Inspection Reports for Lakeview Nursing and Rehabilitation Center

The complaint investigation substantiated that certified nursing assistant V4 physically abused resident R1 by pulling his ear and dragging him out of his chair, resulting in bruising. The incident occurred on 09/04/2025 and was reported and investigated promptly. V4 was suspended and terminated. Police were notified. The resident reported feeling safe and showed no signs of pain or distress at the time of the investigation.

The facility failed to protect a resident from physical abuse by a certified nursing assistant who pulled the resident's ear and forcibly dragged him out of his chair, causing bruising and distress. The abuse was substantiated, the perpetrator was suspended and terminated, and corrective actions including staff education and monitoring were implemented.

The facility was found deficient in multiple areas including call light accessibility, psychotropic medication documentation, ADL care, pressure ulcer prevention, restorative care, respiratory care, medication storage and control, food safety, personal refrigerator monitoring, garbage disposal, infection control, and laundry safety. These deficiencies affected various residents and posed risks ranging from minimal harm to potential for actual harm.

The complaint investigation was triggered by a verbal altercation on 5/8/25 between residents R2 and R3, where R3 spilled water on R2. The investigation dated 5/14/25 found no harm to either resident. Both residents denied abuse and expressed feeling safe. The Chicago Police Department was notified but took no further action.

The facility failed to ensure residents' right to be free from abuse in 2 of 4 residents reviewed. The investigation found a verbal altercation where R3 spilled water on R2, but no physical harm occurred. Both residents received psychiatric services, expressed feeling safe, and denied experiencing abuse. The police were notified but took no further action.

The complaint investigation found substantiated incidents of resident-to-resident abuse involving R1 pushing R2 on 04/06/2025 and punching R4 on 04/29/2025. R1 exhibited increased aggression and socially inappropriate behavior, including refusal of medication and threats to staff and residents. R4 declined police involvement and reported feeling safe in the facility.

The facility failed to prevent and protect residents from resident-to-resident abuse, including physical altercations where R1 pushed R2 and punched R4, accompanied by verbal threats and derogatory language. Staff intervened and separated involved residents, with R1 placed on 1:1 monitoring and eventually sent to the hospital.

The complaint investigation found substantiated issues with nurse call response delays and resident-to-resident physical abuse involving residents R1 and R2, resulting in minor injuries and psych evaluations. Both residents declined police involvement and expressed feeling safe in the facility.

The facility failed to respond promptly to nurse call lights for 3 of 10 sampled residents, with documented delays up to two hours. Additionally, the facility failed to ensure residents' right to be free from abuse, with two residents involved in a physical altercation resulting in minor injuries and psych evaluations.

The complaint investigation substantiated that resident R1 physically abused resident R2 by hitting him in the back on 11/30/2024. Multiple staff and residents witnessed or reported the incident. R1 was placed on 1:1 supervision and transferred for psychiatric evaluation. The facility did not have an abuse care plan for R1.

The facility failed to follow its policy to ensure a resident was free from abuse. Resident R1 physically hit resident R2 in the back during a verbal altercation. No injuries were observed, but the incident was witnessed by staff and residents. R1 was transferred to the hospital for psychiatric evaluation. The facility lacked an abuse care plan for R1.

The complaint involved an allegation that the former receptionist verbally abused resident R2 by telling her to 'shut the f*** up' after R2 gave out a security code. Multiple witnesses confirmed hearing the incident. The resident declined police involvement and reported feeling safe. The facility investigated and was unable to substantiate the abuse but acknowledged inappropriate communication.

The investigation found that the facility failed to prevent verbal abuse by the former receptionist towards resident R2. Although the abuse allegation was ultimately unsubstantiated, the staff member was found to have had inappropriate communication that made the resident feel uncomfortable. The resident reported feeling safe and did not suffer physical or emotional harm.

The complaint investigation found that resident R1 did not receive Tramadol medication on 08/18/2024 and 08/19/2024 despite having a physician's order. Staff reported issues with medication refill prescriptions, emergency medication system outages, and communication failures. R1 reported significant pain and inability to get out of bed without the medication. The facility acknowledged the medication was not administered as ordered and took steps to reorder and retrieve the medication.

The facility failed to administer Tramadol medication to resident R1 on multiple occasions (notably on 08/18/2024 and 08/19/2024) due to prescription and medication availability issues, despite R1 experiencing significant pain. Staff interviews and record reviews confirmed the medication was not available or administered as ordered, and the facility did not adequately address the medication refill and administration process.

The investigation was complaint-driven, focusing on allegations of resident-to-resident abuse, failure to provide adequate treatment and follow-up care, inadequate supervision of a resident with self-harmful behaviors, and medication administration errors.

