Health Inspection

Lakeview Rehab & Nursing Center

Inspection Date: June 12, 2025

Total Violations 1

Facility ID 145654

Location CHICAGO, IL

Inspection Findings

F-Tag F132's

face sheet documents diagnosis that includes but are not limited to Unstable Burst Fracture of T7-T8

Vertebra, Neck Fracture, Neurogenic Bladder, Neuromuscular Dysfunction of Bladder, History of Traumatic Diaper Dermatitis, Major Depressive Disorder. Resident R132's Minimum Data Sheets (MDS), dated [DATE REDACTED], in section C -Cognitive Patterns, documents Brief

Interview for Mental Status (BIMS) Summary Score of 15, which indicates intact cognitive function. Resident R132's MDS, dated [DATE REDACTED] in section H - Bladder and Bowel documents that Resident R132 is always incontinent.

08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident R132's Care Plan, revised 7/16/2024 showed in part that Resident R132 is paraplegic and needs assistance with activities of daily living (ADL) and that Resident R132 has self-care deficit and need's assistance with incontinence care.

On 6/10/2025 at 14:35 PM V21 Certified Nurse Assistant (CNA) stated that residents that are paraplegic or dependent should be turned or have incontinence care performed every two hours or as needed, but not always it gets done. V21 stated that Resident R132 might be getting up and get the incontinence care by the morning shift aide 10:30 AM, but then the resident might not get another change until next shift comes on. V21 said

the next aide starts at 3pm and that shift usually gets residents back in the bed around 6pm. V21 said V21 worked pm shifts as well and that is how V21 is aware of when the dependent residents get returned in bed.

On 6/10/2025 at 14:40 PM V2, Director of Nursing (DON) stated residents should be repositioned every 2 hours and the incontinence care should be also done every two hours for all dependent residents. be given routine daily care and bedtime care by a nurse aides and nurses to promote hygiene. Activities of Daily Living (ADL) care is provided throughout the day, evening and night and as needed per care plan. needed for cleansing the perineum and buttocks after and incontinent episode or with routine daily care. The policy also showed the frequency of peri care should be every two hours, and as needed and as per plan of care.

the authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff. Document also showed in part that DON is responsible for the overall management of resident care 24 hours a day, seven days per week. provides direct nursing care to the residents, and supervises the day-to-day nursing activities performed by nursing assistants. performs all assigned tasks in accordance with facility's policies and procedures and as instructed by supervisors. The document also showed that one of the role responsibilities included but not limited to making resident comfortable and assists residents with bathing and daily hygiene, dressing and undressing, keeping residents dry, assisting residents with bowel and bladder functions and keeps incontinent residents clean and dry. 08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate pressure ulcer care and prevent new ulcers from developing. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32338 Based on observation, interview, and record review, the facility failed to ensure that the low air loss mattress ordered for a resident at risk for pressure ulcer is functioning while the resident is in bed. This failure has the potential to affect one resident (Resident R71) of three residents, reviewed for pressure ulcer prevention interventions,

in a total sample of 64 residents.

On 6/9/25 at 11:39 am, Resident R71 was observed awake in bed. Resident R71's low air loss mattress (LALM) was not functional, and the mattress was almost flat. V4 (Assistant Director of Nursing) was summoned to the room and stated that the machine was not working because the green light was off, and the power was off. V4 turned on the power for the LALM, and stated that if it's not turned on, it cannot work for the resident and that it's possible that someone mistakenly turned it off. V4 added that she (V4) believes the mattress will inflate according to the settings and will remind staff to always ensure that the power is not turned off for the machine. Resident R71's records reviewed are as follows: Insufficiency, Dementia, Muscle Wasting and Atrophy, Poly-Osteoarthritis, and Dermatitis.

POS (Physician Order Sheets) dated 5/2/25 shows that Resident R71 has physician orders for low air loss mattress.

Pressure Ulcer Risk assessment dated [DATE REDACTED] stated Resident R71 is at risk for pressure ulcer.

