Wellspring Lutheran Services: Dignity Violation - MI
He was receiving intravenous antibiotics through a PICC line, a catheter threaded into a large vein, along with insulin and a prescription nasal spray....
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He was receiving intravenous antibiotics through a PICC line, a catheter threaded into a large vein, along with insulin and a prescription nasal spray....
The inspection, completed August 14, 2025, was triggered by a complaint....
The facility's nurses typically work 12-hour shifts, either 7 AM to 7 PM or 7 PM to 7 AM, so the gap was not ambiguous....
The facility was cutting staff because of empty beds, she said....
He came back with open wounds on both legs and his left elbow, complaints of pain in his legs, his back, and his bottom....
R1 said it was too early for his medication....
Crenshaw Blvd., was cited for failing to maintain an environment that supports resident dignity and well-being....
No investigation followed that would have satisfied federal standards....
The violation affected some residents and was classified as having minimal harm or potential for actual harm....
The resident, identified in inspection records as R89, was admitted to McLean County Nursing Home on May 23, 2025....
Aides, nurses, and the food service director all told the same story, one complaint at a time....
He told inspectors on August 13 that he was getting colostomy care every day....
Inspectors visited the facility on August 11 and 12, 2025, as part of a complaint investigation....
The people or facilities now caring for those two residents received almost nothing in writing about what had happened to them during their stay....
The sequence of failures began the Friday before, when Resident B returned to the facility after a hospital stay....
That happened on July 27, 2025, at Landmark at 95th Rehabilitation and Nursing Center on West 95th Street....
The care plan required checks every two hours....
The man, identified in inspection records only as Resident 5, told inspectors he urinated in his brief while waiting for staff to respond....
The incident began on May 21, when V6 found R1 standing in urine in the bathroom....
That resident, identified in inspection records as R4, has morbid obesity, type 2 diabetes, and generalized anxiety disorder....