Elgin Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 3 residents (Resident #1) reviewed for trauma-informed care. The facility failed to ensure Resident #1 had a care plan that identified possible triggers when Resident #1 had a history of trauma. This failure could place residents at an increased risk for severe psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but no less than two hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation did not involve abuse or did not result in bodily injury, to the facility administrator and to other officials in accordance with State law through established procedures for four (Resident #11, Resident #60, Resident #64, and Resident #98) of 10 residents reviewed for abuse. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in 1 of 1 kitchen. The facility failed to ensure meals were served in accordance with facility dining hours and endure residents were not brought into the dining room to wait for an extended period of time for their food to be served. This failure could place residents at risk of cold food, dehydration, weight loss, and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for one of the facility reviewed for the pest control program. The facility failed to keep flies out of resident rooms, the facility kitchen, and the facility common areas. This failure placed residents at risk of infection, feelings of fear, anxiety, disgust, helplessness, shame, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 17 residents (Resident #15) reviewed for resident rights. The facility failed to ensure Resident #15 was treated with dignity and did not have his name written big on the back of his shirt visible to everyone. This failure could place residents at risk of feeling embarrassed or cause emotional distress. Findings Included:Record review of Resident #15's face sheet, dated 06/16/2026, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for three of eight residents. (Resident #9 Resident #30, and Resident #40) reviewed for reasonable accommodation of needs. 1. The facility failed to ensure the call light system in Resident #9's room was in a position accessible to the resident on 06/14/2026 and 06/15/2026.2. The facility failed to ensure the call light system in Resident #30's room was in a position accessible to the resident on 06/14/2026.3. The facility failed to ensure the call light system in Resident #40's room was in a position accessible to the resident on 06/14/2026. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 14 residents (Resident #36, and Resident #68) reviewed for accuracy of assessments. The facility failed to ensure Resident #36's annual MDS, dated [DATE], accurately reflected her smoking status. The facility failed to ensure Resident #68's annual MDS, dated [DATE], accurately reflected his smoking status. These failures could place residents at risk of inadequate supervision due to an inaccurate assessment for smoking status.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 14 residents (Resident #36 and Resident #68) whose comprehensive person-centered care plans were reviewed. 1. The facility failed to include Resident #36 use of smokeless tobacco in his care plan.2. The facility failed to include Resident #68 use of smokeless tobacco in his care plan. This could affect residents by failing to ensure residents received appropriate care for their health conditions.1. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication rooms. The facility failed to ensure that the medications and/or biologicals stored in the medication room were not expired. This failure could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication and/or treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infects for 1 of 2 residents (Resident #17) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions were followed when TN E failed to wear a gown while providing wound care to Resident #17. This failure could place residents at risk for infection, hospitalization, and decreased quality of life.

Inspectors wroteBased on observation, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 6 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement Resident #1's care plan to reflect the interventions placed for monitoring after being hit by another resident after a resident-to-resident altercation that occurred on 03/14/2026. This failure could place residents at risk of not receiving required interventions to meet their current needs.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for two of five residents (Resident #1 & Resident #2) reviewed for misappropriation. The facility failed to prevent a diversion (misappropriation) of Resident #1's Amphetamine-Dextroamphetamine Oral Tablet 20 MG, about 25 pills reported missing on 09/20/2025. Amphetamine-Dextroamphetamine is used to treat ADHD. The facility failed to prevent a diversion (misappropriation) of Resident #2's Norco Oral Tablet 5-325 MG (Hydrocodone- Acetaminophen) Give 1 tablet by mouth three times a day for pain Active 10/24/2024, 87 tablets (a hydrocodone is pain reliever) delivered by pharmacy and 57 tablets reported missing on 09/25/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable and once developed, failed to ensure necessary treatment and services to promote healing for two (Resident #249 and Resident #40) of five residents reviewed for pressure ulcers. A) The facility failed to ensure Resident #249 who was at risk for skin breakdown received weekly skin assessments to identify skin breakdown. Resident #249 did not have a skin assessment from 04/09/2024 through 04/20/2025. Resident #249 developed a necrotic unstageable pressure ulcer to her sacrum that resulted in Resident #249 developing sepsis and requiring surgical debridement. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #70, Resident #85, and Resident #247) reviewed for rights. The facility failed to ensure LVN N and CNA B knocked on Resident #70, Resident #85, and Resident #247's doors when going into the residents' rooms. The deficient practice could place residents at risk of feeling like their privacy was being invaded or the facility was not their home.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 of 8 Residents (Resident # 22, Resident # 50, and Resident # 74) reviewed for ADLs. The facility failed to ensure Resident #22, Resident #50, and Resident #74 nails were trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserve nutritive value and flavor for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure Dietary [NAME] L followed the puree recipe for biscuits and added apple juice instead of water or stock to the bread puree. This failure could place residents at risk of decreased food intake, hungry, unwanted weight loss, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Aide K wore a beard guard when standing over clean dishes in the dishwashing room. 2. The facility failed to ensure Dietary [NAME] M used proper hand hygiene during food preparation. These failures could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being for one (Resident #84) of 10 residents reviewed for care plans, in that: 1. The facility failed to ensure Resident #84's comprehensive care plan included a smoking plan. This failure could place the residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #40 and Resident #1) of 18 residents reviewed for infection control practices. 1. The facility failed to ensure the Treatment nurse used a cleaning technique on Resident #40's Stage 3 sacral pressure ulcer that did not cross contaminate the pressure ulcer. 2. The facility failed to ensure that MA C performed hand hygiene prior to medication administration for Resident #1. The failure related to wound care technique could place residents at risk for healthcare associated cross contamination leading to worsening of pressure ulcers discomfort, pain, and potential infections. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (Resident #1) reviewed for pain management. The facility failed to ensure Resident #1 received scheduled hydrocodone as ordered from 03/29/24 to 03/31/24. This failure placed residents at risk of increased pain and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a resident with urinary incontinence appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents reviewed for urinary catheters (Resident #1) in that, LVN C inserted a Foley catheter (a flexible tube inserted through a narrow opening into a body cavity particularly the bladder, for removing fluid) in Resident #1 on 03/18/2024 without a physician order and there was moderate amount of blood noted in the catheter drainage bag. There was no supporting documentation for the insertion of the Foley catheter. This failure could place residents being treated or monitor for UTI (urinary tract infection) at risk for infections, discomfort, hematuria (blood in the urine).

