A list of the most recent deficiencies for Pavilion of Waukegan. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-22 | 2024-01-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-30 | 2023-12-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-15 | 2023-11-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-15 | 2023-11-27 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-03 | 2023-09-05 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-08-03 | 2023-08-23 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-08-03 | 2023-08-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-03 | 2023-08-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-03 | 2023-08-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-08-03 | 2023-08-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-03 | 2023-08-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-03 | 2023-08-20 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-08-03 | 2023-08-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-03 | 2023-08-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-08-03 | 2023-08-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-07-27 | 2023-08-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-27 | 2023-08-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-27 | 2023-08-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-27 | 2023-08-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-07-27 | 2023-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-27 | 2023-08-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-25 | 2023-05-17 | Y |
| Have proper power supply for life support equipment. | Fire Safety | 2022-11-04 | 2022-12-06 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-11-04 | 2022-12-02 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-11-04 | 2022-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-04 | 2022-12-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-04 | 2022-12-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-04 | 2022-12-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-04 | 2022-12-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-26 | 2022-11-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-10-26 | 2022-11-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-26 | 2022-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-26 | 2022-11-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-26 | 2022-11-19 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-10-26 | 2022-11-19 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-10-26 | 2022-11-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-26 | 2022-11-19 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-11-17 | 2021-12-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-17 | 2021-12-30 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-11-17 | 2021-12-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-17 | 2021-12-30 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-17 | 2021-12-17 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-03 | 2021-11-24 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-11-03 | 2021-11-24 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-11-03 | 2021-11-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-11-03 | 2021-11-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-03 | 2021-11-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-21 | 2021-05-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-04-21 | 2021-05-13 | N |
