Waukegan, IL

Pavilion Of Waukegan

4-star overall rating with 4-star inspections with $8,328 in total fines with 11 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

2217 Washington Street, Waukegan, IL

(847) 244-4100

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

112

Certified beds

Average residents

82

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1989-07-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.88

Registered nurse staffing · state 0.73 · national 0.68

LPN hours / resident day

0.38

Licensed practical nurse staffing · state 0.64 · national 0.87

Aide hours / resident day

1.97

Nurse aide staffing · state 2.13 · national 2.35

Total nurse hours

3.22

All reported nurse hours · state 3.49 · national 3.89

Licensed hours

1.26

RN + LPN hours · state 1.36 · national 1.54

Weekend hours

2.84

Weekend nurse staffing · state 3.09 · national 3.43

Weekend RN hours

0.84

Weekend registered nurse coverage · state 0.56 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.81

CMS adjusted RN staffing hours

Adjusted total hours

2.99

CMS adjusted total nurse staffing hours

Case-mix index

1.48

Higher values indicate more complex resident acuity

RN turnover

17%

Annual RN turnover · state 44% · national 45%

Total nurse turnover

29%

Annual nurse turnover · state 46% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,908

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

22.08

Composite VBP score used to determine payment impact.

Payment multiplier

0.9828

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 22.31% · Performance 22.55% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

2.16

Baseline 9.86% · Performance 8.57% · Measure score 2.16 · Achievement 0 · Improvement 2.16

Total nurse turnover

6.31

Baseline 47.17% · Performance 37.88% · Measure score 6.31 · Achievement 6.31 · Improvement 3.66

Adjusted total nurse staffing

0.36

Baseline 2.54 hours · Performance 2.82 hours · Measure score 0.36 · Achievement 0 · Improvement 0.36

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 11.87%
10.72%
1.1 pts worse
No Different than the National Rate · Eligible stays 70 · Observed rate 17.14% · Lower 95% interval 8.17%
Discharge to community 30.5%
50.57%
20.1 pts worse
Worse than the National Rate · Eligible stays 53 · Observed rate 18.87% · Lower 95% interval 23.08%
Medicare spending per beneficiary 1.51
1.02
0.5 pts worse
Drug regimen review with follow-up 75.56%
95.27%
19.7 pts worse
Numerator 34 · Denominator 45
Falls with major injury 2.22%
0.77%
1.5 pts worse
Numerator 1 · Denominator 45
Discharge self-care score 27.27%
53.69%
26.4 pts worse
Numerator 6 · Denominator 22
Discharge mobility score 13.64%
50.94%
37.3 pts worse
Numerator 3 · Denominator 22
Pressure ulcers or injuries, new or worsened 2.22%
2.29%
0.1 pts better
Numerator 1 · Denominator 45 · Adjusted rate 1.67%
Healthcare-associated infections requiring hospitalization 8.57%
7.12%
1.5 pts worse
No Different than the National Rate · Eligible stays 42 · Observed rate 14.29% · Lower 95% interval 4.85%
Staff COVID-19 vaccination coverage 32.94%
8.2%
24.7 pts better
Numerator 28 · Denominator 85
Staff flu vaccination coverage 29.47%
42%
12.5 pts worse
Numerator 28 · Denominator 95
Discharge function score 22.73%
56.45%
33.7 pts worse
Numerator 5 · Denominator 22
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date 30%
25.2%
4.8 pts better
Numerator 9 · Denominator 30

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 3.8
2.0
1.8 pts worse
1.9
1.9 pts worse
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 4.0 · Expected 2.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 2.2
2.3
0.1 pts better
1.8
0.4 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 1.7 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 100.0%
89.6%
10.4 pts better
93.4%
6.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 87.2%
91.6%
4.4 pts worse
95.5%
8.3 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.2%
Percentage of long-stay residents experiencing one or more falls with major injury 1.0%
3.3%
2.3 pts better
3.3%
2.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 1.3% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 50.5%
50.3%
0.2 pts worse
11.4%
39.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 45.7% · Q2 55.4% · Q3 50.7% · Q4 50.7% · 4Q avg 50.5%
Percentage of long-stay residents who lose too much weight 2.7%
6.5%
3.8 pts better
5.4%
2.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.7% · Q3 4.3% · Q4 1.6% · 4Q avg 2.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 15.2%
18.5%
3.3 pts better
19.6%
4.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 16.9% · Q3 16.4% · Q4 15.9% · 4Q avg 15.2%
Percentage of long-stay residents who received an antipsychotic medication 32.2%
22.8%
9.4 pts worse
16.7%
15.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 32.4% · Q3 31.6% · Q4 38.2% · 4Q avg 32.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.1%
0.1 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 18.6%
17.2%
1.4 pts worse
16.3%
2.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 39.2% · Q3 4.9% · Q4 10.2% · 4Q avg 18.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 11.9%
15.0%
3.1 pts better
14.9%
3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 17.2% · Q3 4.7% · Q4 10.2% · 4Q avg 11.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.6%
1.1%
0.5 pts better
1.0%
0.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 8.0%
1.7%
6.3 pts worse
1.7%
6.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 8.6% · Q3 6.6% · Q4 1.4% · 4Q avg 8.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 27.0%
21.3%
5.7 pts worse
19.8%
7.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 21.3% · Q3 28.4% · Q4 32.7% · 4Q avg 27.0%
Percentage of long-stay residents with pressure ulcers 6.3%
5.2%
1.1 pts worse
5.1%
1.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 9.3% · Q3 8.0% · Q4 1.4% · 4Q avg 6.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 100.0%
68.8%
31.2 pts better
81.7%
18.3 pts better
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit 15.3%
14.0%
1.3 pts worse
12.0%
3.3 pts worse
Short Stay · 20240701-20250630 · Adjusted 15.3% · Observed 17.0% · Expected 12.4% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 0.0%
2.3%
2.3 pts better
1.6%
1.6 pts better
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 8.2%
63.0%
54.8 pts worse
79.7%
71.5 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 8.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 22.9%
26.2%
3.3 pts better
23.9%
1 pts better
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 26.4% · Expected 27.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-05-21 · Fire 2025-05-21

