Aspyre of Waukegan

Inspectors wroteBased on interview and record review the facility failed to supervise a resident with dementia, poor safety awareness, and known exit seeking behaviors resulting in the resident eloping from the second floor of the facility through an alarmed door, walking down 14 interior steps, and going out a second alarmed door that led outside. R1 proceeded down 4 concrete steps, onto a wooden deck, turned right, and went down a wooden ramp, across the facility's parking lot, then crossed a busy 4 lane street. R1 then walked through another parking lot of an apartment complex and was found unresponsive (deceased ) near the back of the apartment building approximately 125 yards from the facility's emergency exit door on 4/8/26. This applies to 1 of 6 residents (R1) reviewed for safety and supervision in the sample of 12. The Immediate Jeopardy began on 4/8/26 when R1 eloped from the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident received a higher level of care for a resident experiencing respiratory distress. This delay in medical intervention resulted in R77's death. This applies to 1 of 21 residents (R77) reviewed for care and services in the sample of 21. The Immediate Jeopardy began on [DATE] when the resident (R77) was found having respiratory distress and died the same day. V1 (Administrator) was notified of Immediate Jeopardy on [DATE] at 2:45 PM. This surveyor confirmed by interview and record review that Immediate Jeopardy was removed on [DATE] but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on observation, interview and record review the facility failed to identify and assess a pressure ulcer prior to developing a new unstageable pressure ulcer and failed to implement pressure relieving interventions for a resident at risk for developing pressure ulcers. This failure resulted in R59 developing an unstageable pressure ulcer to her right ischium. This applies to 1 of 6 residents (R59) in the sample of 21 reviewed for pressure injuries.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that dishware and utensils were sanitized prior to use, failed to safely store open lunch meat in the refrigerator, failed to store bulk item scoops in a sanitary manner and failed to ensure hands were washed before preparing food items. This applies to all 77 residents who reside at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to have a Water Management Plan that includes an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread, control measures to prevent the growth of opportunistic waterborne pathogens and a system to monitor the control measures. The facility also failed to ensure residents with wounds and an indwelling urinary catheter were placed on Enhanced Barrier Precautions and facility staff failed to remove their gloves and wash their hands to prevent the spread of infection. This applies to all 77 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with limited range of motion had splints in place for 4 of 12 residents (R63, R6, R16, R32) reviewed for range of motion in the sample of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were stored in a locked area, failed to ensure medications were stored in a manner to not compromise the integrity of the medication and failed to have schedule II controlled substances double locked. This applies to 5 of 5 residents (R29, R13, R48, R50 and R64) reviewed for medication storage in the sample of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the pureed rice was in the form to meet the resident's needs for 6 of 6 residents (R5, R23, R37, R39, R49 and R64) reviewed for pureed diets in the sample of 21.

Inspectors wroteBased on interview and record review the facility failed to ensure a PASRR (Preadmission Screening and Resident Review) was completed after a Serious Mental Illness (SMI) diagnosis change for 1 of 6 residents (R4) reviewed for PASRR in the sample of 21.

Inspectors wroteBased on interview and record review the facility failed to ensure a PASRR (Preadmission Screening and Resident Review) was completed for a resident with a SMI (Serious Mental Illness diagnosis for 1 of 6 residents (R54) reviewed for PASRR in the sample of 21.