Care plan dated 3/22/22 states Resident R71 is at increased risk for alteration in skin integrity related to: Impaired Mobility Status, Comorbidities, Incontinence of bladder, Incontinence of bowel. Intervention states to use Pressure reducing/relieving mattress and Wheelchair Cushions.

Basic Interview for Mental Status (BIMS) Score is 13 out of 15 (No Cognitive Impairment). recognize the following information and to act on it in such a way as to practice evidence-based recommendations for the prevention treatment of pressure injuries to the residents who reside in this facility.

the resident that provides a flow of air to assist in managing the heat and humidity of the skin. While pressure ulcer/pressure injury prevention and treatment are paramount goals for all residents, it is imperative that facility comply with what is considered non-deficient practice as stated below: Provide preventive care, consistent with professional standards of practice, to residents who may be at risk for development of pressure injuries. Provide treatment consistent with professional standards of practice to an existing pressure ulcer/pressure injury. 08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52136 Based on observations, interviews, and record reviews, the facility failed to provide range of motion exercises and apply restorative devices, potentially contributing to the progression of contractures. This deficient practice affected three (Resident R57, Resident R73, and Resident R74) of three residents reviewed for restorative care in a sample of 64.

1. On 06/9/25 at 10:08 AM, Resident R73 was observed in bed no hand protector/splint in place.

On 6/11/2025 at 9:45 AM, Resident R73 was observed in bed resting with contractures to Resident R73's right and left hand. No hand splits, hand rolls or other restorative braces/services observed in place. V30 (Restorative Nurse, Licensed Practical Nurse) and V31 (Certified Nursing Assistant) entered the room, observed Resident R73 and affirmed that no hand protectors, braces, or other restorative braces/services were in place. V30 stated Resident R73 is on Passive range of motion programs for all extremities and is to receive two sets of 10 reps (repetitions) and wear bilateral splints for hands but can alternate with palm protectors. V30 checked the dresser of Resident R73 and stated that there was no splint or palm protector in available and that she (V30) was informed this week and informed the administrator to order the devices. V30 stated a kerlix or towel could be used in place for temporary use until device arrives at the facility and was not sure why these interventions were not put into place. V31 explained Resident R73 tolerates all rehab but has not had splint available for use in a while. Resident R73's face sheet dated June 11, 2025, documents in part diagnosis information: Contracture of right and left hand, contracture of muscle of left upper arm, quadriplegia, dementia, major depressive disorder, anxiety, unspecified intellectual disabilities. Resident R73's Minimum data set (MDS) dated [DATE REDACTED], documents in part that Resident R73 has impairment with short term and long-term memory, is rarely/never understood, and has impairment of both upper and lower extremities. Resident R37's care plan (12/27/2022) identifies Resident R73 benefits from a splint/brace due to impaired range of motion/loss of functional movement and has an intervention including but not limited to, staff to apply splint/palm protector for 4-6 hours daily or as tolerated. Resident R73's Physician order summary report dated 6/11/2025, documents in part that Resident R73 may use right palm guard for 4-6 hours, if palm guard unavailable may use rolled hand towel.

Purchase form dated 6/9/2025 documents Palm guard x 4 was ordered by V30 (Restorative Nurse, Licensed Practical Nurse) .

On 06/11/25 at 10:14am V2 (Director of Nursing) stated it is the expectation for the restorative nurse/aide to check the resident's skin and perform range of motion exercises to prevent further breakdown, a rolled hand towel that could be stabilized with a kerlix should be utilized if a splint/ palm protector isn't available. V2 stated V2 was just informed today by V30 that there were no available splints/palm protectors available in the facility, V30 is responsible to track supplies and order all restorative supplies and equipment, Job description titled Restorative nurse undated, documents in part; . the restorative nurse is responsible for

the development, implementation, monitoring, and supervision of the restorative nursing program; .Essential job functions: . 9. maintain current listing by resident of all assistive devices and care plan each .18. ensure that restorative equipment and supplies are available as needed .21. Educate and manage the facilities activity of daily living documentation and training program .

Job description titled Restorative aide undated, documents in part; .4. Assist residents to apply and remove splints or protheses .

