Lakeside Health & Rehab Center
LAKESIDE HEALTH & REHAB CENTER in CARLINVILLE, IL — inspection on May 26, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
mechanical lift and staff do not want to lift her into her wheelchair and then lift her into the shower chair. R15 stated she wants to cry when staff do not want to assist her in the shower chair and does not understand why staff will do things for other residents and not for her. On 5/22/2026 at 8:43 AM V24, Medical Director, stated it is possible for a resident to feel a lack of dignity and sadness when being left in urine and feces for extended periods of time.On 5/22/26 at 1:00 PM V2, Director of Nursing, stated she expects residents to be cleaned up as soon as staff are made aware. V2 stated she hopes call lights are answered immediately but expects them to be answered within 2-3 minutes because there is enough staff in the facility to answer the lights and report back to the appropriate department. V2 stated she expects staff to treat all residents with dignity and respect and treat residents how they would want themselves and their family to be treated.
The Facility's Resident Council minutes and Grievances were reviewed.
The Facility's Resident Council Minutes dated 4/1/26 documents Nursing: Certified Nursing Assistants (CNA's) not answering call lights in timely manner.The Facility's Grievance Summaries dated 3/4/26 documents residents in resident council meeting stated their call light stays on for long periods of time without being answered.
The Facility's Grievance Summaries dated 4/1/26 documents residents in resident council meeting stated that call lights are not being answered in a timely manner.The Facility's Call Light Guidance Policy dated 7/1/2023 documents Resident call light shall be responded to within a reasonable amount of time. It is the responsibility of all staff to respond to call lights.The Facility's Incontinence Care Policy dated 7/1/23 documents All incontinent residents will receive incontinence care in order to keep skin clean, dry, and free of irritation and/or odor.The Facility's ADL Support Policy dated 7/1/23 documents Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing grooming, and oral care), mobility (transfer and ambulation, including walking), elimination (toileting), dining (meals and snacks), and communication (speech, language, and any functional communication systems.)The Facility's Resident Rights Policy dated 7/2/2023 documents Employees shall treat all residents with kindness, respect, and dignity.
145456 05/26/2026
Lakeside Health & Rehab Center 1200 University Avenue Carlinville, IL 62626
documents R61 was admitted to the facility on [DATE] with diagnoses including human immunodeficiency virus (HIV), toxoplasma meningoencephalitis, cryptococcosis, and streptococcal pneumonia. R61's Minimum Data Set (MDS) dated [DATE] documented R61 was cognitively intact and required partial assistance with bed mobility and transfer. 05/20/2026 10:03 AM, R61 was sitting up in his bed. He was very thin with orbital wasting. He stated he did not receive his IV medications in the Facility for a couple of days on admission and ended up in the ICU (Intensive Care Unit). R61's Physician Order dated 4/23/26 documents Ganciclovir Sodium Intravenous Solution (Ganciclovir Sodium), use 7 milliliters (mL) IV every 12 hours for four weeks related to pneumonia. On 4/24/26 at 4:25 PM, The Facility's (Secure Messaging System) documents V24, Medical Director, was notified that the pharmacy could not deliver R61's IV Ganciclovir Sodium medication to the Facility due to stability issues. On 4/24/26 at 9:43 PM, The Facility's (Secure Messaging System) documents V24 ordered to send R61 to the ER if the Facility cannot obtain the medication. On 4/25/26 at 6:09 AM, The Facility's (Secure Messaging System) documents R61 had not yet been sent to the ER. R61's Progress Note dated 4/25/26 at 9:07 AM documents R61 was not sent to the ER until 6:45 AM. R61's Hospital Records dated 4/25/26 document R61 was admitted to the hospital and later decompensated, requiring transfer to ICU and intubation. On 5/21/2026 at 10:20 AM, V3, Infection Preventionist, stated if the provider gives an order to send a resident to the ER, she would do it immediately unless the provider specified it was a non-emergent transport. On 5/21/2026 at 10:45 AM, V11, Licensed Practical Nurse (LPN), stated if the physician gives an order to send a resident to the ER, she would send them immediately. On 5/21/2026 at 11:05 AM, V9, LPN, stated if the physician wanted a resident to be sent to the ER, she would send them immediately or as soon as possible. On 5/21/2026 at 10:50 AM, V2, Director of Nursing (DON), stated if the physician wants a resident to be sent out to the hospital, they should be sent immediately. On 5/22/26 at 8:41 AM, V24 stated R61 was a very sick, complex patient, so he wanted him to be sent to the hospital if the Facility could not provide the IV Gencyclovir.
