Health inspection·November 19, 2025

F 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a light fixture was in safe operating order. This failure resulted in the light fixture falling from the ceiling, landing on the resident while in bed, and R1 sustaining a second degree burn. This applies to 1 of 3 residents (R1) reviewed for safe physical environment in the sample of 3.The findings include:R1' s electronic face sheet documents R1 has diagnoses that include peripheral vascular diseases, left leg amputee, and hypertension.R1's facility assessment, dated 10/3/25, show R1 has no cognitive impairment.R1's Emergency Department (ED note), dated 10/6/25, documents, Patient presented from facility burned to right upper arm. EMS stated light fixture caught on fire and plastic pieces came down on patients' right arm second degree burn noted. Patient alert and denied shortness of breath said he was in his room when the light fixture above had a clot fire and melted plastic pieces dripped down his arm, patient complaining of pain in his right upper arm-skin: warm to touch, 14x 7 centimeter (cm) with blanching erythema as well as epidermal desquamation, the distal palmar surface of the left middle finger has mild blanching erythema. Diagnoses: second degree burns with deep and superficial partial thickness burn-right upper arm as well as superficial partial thickness burn of the palmar aspect of his distal left middle finger due to melted plastic without evidence of infection, tetanus updated in the ER patient was given pain med-improvement of pain. R1 was discharged with topical antibiotic ointment applied three times a day-TID. On 11/18/25 at 10 AM, R1 was alert and pleasant lying in bed. A dressing was noted to his right upper arm. R1 stated, That time when I got burned, I was eating my cereal for breakfast, all of a sudden the light fixture on the ceiling above me exploded, the plastic covering fell on me, it was so hot it burned me it hurt so bad (pointing to his right upper arm), my blankets, my hospital gown were on fire, I was yelling for help! R1's left middle finger redness had subsided. V2 (Director of Nursing) removed R1's dressing. R1's right upper arm was still reddened with several small open areas with clear drainage noted. V2 said R1's right upper arm that was burned was being treated with antibiotic ointments covered with dry dressing.On 11/19/25 at 9:30 AM, V4 (Registered Nurse-RN) said she was R1's Nurse last 10/6/25. V4 (RN) said she was outside R1's room passing morning meds when she heard R1 yelling for help. V4 said she went to R1, there was fire in the ceiling above him; there was fire noted on the side of his bed. V4 said she screamed, help, fire! fire! as she was pulling R1's bed away from the ceiling. V4 said V5 (Certified Nursing Assistant-CNA) came to help pull R1 away from the fire. 911 was called. R1 was sent to the ER. R1 came back to the facility with second degree burns.On 11/18/25 at 1:36 PM, V5 (CNA) said that day (10/6/25) he was collecting breakfast trays from rooms as breakfast was just finishing, when he heard loud screams coming from R1's room. V5 said he ran towards R1's room, the Nurse (V4) was already there pulling R1 in his bed for safety away from the ceiling. A ceiling tile fell on top of R1, smoke was noted in the ceiling, fire sparks were noted inR1's covers. R1 was shocked and confused. R1 was noted to (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 2 Event ID: 145669 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 145669 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Elevate Care Waukegan 2222 Audrey Nixon Boulevard 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)