2. On 6/9/25 at 11:26 am, Resident R74 complained that staff has not been giving range of motion exercises for the

left arm and left leg. Resident R74 explained he has left side weakness from the stroke, and he does not want to get contracted.

3. On 6/9/25 11:41am, Resident R57 complained staff has not helped him with range of motion exercises for more

than 2 weeks.

On 6/9/25 at 12:45 pm, V29 (Restorative Aide) stated that he (V29) is the restorative aide for the second floor and Resident R57 is not on the list of residents he performs range of motion (ROM) exercises for. The surveyor asked V29 for the list of residents on range of motion exercises for the second floor. V29 Presented a list titled Restorative Hot List dated 6/26/24, that did not include Resident R57 but includes Resident R74. V29 added that the list needs to be updated. In the presence of Resident R74 (cognitively intact resident), V29 stated he (V29) has not been able to do ROM (range of motion) exercises for everyone on the list because of time. V29 added, Sometimes, I go on escort with residents. Sometimes, I work on the floor if there is a call off. Today, I have to do escort at 12:15pm.

On 6/9/25 at 1:10pm, V30 (Restorative Nurse) stated all residents are supposed to be on restorative range of motion exercises. V30 stated the list presented by V29 was an old list. At this time, V30 presented another list titled Restorative Nursing Programs Master Log that includes almost all residents. This list shows Resident R74 is supposed to have passive range of motion (PROM), active range of motion (ROM), splint or brace, and receive assistance with bathing and dressing. The list also shows Resident R57 is supposed to have passive range of motion and bed mobility exercises. Resident R74's records reviewed are as follows: Gait, Lack of Coordination, History of Falling, Polyosteoarthritis, Pain in Right Lower Leg, and Generalized Muscle Weakness.

08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Care plan dated 9/14/22 states that Resident R74 would benefit from participation in range of motion and that the restorative aide or unit aide will complete range of motion for resident.

Brief Interview for Mental Status (BIMS) Score is 14 out of 15 (No Cognitive Impairment). Resident R57's records reviewed are as follows: and mobility, weakness, are still arthritis, and reduced mobility.

Care Plan dated 8/3/22 States that Resident R57 would benefit from bed mobility restorative nursing program.

Intervention states that the restorative aid or certified nursing assistant will provide bed mobility restorative program six to seven days weekly.

BIMS Score is 11 out of 15(Mild Cognitive Impairment).

the resident reaches and maintains his or her highest level of range of motion and to prevent avoidable decline in range of motion. range of motion exercises and records data as instructed. #C21: Performs restorative and rehabilitative procedures as instructed. 08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide safe and appropriate respiratory care for a resident when needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 52232 Based on observations, interviews and record reviews, facility failed to contain and label oxygen equipment properly; failed to display oxygen in use signage and failed to follow physician order for oxygen use. These failures affected six (Resident R17, Resident R20, Resident R24, Resident R41, Resident R102, Resident R124) of six residents reviewed for respiratory care in the sample of 64 residents.

1. On 6/9/2025 at 11:25 AM, observed in Resident R124's room, nasal cannula on the top of the oxygen tank, not

contained, not labeled nor dated, hanging curled on the top of the canister. Resident R124'S Face sheet documented diagnosis that included but are not limited to Centrilobular Emphysema, Nephropathy, Liver disease, Weakness, Nasal Congestion, Primary Insomnia. Resident R124's Minimum Data Sheets (MDS), dated [DATE REDACTED], in section C -Cognitive Patterns, documents Brief

Interview for Mental Status (BIMS) Summary Score of 15, which indicates intact cognitive function. Resident R124's care plan dated 2/19/2024, showed in part that the nasal cannula and/or mask should be monitored. Resident R124's Order Summary Report, included active orders as of 6/11/2025, but not limited to oxygen nasal cannula at 3-4 liters for shortness of breath every day and night.