The Facility's Undated Change of Condition Protocol documents if it is decided that care or observation cannot reasonably be provided in the Facility, the physician will authorize transfer to an acute hospital, ER or another appropriate setting.
145456 05/26/2026
Lakeside Health & Rehab Center 1200 University Avenue Carlinville, IL 62626
at 11:28 AM, documents the following: Resident had increased confusion this AM she is currently in bed however she believes she is in the bathroom and sitting on the toilet, unable to re-orientate.
Both Nephrostomy tubes are patent and draining dark amber urine with foul odor.
Nephrostomy tubes are flushing without difficulty.
Notified (V24, Medical Director), waiting for response.R10's Progress Note, dated 5/13/26 at 12:04 PM, documents the following: MD (Medical Doctor) in facility. NO received to obtain UA (Urinalysis)/C&S (Culture & Sensitivity).R10's Progress Note, dated 5/15/26 at 5:50 PM, documents the following: Per V24, analysis culture reviewed, new order for resident to start cefpodoxime 200mg twice a day for seven days.R10's Hospital Records, dated 1/6/26 - 1/9/26, documents R10 was admitted with the following diagnoses: Complicated UTI, Hydronephrosis, Malfunction of Nephrostomy Tube, Nephrostomy Tube Failure with Subsequent Urinary Leak, and Septic Shock. R10's Hospital Records, dated 1/17/26 - 1/21/26, documents R10 was admitted with the following diagnoses: UTI, Sepsis, and Septic Shock. On 5/21/26 at 10:50 AM, V2 DON (Director of Nurses), stated V2 stated when a resident is on isolation, they are to have a special trashcan inside the room next to the door. V2 stated staff are to provide hand hygiene, preferably wash their hands with soap and water, before and after care, going from a soiled to clean area, and between glove changes. V2 stated improper hand hygiene can lead to resident's developing UTIs. V2 stated when she sees a resident with a UTI, she will in-service the staff on proper perineal care and infection control.
On 5/22/26 at 8:43 AM, V24, Medical Director, stated R10 has the nephrostomy tubes with recurrent kidney stones that cause the tubes to move/dislodge, because of this, R10 has frequent urine infections. R10 would be sent to the hospital, admitted for a urine infection or replacement of the nephrostomy tubes, then would be sent back to the hospital a day or two later with Sepsis. V24 stated every time R10 has to have her nephrostomy tubes changed, the urologist will order antibiotics.
R10 stated not wearing the appropriate personal protective equipment when a resident is on isolation precautions along with a lack of handwashing can cause an increase in their risk for infections with possible hospitalization.
The Nephrostomy Tube Care Procedure, undated, documents the following, in part: The purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube.
Use sterile technique for dressing changes and irrigation.
Steps in the procedure: perform hand hygiene, open sterile drape and create the sterile field, open several packages of gauze pads, open several packages of provodine-iodine swabs, and open the disposable waste bag and place it away from the sterile field.
Perform hand hygiene and put on clean gloves.
Carefully remove the wet/soiled dressing.
Discard the dressing in the disposable waste bag.
Remove gloves, perform hand hygiene, and put on sterile gloves.
Cleanse the nephrostomy tube site.
Discard soiled swabs.
Remove gloves and perform hand hygiene.
For irrigation: Perform hand hygiene and put on sterile gloves.
145456 05/26/2026
Lakeside Health & Rehab Center 1200 University Avenue Carlinville, IL 62626
diagnosis, the types of tasks and services required of nursing, nursing assistants, and other ancillary
hours for the nursing services department, based on state/federal requirements utilizing the staffing
work schedules may be revised by the Director of Nursing Services when deemed necessary and appropriate to ensure that each resident's needs are met.
