CHICAGO, IL - Federal inspectors discovered that residents at Lakeview Rehab & Nursing Center were left in soiled incontinence products for extended periods, with one paraplegic resident receiving care only twice during a 9-hour window, according to a June 2025 inspection report that identified multiple serious care failures at the 150-bed facility.
Prolonged Neglect of Basic Hygiene Needs
The most troubling finding involved a paraplegic resident who required complete assistance with incontinence care. A certified nursing assistant told inspectors that while facility policy required changing and repositioning dependent residents every two hours, "it does not always get done." The aide revealed that this resident might receive morning care around 10:30 AM from the day shift, then wait until the afternoon shift arrived at 3:00 PM for the next change - a gap of approximately 4.5 hours.
The situation worsened in the evenings. Staff reported that afternoon aides typically returned residents to bed around 6:00 PM, potentially leaving them unchanged overnight if protocols weren't followed. The facility's Director of Nursing confirmed that all dependent residents should receive repositioning and incontinence care every two hours, acknowledging the serious deviation from standard practice.
This violation is particularly dangerous for paraplegic residents who cannot reposition themselves or communicate discomfort effectively. Extended contact with urine and feces significantly increases the risk of pressure sores, urinary tract infections, and skin breakdown. The acidic nature of urine and enzymes in fecal matter can cause severe dermatitis within hours. For individuals with limited mobility, these conditions can rapidly progress to deep tissue injuries and systemic infections.
Critical Respiratory Care Failures Endanger Multiple Residents
Inspectors documented widespread failures in oxygen therapy management affecting six residents with respiratory conditions. In one alarming case, a resident's oxygen concentrator was set at 5 liters per minute when physician orders specified only 2-3 liters. The resident himself noticed the error, telling inspectors, "My oxygen should be set at 3 Liters Per Minute."
Excessive oxygen delivery poses serious medical risks. When patients receive oxygen concentrations higher than prescribed, they can develop oxygen toxicity, which damages lung tissue and paradoxically worsens breathing difficulties. In patients with chronic obstructive pulmonary disease (COPD), excessive oxygen can suppress their respiratory drive, potentially leading to carbon dioxide retention and respiratory failure.
Additionally, inspectors found nasal cannulas and oxygen tubing strewn on floors, wrapped around bed rails, and left unprotected on top of oxygen tanks. None of the equipment was properly labeled or dated, making it impossible to track when items needed replacement. Multiple residents lacked required signage warning of oxygen use in their rooms, creating fire hazards throughout the facility.
The facility's infection control procedures for respiratory equipment were non-existent. Used nebulizer masks and nasal cannulas touched contaminated floor surfaces, then were reused without proper cleaning. This practice can introduce bacteria directly into residents' respiratory systems, particularly dangerous for those already experiencing breathing difficulties.
Restorative Care Program Collapses
Three residents with existing contractures went without prescribed range of motion exercises and protective devices for weeks. One quadriplegic resident with severe hand contractures had no splints or palm protectors available, despite physician orders requiring these devices for 4-6 hours daily. When the restorative nurse checked the resident's room, she confirmed that protective devices had been unavailable "for a while" and that she had only recently requested replacements.
The restorative aide responsible for providing range of motion exercises admitted to inspectors that he hadn't been able to perform the prescribed exercises for all assigned residents "because of time." He was working from an outdated list from June 2024 that excluded residents who required services. When pressed, he acknowledged being pulled away for escort duties and floor coverage when staff called off.
Contractures develop when muscles and connective tissues permanently shorten due to prolonged immobility. Without regular range of motion exercises and proper positioning devices, joints become fixed in bent positions, causing pain and further limiting function. For stroke survivors and those with neurological conditions, the failure to provide restorative care can mean the difference between maintaining some independence and becoming completely dependent for all activities.
Medication Storage Violations Risk Patient Safety
The inspection revealed dangerous lapses in controlled substance security and medication storage protocols. Controlled medications requiring double-lock protection were found in an unlocked refrigerator, with the lock discovered on the floor. Completed controlled substance orders that should have been returned to the pharmacy remained in storage areas, creating opportunities for diversion.
Insulin requiring refrigeration was stored at room temperature in medication carts, potentially destroying its effectiveness. When insulin is exposed to temperatures above recommended ranges, its molecular structure breaks down, reducing its ability to regulate blood sugar. For diabetic residents, receiving compromised insulin could result in dangerous blood sugar spikes, leading to diabetic emergencies.
Temperature logs for medication refrigerators showed multiple missing entries, with staff failing to monitor storage conditions for vaccines and temperature-sensitive medications. Without proper temperature monitoring, medications can lose potency or become contaminated, rendering them ineffective or potentially harmful.
Infection Control Breakdown During COVID-19 Isolation
Two residents with confirmed COVID-19 infections were inadequately isolated, creating facility-wide exposure risks. Isolation rooms lacked trash receptacles for contaminated personal protective equipment, forcing staff to carry used gowns and gloves through hallways to dispose of them. One nurse stated she had repeatedly asked management where to discard PPE but "has not received an answer."
A COVID-positive resident was observed attending resident council, removing her mask and coughing among other residents. She was also seen smoking on the facility's wheelchair ramp, wearing an improper cloth mask that didn't cover her nose, while other residents and staff passed nearby. The resident was supposed to remain isolated until June 12 but was freely moving through the facility on June 10.
The facility's infection preventionist confirmed these residents should have remained in their rooms with doors closed, using proper medical-grade masks only when absolutely necessary to leave for medical reasons. The breakdown in isolation protocols exposed all 150 residents to potential COVID-19 transmission.
Pattern of Systemic Failures
The inspection documented additional violations including expired milk in the kitchen, missing food safety protocols, and fire hazards from lint-clogged dryers. Personal refrigerators lacked thermometers and temperature logs, creating food safety risks. Outside garbage dumpsters overflowed with lids unable to close, attracting pests.
These widespread failures reflect systemic breakdowns in basic care delivery, staff training, and administrative oversight. The facility's own policies clearly outlined proper procedures for incontinence care, medication management, and infection control, yet staff either didn't know or didn't follow these protocols.
The June 2025 inspection classified multiple violations as causing "minimal harm or potential for actual harm," affecting groups ranging from "few" to "many" residents. While no immediate jeopardy citations were issued, the pattern of neglect across multiple care areas demonstrates an environment where residents' basic needs and safety were consistently compromised.
Federal regulations require nursing homes to provide care that maintains residents' highest practicable physical, mental, and psychosocial well-being. The violations at Lakeview Rehab & Nursing Center represent fundamental failures to meet these standards, leaving vulnerable residents at risk for preventable complications, infections, and decline in their overall health status.
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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