11 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

9 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Cycle 2 Health 2024-06-12 · Fire 2024-06-12

4 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

9 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Cycle 3 Health 2023-07-27 · Fire 2023-07-27

12 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

11 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-05-21

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2025-06-27

F · Potential for more than minimal harm 2025-05-21

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-06-27

F · Potential for more than minimal harm 2025-05-21

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-06-27

F · Potential for more than minimal harm 2025-05-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-06-27

F · Potential for more than minimal harm 2025-05-21

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2025-06-27

E · Potential for more than minimal harm 2025-05-21

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2025-06-27

E · Potential for more than minimal harm 2025-05-21

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2025-06-27

E · Potential for more than minimal harm 2025-05-21

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2025-06-27

C · Minimal harm 2025-05-21

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2025-06-27

F · Potential for more than minimal harm 2024-06-12

K700 · Miscellaneous Deficiencies

Fire Safety

Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.

Corrected 2024-07-23

E · Potential for more than minimal harm 2024-06-12

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2024-07-23

E · Potential for more than minimal harm 2024-06-12

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-07-23

E · Potential for more than minimal harm 2024-06-12

K225 · Egress Deficiencies

Fire Safety

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Corrected 2024-07-23

E · Potential for more than minimal harm 2024-06-12

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-07-23

E · Potential for more than minimal harm 2024-06-12

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-07-23

E · Potential for more than minimal harm 2024-06-12

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2024-07-23

E · Potential for more than minimal harm 2024-06-12

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2024-07-23

E · Potential for more than minimal harm 2024-06-12

K930 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper storage of liquid oxygen.

Corrected 2024-07-23

F · Potential for more than minimal harm 2023-07-27

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2023-08-20

F · Potential for more than minimal harm 2023-07-27

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2023-08-20

F · Potential for more than minimal harm 2023-07-27

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2023-08-20

F · Potential for more than minimal harm 2023-07-27

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2023-08-20

F · Potential for more than minimal harm 2023-07-27

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-08-20

F · Potential for more than minimal harm 2023-07-27

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-08-20

F · Potential for more than minimal harm 2023-07-27

K531 · Services Deficiencies

Fire Safety

Have elevators that firefighters can control in the event of a fire.

Corrected 2023-08-23

F · Potential for more than minimal harm 2023-07-27

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-09-05

E · Potential for more than minimal harm 2023-07-27

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-08-20

E · Potential for more than minimal harm 2023-07-27

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2023-08-20

E · Potential for more than minimal harm 2023-07-27

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-08-20

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-02

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-12-15

D · Potential for more than minimal harm 2025-10-28

F675 · Quality of Life and Care Deficiencies

Health

Honor each resident's preferences, choices, values and beliefs.

Corrected 2025-11-19

F · Potential for more than minimal harm 2025-05-21

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-06-06

E · Potential for more than minimal harm 2025-05-21

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-05-21

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-05-21

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-05-21

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-05-21

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-05-21

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-05-21

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2025-06-06

D · Potential for more than minimal harm 2025-05-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-06-06

D · Potential for more than minimal harm 2024-06-12

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-06-22

D · Potential for more than minimal harm 2024-06-12

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-06-22

D · Potential for more than minimal harm 2024-06-12

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-06-22

D · Potential for more than minimal harm 2024-06-12

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-22

D · Potential for more than minimal harm 2024-02-13

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2024-03-07

G · Actual harm 2023-12-22

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-01-03

G · Actual harm 2023-11-30

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-15

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-11-27

D · Potential for more than minimal harm 2023-11-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-11-27

F · Potential for more than minimal harm 2023-07-27

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-08-16

E · Potential for more than minimal harm 2023-07-27

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-08-16

D · Potential for more than minimal harm 2023-07-27

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2023-08-16

D · Potential for more than minimal harm 2023-07-27

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-08-16

D · Potential for more than minimal harm 2023-07-27

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-08-16

D · Potential for more than minimal harm 2023-07-27

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-08-16

D · Potential for more than minimal harm 2023-04-25

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-05-17

Penalties and ownership

What sits behind the stars

$8,328 2023-11-15

Fine

Fine · fine $8,328

Fine

$0 2023-11-15

Payment Denial

Payment Denial · denial start 2023-12-23 · 11 days

11 day denial

Ownership

Topper, Aaron

5% Or Greater Direct Ownership Interest · Individual

75% 16 facilities 2007-12-01
Topper, Aaron

W-2 Managing Employee · Individual

0% 16 facilities 2007-07-01

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