Inspectors wroteBased on observation, interview and record review, the facility failed to safely transfer a resident and failed to ensure fall interventions were in place for 2 of 21 residents (R73, R32) reviewed for safety in the sample of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nutritional supplements were given for a resident with significant weight loss. This applies to 1 of 8 residents (R11) reviewed for weight loss in the sample of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications as ordered at ordered times. There were 26 opportunities with 2 errors resulting in a 7.6% error rate. This applies to 1 of 4 residents (R6) observed in the medication pass. On 2/22/26 at 11:00 AM, V13 (Licensed Practical Nurse-LPN) prepared R6's morning medications including Amiodarone 200 mg (milligrams) give via g-tube two times a day for arrhythmia and Metoprolol 25 mg give half of tablet two times a day for hypertension. R6 crushed the medications separately and administered the medications through R6's g-tube. At 11:30 AM, V6 said R6 was her last resident for morning medication pass. On 2/26/26 at 10:51 AM, V16 (LPN) said morning medication pass should be from 8:00 AM to 10:00 AM. R6's Medication Administration Record dated February 2026 shows orders to administer at 9:00 AM; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure an antibiotic was given as ordered for 1 of 3 residents (R2) reviewed for medications in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the dishwasher was sanitizing dishes and failed to ensure kitchen staff washed hands to prevent cross contamination to clean dishes which applies to all 77 resident in the facility reviewed for kitchen sanitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in a manner that would prevent foodborne illnesses. This applies to 71 residents who ate food from the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment. This applies to 8 of 8 residents (R7, R11, R17, R24, R43, R47, R50, R58) reviewed for environment in a sample size of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of controlled medication and verify the accuracy of controlled medication logs for residents with controlled medications. This applies to 4 out of 4 (R57, R5, R26, and R44) residents reviewed for controlled medications in a sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store medications for residents receiving insulins and eye drops. This applies to 5 out of 5 (R61, R23, R44, R71, and R42) residents reviewed for medication storage in a sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents needing assistance with eating, oral care, and grooming. This applies to 4 out of 4 residents (R57, R1, R28, and R26) reviewed for activities of daily living in a sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly provide urinary catheter care for 2 of 2 residents (R44, R67) reviewed for urinary catheter care in a sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide thickened liquids for a resident (R60) with an order for nectar-thickened liquids. This applies to 1 of 4 residents (R60) reviewed for diets in a sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to wear PPE (Personal Protective Equipment) for residents who were on EBP (Enhanced Barrier Precautions). This applies to 2 of 2 residents (R64, R44) reviewed for infection control in a sample of 19.

Inspectors wroteBased on interview and record review the facility failed to complete ongoing assessments of a resident after the resident had sustained a fall with injury for 1 of 3 residents (R2) reviewed for quality of care in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident, that had sustained a recent fall with injury, had fall interventions in place for 1 of 3 residents (R2) reviewed for safety and supervision in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure x-rays were obtained in a timely manner for a resident with an acute injury. This applies to 1 of 3 residents (R1) reviewed for radiology in the sample of 3.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to test and record the concentration level of the sanitizer in the low temperature dishwasher at breakfast, lunch, and supper. This failure has the potential to affect all 79 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow recipes to ensure nutritional value and palatability was retained for 9 residents of 9 residents (R21, R8, R7, R1, R19, R383, R38, R75, and R45) reviewed for pureed diets in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with sutures to a surgical wound was assessed and removed in a timely manner. The facility also failed to ensure sutures were removed from a resident's forehead laceration. This applies to 2 of 18 residents (R37 & R38) reviewed for necessary care and services in the sample in 18.

Inspectors wroteBased on observation, interview and record review the facility failed to identify pressure injuries prior to an unstageable necrotic wound and failed to assess a pressure injury when identified. The facility also failed to ensure pressure reliving interventions and treatments were in place. This applies to 2 of 7 residents (R72 & R62) reviewed for pressure injuries in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were offered and/or received the recommended pneumococcal immunizations to 1 of 5 residents (R72) reviewed for immunizations in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to post their nurse staffing information. This has the potential to affect all 79 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to protect a residents right to be free from resident to resident sexual abuse. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from physical abuse for 3 of 13 resident's (R2, R4, R8) reviewed for abuse in the sample of 13.

Inspectors wroteBased on interview and record review the facility failed to protect a resident's right to be free from physical abuse by another resident. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident (R1) was free from sexual abuse from a resident (R2) with known sexual behaviors. This failure resulted in R1 being sexually abused by R2. These failures apply to 1 of 9 residents (R1) reviewed for abuse in the sample of 9. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 9/6/23 when R2 with a known history of sexually inappropriate behaviors started displaying inappropriate sexual behaviors and the facility failed to put interventions in place, and to notify his physician or nurse practitioner of the behaviors. This led to R2 behaviors escalating and R2 sexually abusing R1. V2 (Director of Nursing/DON) was notified of the Immediate Jeopardy on 9/25/23 at 2:00 PM. [...]