CHICAGO, IL - Federal inspectors documented widespread violations at Lakeview Rehab & Nursing Center during a June 2025 inspection, finding deficiencies in basic resident care, medication safety, infection control, and facility maintenance that potentially affected all 150 residents.
Inadequate Personal Care for Vulnerable Residents
Inspectors found that staff at Lakeview failed to provide proper incontinence care for residents who require assistance with basic daily activities. A paraplegic resident with neurogenic bladder documented that adequate hygiene care was not being provided according to their care plan requirements.
According to the inspection report, a certified nursing assistant stated that dependent residents should receive incontinence care every two hours, but acknowledged this standard was not consistently met. The staff member explained that a resident might receive care at 10:30 AM from the morning shift, then not receive another change until the evening shift arrived at 3 PM - a gap of over four hours.
The facility's Director of Nursing confirmed that residents should be repositioned every two hours and receive incontinence care every two hours for all dependent residents. The facility's own policies required perineal care every two hours and as needed per the care plan, yet implementation fell short of these standards.
This type of care failure can lead to serious medical complications. Prolonged exposure to moisture from incontinence increases the risk of skin breakdown, pressure ulcers, urinary tract infections, and dermatitis. For residents with limited mobility, regular repositioning and hygiene care are essential preventive measures that maintain skin integrity and overall health.
Critical Failures in Pressure Ulcer Prevention
A particularly concerning violation involved a resident at high risk for pressure ulcers whose prescribed low air loss mattress was found completely non-functional. During the inspection, the mattress was observed as "almost flat" with the power turned off, rendering the therapeutic equipment useless.
When facility staff discovered the malfunction, an Assistant Director of Nursing stated that "if it's not turned on, it cannot work for the resident" and suggested someone had mistakenly turned off the power. The resident had physician orders for the specialized mattress and was documented as being at risk for pressure ulcer development.
Low air loss mattresses are critical medical devices designed to reduce pressure on vulnerable skin areas and manage heat and humidity around pressure points. These systems work by providing a continuous flow of air through the mattress surface, which helps prevent the formation of pressure ulcers - painful, potentially life-threatening wounds that can develop when sustained pressure cuts off blood flow to skin and underlying tissue.
When these therapeutic mattresses fail to function, residents face significantly increased risk of developing pressure ulcers, which can progress rapidly from superficial skin damage to deep tissue necrosis. Treatment of advanced pressure ulcers often requires extensive wound care, surgical intervention, and can lead to serious complications including infection and sepsis.
Compromised Infection Control Measures
The inspection revealed serious lapses in infection control protocols that put the entire facility at risk. Two residents with confirmed COVID-19 were not properly isolated according to established protocols, creating potential exposure risks throughout the 150-bed facility.
One COVID-positive resident was observed using a shared bathroom with two other residents, despite facility policies requiring dedicated bathroom facilities for infected individuals. Staff reported they had no proper waste receptacles in isolation rooms for disposing of personal protective equipment, forcing them to carry contaminated materials into hallways before disposal.
"There is not one inside his room. It is [the Infection Preventionist's] responsibility to ensure there are red bins in the isolation rooms to discard used PPE," a housekeeping staff member explained, describing how workers were improvising disposal methods.
The facility's infection preventionist acknowledged that if infected residents share bathrooms with others without proper cleaning protocols, "there is potential to spread infection" to roommates and throughout the facility. Staff were also observed allowing the COVID-positive resident to attend group activities and smoke in common areas while improperly wearing cloth masks instead of required medical-grade face coverings.
Proper isolation protocols are fundamental to preventing healthcare-associated infections. COVID-19 spreads through respiratory droplets, and nursing home residents are particularly vulnerable due to advanced age, underlying health conditions, and close living quarters. Breaches in isolation procedures can rapidly lead to facility-wide outbreaks with potentially fatal consequences for vulnerable residents.
Systemic Failures in Restorative Care Programs
Three residents requiring range of motion exercises and assistive devices were not receiving prescribed care that prevents muscle contractures and maintains mobility. Inspectors found that residents with physician orders for splints and range of motion therapy were not receiving these services due to missing equipment and understaffing.
One resident with hand contractures had no splints or palm protectors available, despite care plan requirements for 4-6 hours daily use. The restorative nurse explained that devices had been ordered but temporary interventions like rolled towels secured with gauze could be used until proper equipment arrived - yet these alternatives were not implemented.
Two cognitively intact residents specifically complained to inspectors that they had not received required range of motion exercises for extended periods. "Staff has not been giving range of motion exercises for the left arm and left leg," one stroke survivor explained, expressing concern about developing contractures.
The facility's restorative aide acknowledged having insufficient time to complete all required exercises and being pulled away for other duties like resident transportation. An outdated resident assignment list further complicated care delivery, with some residents missing from current therapy schedules.
Range of motion exercises are essential for preventing joint contractures, muscle atrophy, and maintaining functional mobility in residents with paralysis, weakness, or limited movement. Without consistent therapy, joints can permanently stiffen, muscles can waste away, and residents can lose whatever independence they might otherwise maintain.
Additional Issues Identified
The inspection documented numerous other violations affecting resident safety and quality of care:
Medication Safety Concerns: Controlled substances were stored in unlocked refrigerators, expired medications remained in resident care areas, and required documentation for narcotic counts was incomplete. Insulin requiring refrigeration was improperly stored at room temperature, and multi-dose medications lacked proper dating.
Respiratory Care Deficiencies: Six residents receiving oxygen therapy had equipment that was improperly maintained, unlabeled, or set to incorrect flow rates contrary to physician orders. Oxygen tubing was found lying on floors creating infection risks, and required safety signage was missing from rooms.
Food Safety Violations: Expired milk products remained in kitchen storage, sanitation equipment was improperly maintained, and personal refrigerators in resident rooms lacked required temperature monitoring and maintenance.
Environmental Hazards: Overflowing garbage dumpsters remained unclosed, creating pest attraction risks. A lint-filled dryer posed fire hazards due to lack of regular cleaning and maintenance schedules.
The violations documented at Lakeview Rehab & Nursing Center represent systematic failures in fundamental aspects of nursing home operations. These deficiencies in basic care, medical device management, infection control, and facility maintenance create an environment where residents face unnecessary health risks and compromised quality of life. The inspection findings highlight the critical importance of consistent oversight, adequate staffing, and rigorous adherence to established care protocols in nursing home settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakeview Rehab & Nursing Center from 2025-06-12 including all violations, facility responses, and corrective action plans.
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