The facility failed to protect residents from physical and verbal abuse, resulting in injury to one resident. It also failed to provide appropriate treatment and follow-up care for residents' pain complaints, leading to fractures and delayed medical intervention. Additionally, the facility failed to provide adequate supervision to a resident with unsafe behaviors, resulting in a nasal fracture. Medication administration practices were also found deficient.

The facility was found deficient in multiple areas including failure to protect resident dignity by not covering resident information, improper medication self-administration procedures, inadequate home-like environment maintenance, incomplete criminal background checks for residents and employees, failure to provide communication devices for residents with impairments, improper pressure ulcer prevention mattress settings, failure to change midline catheter dressings timely, inadequate respiratory care practices, failure to post accurate daily nurse staffing information, improper food storage temperature monitoring, and lapses in infection prevention and control practices.

The complaint investigation found that the facility did not complete an incident report, comprehensive assessment, or document vital signs after resident R1's fall on 3/24/24. The fall was self-reported by R1 and witnessed by a CNA but was not properly documented or assessed by nursing staff during the night shift. The Director of Nursing confirmed expectations for documentation and assessment were not met.

The facility failed to complete an immediate comprehensive assessment, incident report, and proper documentation in the electronic health record following a fall incident reported by resident R1 on 3/24/24. Nurses did not check vital signs or perform assessments as required, and documentation was missing for the 7pm-7am shift after the fall.

The investigation was complaint-driven, focusing on allegations that the facility failed to provide timely incontinence care, restorative services, and adequate staffing. The findings confirmed these issues affecting residents R8 and R9, with substantiation implied by the detailed observations and interviews.

The facility failed to provide timely incontinence care for one resident, failed to follow restorative care policies for two residents by not providing recommended range of motion exercises, and failed to provide adequate staffing to ensure restorative services were delivered consistently. These deficiencies affected multiple residents and had the potential to impact all residents in the facility.

The complaint investigation included breaches of confidentiality via social media, failure to report and investigate injuries and alleged misappropriation of property, and concerns about medication administration and nursing care. Substantiation status is not explicitly stated.

The facility failed to maintain confidentiality of residents' medical information shared on a social media platform, failed to timely report and investigate an injury of unknown origin and alleged misappropriation of resident property for two residents, failed to conduct ongoing assessment and timely care for a resident with a femur fracture, and failed to administer medications according to physician orders for multiple residents.

The facility failed to maintain hot food temperatures at the required minimum of 135°F during tray assembly, with observed food temperatures below this threshold, potentially affecting 139 residents. The Dietary Supervisor confirmed procedures and risks associated with improper food temperatures.

The complaint investigation included medication administration errors for residents R9 and R10, multiple falls involving residents R1 and R2 resulting in fractures, and improper enteral tube feeding management for resident R4.

The facility failed to ensure residents received medications according to physician orders, failed to provide adequate supervision and assistance to prevent falls resulting in fractures for two residents, and failed to follow policy for enteral tube feeding and flushing for one resident.

The investigation was complaint-related, focusing on the failure to prevent falls for resident R1. The complaint was substantiated as the facility did not provide adequate supervision or update care plans appropriately, resulting in actual harm to the resident.

The facility failed to follow its policy to update and implement fall prevention interventions in the care plan for resident R1, resulting in multiple falls with subdural hematomas. Observations and interviews revealed inadequate supervision and incomplete documentation of interventions such as one-on-one monitoring.

The complaint investigation included issues related to call light accessibility, medication errors including administration of morphine without order, infection control lapses, failure to update care plans, improper supervision of high fall risk residents, inaccurate resident records including COVID-19 testing, failure to follow dietary menus, pest control issues, and vaccination education and tracking failures.

The facility failed to ensure call lights were accessible to residents, maintain privacy of medical records, follow medication administration guidelines including crushing extended-release medications, provide adequate supervision and safety equipment for high fall risk residents, maintain accurate resident records including COVID-19 testing, ensure infection control practices such as cleaning reusable equipment and proper storage of oxygen supplies, provide nutritional needs including pureed diets, properly dispose of garbage to prevent pest harborage, and implement quality assurance programs. Additionally, the facility failed to develop and implement policies and procedures for influenza, pneumococcal, and COVID-19 vaccinations for residents and staff.

The facility failed to properly assess residents for safe self-administration of medications, ensure call lights were within reach for residents, maintain privacy of residents' personal information and urine collection bags, and secure medication carts to prevent tampering or hazards. These deficiencies affected multiple residents and had the potential to impact all residents on affected floors.

The complaint investigation involved resident R1 who experienced falls due to inadequate supervision and failure to use assistive devices properly. The resident reported incidents where wheelchair wheels were not locked, and staff failed to provide necessary assistance, leading to falls and hospital evaluations.

The facility failed to provide adequate supervision and assistive devices to prevent accidents in 1 of 3 residents reviewed. The resident experienced multiple falls due to insufficient supervision and failure to use safety equipment properly, resulting in hospital visits but no apparent injuries.