Lakeview Rehab & Nursing Center in Chicago Cited for Multiple Care Deficiencies in June 2025 Inspection
Federal health inspectors documented multiple care deficiencies at Lakeview Rehab & Nursing Center, a Chicago nursing facility located at 735 West Diversey, during an inspection conducted on June 12, 2025, according to data released by the Centers for Medicare & Medicaid Services (CMS) in August 2025.
The inspection, part of CMS's regular oversight program for Medicare and Medicaid certified facilities, identified violations in several critical care areas, with findings classified as "minimal harm or potential for actual harm" affecting multiple residents.
Pressure Ulcer Prevention Failures
Inspectors found that the facility failed to ensure proper functioning of specialized medical equipment designed to prevent pressure ulcers. According to the inspection report, a resident identified as R71 was discovered in bed with a non-functional low air loss mattress on June 9, 2025.
"The machine was not working because the green light was off, and the power was off," the Assistant Director of Nursing told inspectors when summoned to the room. The staff member turned on the power for the mattress and acknowledged that without power, the equipment "cannot work for the resident."
The resident's medical records indicated they had been assessed as at risk for pressure ulcers and had physician orders for the specialized mattress dating from May 2, 2025. The care plan documented that the resident required pressure-reducing equipment due to impaired mobility, incontinence, and other comorbidities.
Oxygen Equipment Management Issues
The inspection also revealed widespread problems with oxygen equipment management affecting six residents. Inspectors documented multiple violations including:
- Oxygen tubing found touching the floor and not properly contained or labeled
- Missing oxygen-in-use signage on resident room doors
- Oxygen concentrators set at incorrect flow rates
- Equipment not dated or changed according to physician orders
In one instance, resident R102's oxygen concentrator was set at 5 liters per minute when physician orders specified 2-3 liters per minute. The facility's registered nurse acknowledged that oxygen levels set higher than ordered "can result in hyperoxygenation" and confirmed that staff nurses were assigned to check oxygen settings daily.
The Director of Nursing stated that oxygen tubing should be changed weekly, contained in plastic bags when not in use, and labeled with dates. "Containment of oxygen tubing in a plastic bag helps with infection control," she told inspectors.
Range of Motion Exercise Deficiencies
Three residents were affected by failures to provide prescribed range of motion exercises and restorative devices, potentially contributing to the progression of contractures. Inspectors observed resident R73 with contractures to both hands but no splints, hand rolls, or other prescribed restorative devices in place.
The facility's restorative nurse found no splints or palm protectors available and stated she had informed the administrator to order the devices. She acknowledged that temporary alternatives like rolled towels secured with kerlix could have been used but were not implemented.
Residents R74 and R57 both reported to inspectors that staff had not been providing range of motion exercises. R74, described as cognitively intact, stated he had left side weakness from a stroke and expressed concern about developing contractures. The restorative aide admitted to inspectors that he had "not been able to do ROM exercises for everyone on the list because of time," citing additional duties like resident escorts and floor coverage during staff shortages.
Controlled Medication Storage Violations
The inspection also identified failures in controlled medication storage protocols. Inspectors found controlled medications stored in an unlocked refrigerator on the third floor medication storage room. When asked about the security, a licensed practical nurse discovered the lock on the floor and acknowledged "the refrigerator should be locked because we have controlled medications in the refrigerator."
The refrigerator contained boxes of Lorazepam, a controlled substance that requires secure double-locked storage under federal regulations.
Facility Response and Context
Lakeview Rehab & Nursing Center, which operates under federal provider number 145654, is required to submit a plan of correction addressing all cited deficiencies. The facility has the opportunity to dispute findings and provide documentation of corrective actions taken.
The inspection findings represent conditions observed at the time of the June 2025 survey. Facilities typically have specific timeframes to correct violations based on their severity level, with immediate jeopardy situations requiring rapid response and less severe issues allowing longer correction periods.
About CMS Nursing Home Inspections
All nursing facilities participating in Medicare or Medicaid programs undergo regular inspections by state survey agencies under contract with CMS. These inspections assess compliance with federal regulations covering quality of care, resident rights, administration, and environmental standards.
Inspection data is typically released 4-6 weeks after surveys are completed, allowing facilities time to respond to findings and submit correction plans. The data used in this report was released by CMS in August 2025 and includes inspection activity through July 31, 2025.
The scope and severity of violations are classified using a matrix that considers both the number of residents affected and the level of harm or potential harm. Deficiencies classified as "minimal harm or potential for actual harm" indicate situations where residents experienced or could experience minor negative outcomes.
Important Information for Families
Family members with loved ones in nursing facilities are encouraged to review inspection reports and discuss any concerns with facility administration. Current inspection data for all Medicare and Medicaid certified nursing homes is available through CMS's Care Compare website.
Residents and families can also contact their state's long-term care ombudsman program for assistance with concerns about care quality or to file complaints about nursing home conditions.