Inspection·July 30, 2024

F 0563 Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow their policy by not ensuring restricted visitor information was posted for 2 of 3 residents (R1, R3) reviewed for safety in the sample of 3. Residents Affected - Few The findings include: 1. R1's face sheet printed on 7/30/24 showed diagnoses including but not limited to dementia with mood disturbance, psychosis, dysphagia, and adult failure to thrive. The same face sheet showed the names of five family members allowed to visit R1. The face sheet showed instructions to call R1's state guardian if anyone else attempts to visit. R1's facility assessment dated [DATE] showed severe cognitive impairment and total staff assistance required for all ADLs (activities of daily living). R1's July 2024 physician order summary showed hospice care and receiving comfort medications. On 7/30/24 at 10:00 AM, V3 (Social Service Director/SSD) stated R1 was admitted to the facility in November of 2022 and at that time, only five family members were allowed in to see her (R1). V3 said in October of 2023 the state guardian office removed all visitor restrictions after a pending adult protective services case against R1 was resolved (not guilty). V3 said the family dynamics are dysfunctional and the staff had no knowledge of a father even existing until he came to the facility in March of 2024. The father was verbally aggressive, rude, and demanding. The state guardian was notified and instructions to deny R1's father access to the facility was given. V3 said approximately one week later, the father was at the front desk with an aunt and pastor. V3 was notified and made the father leave immediately. V3 said staff are all aware that the father is not allowed in the building, and he has not tried to return. V3 said there is a binder at the front desk showing the receptionists all visitors that are not allowed in the facility. The restricted visitors' names are also posted on a sign behind the front desk. The electronic medical records also show under the special instructions banner who is not allowed to visit. On 7/30/24 at 10:23 AM, V4 (Receptionist) stated she works the day shift, another person covers the afternoon shift, and a third person covers the night shift. V4 said she just knows who is and who is not allowed to visit. V4 said she has it memorized for the current residents and asks a nurse or V3 (SSD) if it is a newer resident. V4 said at one time there was a binder of who is not allowed in the facility, but it was missing. V4 said she could not recall the last time she saw it at the front desk. V4 said signs or notes are also posted at the front desk with names of people that cannot visit. This surveyor observed the front desk area and there was no signage related to restricted visitors. V4 did provide a front desk green binder that showed the names of people that could take (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: 146159 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 146159 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Terrace 1615 Sunset Avenue Waukegan, IL 60087 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)