2. On 6/9/2025 at 11:45 AM, observed Resident R24's room empty with oxygen nasal cannula, wrapped around the

bed's rail and touching the floor. Nasal cannula was not labeled or dated. Resident R24's face sheet documents in part diagnosis included but not limited to History of Sepsis, Chronic Kidney Disease, Acute Kidney Failure, Seizures, Obstructive and Reflux Uropathy, Hypertensive Heart Disease, Hypothyroidism, Myoneural Disorder, Personal history of COVID 19, Localized swelling, mass and lump in a trunk, Functional Quadriplegia, TIA. Resident R24's Minimum Data Sheets (MDS), dated [DATE REDACTED], in section C - Cognitive Patterns, documents Brief

Interview for Mental Status (BIMS) Summary Score of 7, which indicates severe impaired cognitive function. Resident R24's care plan, revised on 9/8/2023, showed in part that Resident R24 receives oxygen 2 liters per minute via nasal cannula and showed to administer oxygen as ordered per MD. Care plan also showed in part, to monitor that nasal cannula and/or mask is properly positioned. Resident R24's Order Summary Report from 6/11/2025, showed in part an active order dated 3/30/2025, to change oxygen tubing and bottle weekly on Sunday. Order Summary Report also showed active order dated 4/28/2025, for Oxygen 2-3 liters/minute per Nasal Cannula every day and night.

On 6/9/2025 at 11:27 AM, Resident R24's said that Resident R24 uses nasal cannula at night and that the Resident R24 coiled it on the top of the oxygen tank, so it does not touch the floor because there was no bag to place the tubing into.

On 6/11/2025 at 10:17 AM, V2 (Director of Nursing) stated that oxygen tubing should be changed every week and according to MD's (medical doctor) orders, or as needed. V2 stated, that the oxygen tubing should be contained in a plastic bag when not in use, and labeled with a date on the bag so the staff would know when to change the tubing next. V2 also said, that containment of Oxygen tubing in a plastic bag, helps with infection control. The oxygen canisters should also be labeled and dated and replaced every 30 days.

3. Review of Resident R17's physician orders documents an active physician order for Oxygen at (2) L/Min (liters per

minute) per Nasal Cannula.

On 6/9/2025 at 11:05 AM, Resident R17 was observed lying in bed receiving oxygen from an oxygen concentrator via nasal cannula at 2 liters per minute. No sign was observed on Resident R17's door or in the near vicinity of Resident R17's room to alert others of oxygen in use. V6 (Registered Nurse) observed the resident's door and affirmed that there should be an oxygen sign on the door and the sign must have fell off. V6 searched the nearby vicinity of Resident R17's room and affirmed that there was no sign that fell . V6 stated, I will go get a sign and put it on now.

4. On 6/09/25 at 11:31am, Resident R20 was observed, in her (Resident R20) room, sitting on the side of bed. Observed Resident R20's

nasal cannula tubing hanging over the oxygen concentrator laying on the floor. Also observed was Resident R20's nebulizer mask connected to the nebulizer laying on the floor. Resident R20 said, I (Resident R20) don't know why my (Resident R20) stuff is on the floor. This place is gross. Everything about this place is gross. Resident R20's face sheet documents diagnoses that include but are not limited to chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and pulmonary embolism. Resident R20's Brief Interview of Mental Status (BIMS) score, dated 5/23/25, documents, in part, a BIMS score of 15 which indicates Resident R20 is cognitively intact. Resident R20's Order Summary Sheet, dated 6/11/25, documents, in part, Oxygen at (2) L/Min per Nasal Cannula as needed for Shortness of Breath maintain O2 sats above (92%). Resident R20's care plan, date initiated 6/02/25, documents, in part, Active Infection (Resident R20) has tested positive for COVID-19. This places resident at high risk for developing Acute Respiratory Distress, Secondary infections such as Pneumonia, and increased risk for Fluid Volume Deficit. The following clinical symptoms have been noted: _Cough, _Fever, _SOB, _Fatigue, _Headache, _Congestion, or _Other . with interventions that document, in part, . oxygen per order .

On 6/11/25 at 10:17am, V2 (Director of Nursing/DON) said, Oxygen tubing is changed weekly and as needed. The oxygen tubing should be labeled with the date it was changed. Resident's oxygen tubing and masks should be put in a bag when not in use to keep it clean and for infection control.

