Inspection Reports for Admiral at the Lake
929 W Foster Ave, Chicago, IL 60640, United States, IL, 60640
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 14, 2025, identified deficiencies related to residency requirements, disaster preparedness drills, employee record updates, tuberculosis risk assessments, and dementia-specific training. Earlier inspections showed similar issues with residency compliance, disaster preparedness, employee background checks, and training programs. Prior reports from August 23, 2024, cited deficiencies in securing hazardous compounds in the memory care unit, which were addressed with corrective actions and staff training. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports, and no complaint investigations were noted. The pattern of findings suggests ongoing challenges in regulatory compliance, particularly in resident care documentation and safety training, with some corrective measures taken but recurring issues remaining.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 14, 2025
Visit Reason
Annual Licensure Survey conducted to assess compliance with residency requirements, disaster preparedness, health care worker background checks, tuberculosis screening, and Alzheimer's/dementia program training.
Findings
The facility was found deficient in multiple areas including failure to meet residency requirements for one resident, incomplete tornado drills on all shifts, failure to update employee hire dates in the Registry Portal for four employees, lack of documented annual TB risk assessment for one resident, and inadequate dementia-specific orientation training for one employee in the Memory Care unit.
Deficiencies (5)
Failed to ensure residency requirements are met for one resident requiring extensive assistance and hospice care.
Failed to conduct tornado drills on all shifts during February as required.
Failed to update the Registry Portal to include employee hire dates for four employees.
Failed to ensure documented annual TB risk assessment or TB signs and symptoms check for one resident.
Failed to ensure four hours of dementia-specific orientation prior to assuming job responsibilities without direct supervision for one employee in the Memory Care unit.
Report Facts
Employee hire dates missing: 4
Tornado drills conducted: 3
Resident reviewed for residency requirements: 3
Resident reviewed for TB risk assessment: 3
Hours of dementia-specific orientation training completed: 0.75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E8 | Care Partner | Named in deficiency for incomplete dementia-specific orientation training. |
| E3 | Director of Nursing | Confirmed resident R1's condition and discussed staff orientation training. |
| E6 | Facilities Manager | Reported tornado drills had not been conducted this year. |
| E5 | Human Resources Generalist | Confirmed Registry Portal was not updated with employee hire dates. |
| E13 | Care Partner | Observed assisting resident R1 with mobility and care. |
| E14 | Infection Control Nurse | Reported resident R2's TB skin test was not done due to adverse reaction and assessment was not documented. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 14, 2025
Visit Reason
The document is related to the Annual Assisted Living Licensure Survey conducted on 7/14/2025 at The Admiral at the Lake.
Findings
The report includes evidence of correction and payment of violations from the annual survey. It details corrective actions for deficiencies related to residency requirements, disaster preparedness, health care worker background checks, tuberculosis skin test procedures, and Alzheimer’s and dementia training programs.
Deficiencies (5)
Residency requirements not met for all residents.
Disaster preparedness, specifically related to tornado drills, was deficient.
Health Care Worker Background Checks for Employment Verification were not properly conducted.
Tuberculin (TB) Skin Test Procedures were not fully compliant.
Training for Alzheimer’s and Dementia programs was insufficient.
Report Facts
Date of Survey: Jul 14, 2025
Date of Compliance for Residency Requirements: Jul 26, 2025
Date of Compliance for Disaster Preparedness: Jul 25, 2025
Date of Compliance for Health Care Worker Background Checks: Jul 25, 2025
Date of Compliance for TB Skin Test Procedures: Jul 25, 2025
Date of Compliance for Alzheimer’s and Dementia Training: Jul 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Dittmer | Administrator, Director of Health Services | Named in corrective actions and as the person conducting education and oversight |
| Chantal Chine | DON | Involved in review of care plans and corrective actions |
| Karen Clinton | Social Services Coordinator | Named in attendance and corrective action oversight |
| Daisy Krygowski | Resident Accounts Admin | Named in attendance and corrective action oversight |
| Merun Varughese | Infection Preventionist | Involved in TB policy review and infection control education |
| Bethany Tallon | HR Generalist | Involved in employment verification corrective actions |
| Linda Vestrand | HR Director | Involved in employment verification corrective actions |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 23, 2024
Visit Reason
Annual licensure survey conducted to assess compliance with environmental and safety regulations at the facility.
Findings
The facility failed to secure hazardous compounds in the memory care unit, including unlocked utility room cabinets containing moisturizers labeled as hazardous, presence of dishwashing soap in the kitchen preparation room, and scattered boxes of gloves posing choking hazards. The Chief Operating Officer agreed these items should be secured.
Deficiencies (1)
Facility failed to maintain hazardous compounds secure and out of reach in the memory care unit for 9 residents identified as wanderers.
Report Facts
Residents affected: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chief Operating Officer | Agreed that utility room should be locked, kitchen cleaning detergent should not be accessible, and gloves should be secured |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 23, 2024
Visit Reason
The inspection was an annual survey conducted to assess compliance with licensure and certification requirements, focusing on environmental safety related to hazardous compounds storage in the memory care unit.
Findings
The facility was found to have failed to maintain hazardous compounds secured and out of reach in the memory care unit, with unlocked utility room doors and accessible hazardous cleaning products posing risks to residents identified as wanderers. Immediate corrective actions were taken to secure these hazards, and staff training and monitoring plans were implemented.
Deficiencies (1)
Facility failed to maintain hazardous compounds secure and out of reach in the memory care unit for 9 residents identified as wanderers, including unlocked utility room door and accessible hazardous cleaning products.
Report Facts
Residents affected: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chantel Chine | Director of Nursing | Created daily spot check plan and completed monitoring audits |
| Sara V. ADON | Assistant Director of Nursing | Co-signed nursing in-service regarding safe keeping of compounds and hazards |
| Mary Beth Lutjen | Conducted culinary services in-service training on kitchen chemical lock-up | |
| E1 | Chief Operating Officer | Agreed that utility room should be locked and hazardous compounds secured |
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