The CMS (Centers for Medicare and Medicaid Services), form 671, dated 5/19/26, documents there are 54 residents residing in the facility.
145456 05/26/2026
Lakeside Health & Rehab Center 1200 University Avenue Carlinville, IL 62626
stability issues with the delivery. He sent R61 to the hospital because he was already a very sick,
On 5/22/26 at 1:00 PM, V2, Director of Nursing (DON), stated the Facility should have checked to see
immediately called the pharmacy to see if the medication was available or if there was another way we could obtain the medication or a similar medication.
Then she should have contacted the doctor for further instructions. 2.) R15's Undated Face Sheet documents R15 was admitted to the facility on [DATE] and has a medical diagnosis of Hypertension, Anxiety Disorder, Bipolar Disorder, Depression, and Ogilvie syndrome.
R15's MDS dated [DATE] documents R15 is cognitively intact.
On 5/20/26 at 9:59 AM V19, Licensed Practical Nurse (LPN), observed entering R15's room with medications in a medication up. V19 observed handing R15 the medication cup and exiting R15's room.
On 5/20/26 at 10:03 AM R15 observed with medications spread over bedside table. R15 stated some nursing staff do not watch her take her medications and will leave them on her table.
On 5/20/26 at 10:05 AM R15 observed V19 in the hallway and called V19 into room. R15 informed V19 she was missing a medication and V19 stated she would check on the medication. V19 instructed R15 to take her medications that were on her table since she was now in the room. V19 stated she left the room after giving R15 her medication cup because she had to go check on another resident.
On 5/21/2026 at 10:45 AM V11, LPN, stated nurses are to stay with the residents when administering medications.
On 5/21/2026 at 10:50 AM V2, Director of Nursing, stated the nurses are to stay with the residents when administering medications until all have been taken. V2 stated they only have one resident that is allowed to have medication at bedside, and it is his nose spray.
On 5/21/2026 at 11:05 AM V9, LPN, stated that when administering medications, the nurse is to stay with the resident until all medications are taken.
The Facility's Medication Administration Policy initiated 7/1/23 documents, Medications will be administered safely to residents within the facility by licensed nurses at the specified time/timeframe, following the recommended administration method and will be documented as required. It is the responsibility of all licensed nursing staff to safely administer medications to residents.
Ensure medication has been swallowed before leaving.
145456 05/26/2026
Lakeside Health & Rehab Center 1200 University Avenue Carlinville, IL 62626
chart so that personnel and visitors are aware of the need for and type of precautions. (1) The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/pr instructions to see a nurse before entering the room.
Ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner (red bag), are placed in the resident's room.
The Facility's Hand-Washing Policy dated 7/1/2023 documents This facility considers hand hygiene the primary means to prevent the spread of infections.
All staff will properly wash hands after direct contact with any contaminated substance, after direct resident care, and as instructed.
Employees must wash their hands for fifteen (15) to twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin.
After removing gloves.
After handling items potentially contaminated with blood, body fluids, or secretions.
The Facility's Incontinence Care Policy dated 7/1/2023 documents All incontinent residents will receive incontinence care in order to keep skin clean, dry, and free of irritation and/or odor.
Procedure: wash all soiled skin areas and dry well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination.
The Nephrostomy Tube Care Procedure, undated, documents the following, in part: The purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube.
Use sterile technique for dressing changes and irrigation.
Steps in the procedure: perform hand hygiene, open sterile drape and create the sterile field, open several packages of gauze pads, open several packages of provodine-iodine swabs, and open the disposable waste bag and place it away from the sterile field.
Perform hand hygiene and put on clean gloves.
Carefully remove the wet/soiled dressing.
Discard the dressing in the disposable waste bag.
Remove gloves, perform hand hygiene, and put on sterile gloves.
Cleanse the nephrostomy tube site.
Discard soiled swabs.
Remove gloves and perform hand hygiene.
For irrigation: Perform hand hygiene and put on sterile gloves.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.