It is the policy of the facility to ensure that oxygen is stored and transported safely . and environment that enhances or promotes your quality of life . You have the right to receive services with reasonable accommodations to individual needs and interests . The facility must provide a safe, clean, comfortable, home-like environment, allowing you the opportunity to use your personal belongings to the extent possible. The facility will provide housekeeping and maintenance services .

5. On 6/9/2025 at 11:26 am, observed Resident R102 with a nasal cannula applied to his face and connected to

Resident R102's oxygen concentrator which was set at 5 Liters Per Minute. Resident R102 stated, My oxygen should be set at 3 Liters Per Minute.

On 6/9/2025 at 11:31 am, V13, (Registered Nurse-(RN) stated Resident R102's oxygen concentration is supposed to be set on 2-3 Liters Per Minute as needed. V13 stated oxygen concentration levels set higher than physician's order recommendations can result in hyperoxygenation. V13 stated all staff nurses are assigned to check their resident's oxygen concentration settings daily and/or every shift.

On 6/9/2025 at 11:36 am, V13, (Registered Nurse-(RN) affirmed Resident R102's nasal cannula tubing connected to Resident R102's nebulizer machine was not labeled and not bagged. Resident R102's Face Sheet dated 6/11/2025, documents in part a diagnosis of but not limited to Chronic Obstructive Pulmonary disease, Barret's Esophagus without Dysplasia, Shortness of Breath, Chest Pain, and Hypertensive Heart Disease without heart failure. Resident R102's Physician Order Sheet dated 6/11/2025 documents an active order dated 5/20/2025, O2 at 2-3 Liters via nasal cannula as needed for shortness of breath.

6. On 6/9/2025 at 12:01 pm, Resident R41's oxygen tank was observed in a holder next to his bed with a nasal

cannula undated and unbagged hanging on the oxygen tank's handle. V14, (Certified Nurse Aid) stated the oxygen tank belonged to Resident R41.

On 6/9/2025 at 12:07 pm, V13, (Registered Nurse-(RN) assessed Resident R41's nasal cannula tubing attached to Resident R41's oxygen tank and affirmed the tubing was not labeled and not bagged. V13 stated all oxygen tubing, masks, and nasal cannulas should be labeled and bagged. V13 stated undated and unbagged oxygen supplies poses an infection risk to the resident. Resident R41's Face Sheet dated June 11, 2025, documents in part a diagnosis of but not limit Acute Respiratory

08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident R41's Physician's Order Sheet documents an active order dated 2/19/2024 for Oxygen 2-3 Liters Per Minute Per Nasal Cannula continuously for shortness of breath. Resident R41's Physician's Order Sheet documents an active order dated 3/19/2023 Change Oxygen tubing and bottle weekly on Sunday. oxygen to maintain levels of saturation the resident as needed and as ordered by the attending physician.

Portable oxygen units are used to support resident mobility in the facility and for outside the facility. 1. Check orders for accurate oxygen liter flow. 2. Tubing, Humidifier bottles and filters will be changed, cleaned and maintained no less than weekly and PRN. Each will be labeled with date, time and initiated by staff completing this service to equipment. 08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on observations, interviews, and record review, the facility failed to ensure controlled medications were stored in a double locked setting, failed to ensure completed controlled medications were returned to

the pharmacy, and failed to ensure out going nurse signed the Narcotic/Controlled Substance Shift-to-Shift Count Sheet. These failures affected 3 (Resident R14, Resident R106, and Resident R150) residents reviewed for controlled medications

in the total sample of 64 residents.

On 06/09/2025 at 11:52 am, during the medication storage task with V7 (Licensed Practice Nurse). V7 opened the 3rd floor medication storage room using a key code. There was a small refrigerator inside the 3rd floor medication storage room. V7 opened the small refrigerator by unlatching the door. This surveyor inquired if the refrigerator was locked. V7 stated there is no lock, I just unlatched it. Requested V7 to check if

the small refrigerator has controlled substances. V7 showed Resident R14's two boxes of Lorazepam 2mg/ml. V7 stated the refrigerator should be locked because we have controlled medications in the refrigerator. V7 searched for the lock and stated the lock is on the floor. Resident R14's (printed: 06/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) primary osteoarthritis, essential hypertension, and history of falling. Lorazepam oral concentrate 2mg/ml give 0.5 by mouth every 2 hours as needed for 14 days. Order Status: completed. End date: 06/04/2025.