Inspectors wroteBased on observation, interview, and record review the facility failed to use the results of an assessment to develop, review and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 4 (Resident #54, Resident #58, Resident #61 and Resident #63) of 22 Residents reviewed for care plans. A) The facility failed to develop and implement a comprehensive care plan that included interventions for when Resident #54 regularly refused his monthly weights to monitor malnutrition with signs or symptoms of muscle wasting/ significant weight loss. B) The facility failed to develop and implement a comprehensive care plan that included documentation of Resident #58's PTSD diagnosis and triggers to prevent re-traumatization or psychosocial harm. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 3 (Resident #58, Resident #61, and Resident #63) of 3 residents reviewed for trauma informed care. The facility failed to provide care in a manner to eliminate and /or mitigate triggers for Resident #58, Resident #61 and Resident #63, who had active diagnoses of Post-Traumatic Stress Disorder. This failure could place residents at increased risk for psychological distress due to re-traumatization.

Inspectors wroteBased on observation and interviews, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally from the only kitchen in the facility in that: 1. The facility failed to provide palatable food that was attractive or appetizing to residents' who complained about food texture, quality, appearance, and taste. 2. The facility failed to follow a recipe when preparing foods. 3. The test tray of the lunch meal foods were dry, over seasoned, and unattractive. This failure could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure dry storage food was properly labeled and dated. 2. The facility failed to ensure dry storage items were sealed properly. 3. The facility failed to ensure beverages left in the freezer were covered/ sealed. 4. The facility failed to ensure damaged or dented canned food items were kept in a separate designated area. 5. The facility failed to properly label and date items in the refrigerator and freezer. 6. The facility failed to ensure expired food was discarded- one container of jelly. 7. The facility failed to ensure kitchen staff practiced proper hand hygiene and glove use. 8. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choices of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging independence in the community for 1 of 2 residents ( Resident #43) reviewed for activities. The facility failed to assess and provide activities for Resident #43 after she experienced a change of condition. This failure could place residents at risk for a decline in social, mental, psychosocial well-being and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1of 3 residents reviewed with limited range of motion (Resident #43), received appropriate treatment and services to prevent a decline in range of motion. The facility failed to ensure Resident #43 had interventions in place for her right- hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her right hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for one of two medication aides (MA C) observed for infection control practices during medication pass. MA C failed to sanitize her hands between residents and grabbed the drinking cups and medication cups by putting her fingers inside the cups during medication pass for Resident #146 and Resident #85. This failure could place residents who require assistance with medication administration at risk for healthcare associated cross-contamination and infections.

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASRR Comprehensive Service Plan form for one (Resident #1) of two resident reviewed for PASRR services. The facility failed to submit a second NFSS request form for PASRR Specialized Services. This failure could place residents with a positive PASRR (this assessment helps decide if a nursing facility was the best place for a person with a behavioral, intellectual or developmental disability) evaluation at risk for not receiving specialized PASRR services to enhance the resident's highest level of functioning and could contribute to a decline in physical, mental, psychosocial well-being and quality of life.