Aspyre of Waukegan: Antibiotic Dosing Error - IL
The resident, identified in inspection records only as R2, arrived at the facility on a date redacted from the report with a list of diagnoses that reads like a catalog of compounding vulnerabilities: pneumonia, severe protein calorie malnutrition, legal blindness, dysphagia, chronic obstructive pulmonary disease, decreased white blood cell count, hypothyroidism, hypotension, and bipolar disorder, among others. Her discharge instructions from the hospital, dated December 18, 2025, were straightforward. She was to receive doxycycline 100 mg once daily for three days, starting December 19.
She got the first pill. Nobody gave her the second or third.
The electronic medication administration record showed the order had been entered as a one-time dose rather than as a daily dose across three consecutive days. The distinction matters. Doxycycline prescribed for a bacterial infection like pneumonia is a course of treatment, not a single intervention. The full course is what treats the infection. One dose is not.
The Director of Nursing confirmed the mistake to inspectors on the morning of December 31. "R2 got her doxycycline on the 19th," she said. She explained that the order had been entered for doxycycline 100 mg, one capsule by mouth, one time only for three days. "The doxycycline should have been scheduled one time a day for the duration of 3 days," she said. "R2 received just one dose on the 19th. It looks like the order was entered wrong. It should have been for 3 days."
Twelve days passed between December 19 and December 31. The inspection report does not say whether anyone at the facility caught the error before inspectors arrived, whether R2's pneumonia resolved, or whether she required additional treatment. It does not say who entered the order incorrectly or whether that person was a nurse, a pharmacist, or a data entry staff member. It does not say whether anyone reviewed her medication administration record in the days after December 19 and noticed she had stopped receiving the antibiotic.
The report also does not say whether R2 was told.
What it does say is that R2's medical situation at the time of admission left little margin for error. Severe protein calorie malnutrition weakens the immune system. A decreased white blood cell count does the same. Chronic obstructive pulmonary disease already compromises lung function. A resident with that combination of conditions, admitted specifically because of pneumonia, receiving one-third of her prescribed antibiotic course is not a paperwork problem.
Inspectors classified the violation under the federal standard requiring facilities to ensure residents receive pharmaceutical services that meet their needs, citing the pharmacy services tag. The level of harm was recorded as minimal harm or potential for actual harm, the lower end of the federal harm scale. The deficiency affected few residents, with R2 identified as the one resident out of six reviewed for medications whose antibiotic was not administered as ordered.
The facility's own medication administration policy, in effect since March 2021, states its purpose as ensuring medications are given in a safe manner to prevent medication errors.
The inspection report, a complaint survey, covers a single finding. It does not describe what happened to R2 after December 19, and it does not say whether she was still a resident of the facility when inspectors walked through the door twelve days later. Her chart showed a hospital had sent her there to recover. Whether the incomplete antibiotic course affected that recovery, the record does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aspyre of Waukegan from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Aspyre of Waukegan in WAUKEGAN, IL was cited for violations during a health inspection on December 31, 2025.
Her discharge instructions from the hospital, dated December 18, 2025, were straightforward.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.