Lorazepam 2mg/ml give 1ml by mouth every 15minutes as needed for active seizure for 14 days. Order Status: Completed. End date: 06/04/2025. Lorazepam 2mg/ml give 1mg by mouth every 2 hours for 14 days.

Order Status: completed. End date: 06/04/2025. Of note, Resident R14's Lorazepam was completed on 06/04/2025.

On 06/11/2025 at 11:52 am, V34 (Clinical Nurse Consultant) stated the expectation is if the controlled medication is already completed, it should be completely out of the facility. Meaning, the controlled medications should be returned to the pharmacy and not kept in the cart or storage room.

On 06/09/2025 at 12:05 pm, during the medications storage task with V9 (Licensed Practice Nurse) the (June 2025) 2nd Floor Team 2 Narcotic/Controlled Substance Shift-to-Shift Count Sheet had missing entries

on Date: 7, 3rd shift, Off going Nurse and on Date: 8, 3rd shift, Off-going Nurse. This observation was pointed out to V9. V9 stated (V11 - LPN) did not sign when she got off on 06/07/25 and 06/08/25. The expectation is to sign the shift to shift count sheet to document the oncoming and outgoing nurses counted

the controlled medications during shift change to ensure the count is good. V9 stated they only have two residents in Team 2 that have controlled medications. They are (Resident R106 and Resident R150).

On 06/11/2025 at 10:00am, V2 (Director of Nursing) stated, Controlled medications should be double locked to prevent theft. It is also a safety issue if controlled medications are not properly stored. We are using the key now on our refrigerators in our medication storage rooms. No more codes so nurses don't have to memorize the codes.

On 06/11/2025 at 10:10am, V2 stated at the beginning of the shift of the incoming nurse and end of the shift of the outgoing nurse, they must count all controlled medications to ensure all controlled medications in the cart are accounted for. The incoming nurse is taking responsibility of all the controlled meds in the cart. The outgoing nurse and incoming nurse must sign in the shift to shift count sheet to document the controlled medications were counted. Resident R106's (Active Order as of: 06/09/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) neuralgia and neuritis, hemiplegia and hemiparesis, and low back pain. Order Summary: Clonazepam Oral tablet give 0.25mg by mouth three time a day. Order Date: 05/21/2025. Zolpidem 10mg. give 10mg by mouth at bedtime. Order Date: 05/01/2025. Resident R106 (05/01/2025) Controlled Drug Receipt/Record Disposition Form documented, in part Zolpidem Tab 10mg. Resident R106 (06/07/2025) Controlled Drug Receipt/Record Disposition Form documented, in part Clonazepam 0. 5mg take 1/2 tab by mouth three times daily.

R150s' (Active Order as of: 06/09/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) post-traumatic stress disorder, sleep disorder and wedge compression fracture of first lumbar vertebra. Order Summary: Oxycodone 5mg. give 5mg by mouth every 6 hours. Order Date: 06/04/2025. Resident R150's (Controlled Drug Receipt/Record Disposition Form documented, in part Oxycodone 5mg every 6 hours.

The (undated) Licensed Practical Nurse Job Description documented, in part Position summary: The Licensed Practical Nurse provides direct nursing care to the residents and supervises the day-to-day nursing activities performed by nursing assistants. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times. C. Role Responsibilities - Drug Administration: 6. Ensures that narcotic records are accurate for your shift. 10.

Dispose of drugs and narcotics as required, and in accordance with established procedures.

The (undated) Registered Nurse Job Description documented, in part Position summary: The Registered Nurse provides direct nursing care to the residents and supervises the day-to-day nursing activities performed by nursing assistants. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times. C. Role Responsibilities - Drug Administration: 6. Ensures that narcotic records are accurate for your shift. 10. Dispose of drugs and narcotics as required, and in accordance with established procedures.

