. (Approximately two
hours after his fall.)
R2's 9/28/23 Nurses Note from 2:29 PM showed R2 had slipped in the bathroom and a physical
examination was completed. (The note did not mention neurological status.)
The facility's Fall Prevention Program (Revision 5/2023) does not address unwitnessed falls or
neurochecks.
On 11/15/23 at 12:35 PM, 15 minute neurochecks from 9/28/23 were requested and not provided.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145621
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the
Respond appropriately to all alleged violations.
FAQ · About this visit
Common questions about this visit
What happened during the November 15, 2023 survey of WAUKEGAN HEALTH AND REHAB?
This was a inspection survey of WAUKEGAN HEALTH AND REHAB on November 15, 2023. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WAUKEGAN HEALTH AND REHAB on November 15, 2023?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.