Cycle 1
Health 2025-01-10 · Fire 2025-01-10
10 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Waukegan, IL
The Terrace
3-star overall rating with 3-star inspections with $108,886 in total fines with 10 recent health deficiencies
1615 Sunset Avenue, Waukegan, IL
(847) 244-6700
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
115
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-04-15
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
0.93
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.37
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.05
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.61
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.77
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
2.74
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,883
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.98
Baseline 62.71% · Performance 51.52% · Measure score 2.98 · Achievement 2.98 · Improvement 2.46
Adjusted total nurse staffing
0
Baseline 3.52 hours · Performance 2.31 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.84% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 11.43% · Lower 95% interval 7.47% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 52 · Denominator 52 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 52 |
| Discharge self-care score | 57.58% |
53.69%
3.9 pts better
|
Numerator 19 · Denominator 33 |
| Discharge mobility score | 60.61% |
50.94%
9.7 pts better
|
Numerator 20 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 2 · Denominator 52 · Adjusted rate 2.49% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.17% |
8.2%
3 pts worse
|
Numerator 6 · Denominator 116 |
| Staff flu vaccination coverage | 61.32% |
42%
19.3 pts better
|
Numerator 65 · Denominator 106 |
| Discharge function score | 51.52% |
56.45%
4.9 pts worse
|
Numerator 17 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 100% |
25.2%
74.8 pts better
|
Numerator 30 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
89.6%
8.3 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.3% · Q4 94.6% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.3%
1.5 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 5.6% · Q3 5.4% · Q4 6.8% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 91.4% |
50.3%
41.1 pts worse
|
11.4%
80 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.5% · Q3 82.9% · Q4 86.4% · 4Q avg 91.4% |
| Percentage of long-stay residents who lose too much weight | 11.0% |
6.5%
4.5 pts worse
|
5.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 23.7% · Q3 6.2% · Q4 1.7% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
18.5%
2 pts worse
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 27.0% · Q3 20.3% · Q4 9.1% · 4Q avg 20.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.9% |
22.8%
3.1 pts worse
|
16.7%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 26.8% · Q3 26.5% · Q4 21.4% · 4Q avg 25.9% · 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 | 27.9% |
17.2%
10.7 pts worse
|
16.3%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 25.5% · Q3 32.3% · Q4 28.1% · 4Q avg 27.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.4% |
15.0%
7.4 pts worse
|
14.9%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 17.2% · Q3 17.7% · Q4 32.2% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.1%
0.8 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.4% |
1.7%
2.7 pts worse
|
1.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 3.0% · Q3 4.3% · Q4 2.9% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.6% |
21.3%
2.7 pts better
|
19.8%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 18.9% · Q3 13.4% · Q4 20.9% · 4Q avg 18.6% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
5.2%
1.3 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.8% · Q3 1.3% · Q4 4.7% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.1% |
68.8%
7.3 pts better
|
81.7%
5.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 80.0% · Q3 81.0% · Q4 60.0% · 4Q avg 76.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
14.0%
4.7 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 20.0% · Expected 11.9% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.8% |
63.0%
7.8 pts better
|
79.7%
8.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 70.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.4% |
26.2%
12.2 pts worse
|
23.9%
14.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.4% · Observed 45.0% · Expected 27.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-28 · Fire 2024-02-28
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-04-12 · Fire 2023-04-12
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (12 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-28
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-04-04
F · Potential for more than minimal harm
2024-02-28
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-04-04
F · Potential for more than minimal harm
2023-04-12
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2023-05-18
F · Potential for more than minimal harm
2023-04-12
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-05-18
F · Potential for more than minimal harm
2023-04-12
E22 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for sheltering.
Corrected 2023-05-18
F · Potential for more than minimal harm
2023-04-12
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2023-05-18
F · Potential for more than minimal harm
2023-04-12
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2023-05-15
F · Potential for more than minimal harm
2023-04-12
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2023-05-15
F · Potential for more than minimal harm
2023-04-12
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-05-15
F · Potential for more than minimal harm
2023-04-12
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-05-15
F · Potential for more than minimal harm
2023-04-12
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-05-15
F · Potential for more than minimal harm
2023-04-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-15
F · Potential for more than minimal harm
2023-04-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-15
F · Potential for more than minimal harm
2023-04-12
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-05-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-31
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 2026-01-16
F · Potential for more than minimal harm
2025-06-23
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 2025-06-27
F · Potential for more than minimal harm
2025-01-10
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 2025-02-07
E · Potential for more than minimal harm
2025-01-10
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 2025-02-14
E · Potential for more than minimal harm
2025-01-10
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 2025-02-07
E · Potential for more than minimal harm
2025-01-10
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 2025-02-07
D · Potential for more than minimal harm
2025-01-10
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 2025-02-07
D · Potential for more than minimal harm
2025-01-10
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-10
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2025-02-07
D · Potential for more than minimal harm
2025-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-07
D · Potential for more than minimal harm
2024-12-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-12-11
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 2024-12-20
D · Potential for more than minimal harm
2024-12-11
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-07-30
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2024-08-14
F · Potential for more than minimal harm
2024-02-28
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 2024-03-22
E · Potential for more than minimal harm
2024-02-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-22
C · Minimal harm
2024-02-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-01-31
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 2024-02-23
D · Potential for more than minimal harm
2023-11-07
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 2023-11-28
D · Potential for more than minimal harm
2023-11-01
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 2023-11-15
J · Immediate jeopardy
2023-09-26
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 2023-10-12
D · Potential for more than minimal harm
2023-05-22
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-06-09
F · Potential for more than minimal harm
2023-04-12
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-05-05
F · Potential for more than minimal harm
2023-04-12
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-05-05
F · Potential for more than minimal harm
2023-04-12
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-04-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-04-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-12
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 2023-05-05
D · Potential for more than minimal harm
2023-04-12
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 2023-05-05
D · Potential for more than minimal harm
2023-04-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-05-05
Penalties and ownership
What sits behind the stars
$108,886
2023-09-26
Fine
Fine · fine $108,886
Fine
Ownership
Rpfg Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Laureate Chicagoland Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Ahmad, Shaun
Corporate Officer · Individual
Dempsey, Kathleen
W-2 Managing Employee · Individual
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