The (May 2024) Controlled substances documented, in part Policy: Medications classified by the FDA (Food and Drugs Administration) as controlled substances have high abuse potential and may be subject to special handling, storage, and record keeping. Procedure: 4. While a controlled substance is in use, the nursing staff will maintain the following medication records: b. All schedule II controlled substances (and other schedules, if facility policy so dictates will be counted each shift of whenever there is an exchange of keys between off-going and on-coming licensed nurses. The two nurses will 2. Both nurses will count the number of packages of controlled substances that are being reconciled during the shift/shift count and document on the Shift Controlled Substance Count Sheet. 4. Both nurses will sign the Shift/Shift controlled substances count Sheet acknowledging that the actual count of controlled substances and count sheet matches the quantity documented. 08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, interview, and record review, the facility failed to refrigerate unopened insulin pens, label multi-dose medications, discard expired medications, and monitor refrigerator temperatures. These failures affected seven residents (Resident R1, Resident R50, Resident R64, Resident R67, Resident R74, Resident R97, Resident R100) and has the potential to affect all 57 residents on the 3rd floor.

The (06/09/2025) 3rd floor census was 57 residents.

On 06/09/2025 at 11:34 am, during the medication storage and labeling task with V6 (Registered Nurse) of

the 3rd floor Team 1 cart with the following observations:

1. Resident R67's Latanoprost has no open date.
2. Resident R64's unopened Insulin Glargine in the med cart. Resident R64's unopened Glargine has pharmacy auxiliary label

which read Refrigerate.

3. Resident R50's fluticasone nasal spray has no open date.

On 06/09/2025 at 11:43 am, V6 stated her (Resident R64) unopened Lantus (Insulin Glargine) should be stored in the refrigerator. Latanoprost and Fluticasone should have open dates, so V6 knows how long these have been opened to prevent giving expired medications to residents.

On 06/09/2025 at 11:50 am, during the storage and labeling task with V7 (Licensed Practice Nurse) of the 3rd floor medications storage room observed 'The (June 2025) 3rd floor Daily check Refrigerator Temperature Log has missing entries on Date: 7, Temperature, and Initial.' This observation was pointed out to V7. V7 stated the night shift nurse are supposed to check the refrigerator temperature nightly to ensure

the medications in the refrigerator are kept in correct temperature so medications will not go bad. V7 said,

We keep our unopened insulin pens in the refrigerator. The refrigerator is used to keep medications that need refrigeration for all the residents on the 3rd floor.

On 06/09/2025 at 11:58am, during the medication storage task with V9 (Licensed Practice Nurse) of the 2nd floor Team 2 medication cart with the following observations:

4. Resident R1's Artificial Tears with open dated 5/6/25
5. Resident R74's Artificial Tears with open date 4/25/25.

On 06/09/2025 at 12:25pm, during the medication storage task with V10 (Licensed Practice Nurse) of the 1st floor medication room. The (June 2025) 1st floor daily check Refrigerator Temperature Log was monitored once daily. Inquiring if there are vaccines in the refrigerator. V10 took out from the refrigerator the following vaccines:

6. Resident R97's Prevnar 20.
7. Resident R100's Prevnar 20.

On 06/09/2025 at 12:26pm, inquiring how often the facility should check the temperature if vaccines were in

the refrigerator, V10 stated, I have to check with my supervisor.

On 06/10/2025 at 2:56pm, V34 (Clinical Nurse Consultant) stated the expectation is to the follow the pharmacy auxiliary label on the Lantus which is to refrigerate.

On 06/11/2025 at 10:01am, V2 (Director of Nursing) staff are expected to check the refrigerator temperature daily to maintain proper temperature for medications to prevent bacterial built up and to keep potency of medications.

On 06/11/2025 at 10:03am, V2 stated eye drops should be labeled with the date it was opened so we can monitor when the medications expires and to prevent giving expired medications. Resident R1's (Active Order as of: 06/09/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) nervousness, ocular manifestation of Vitamin A deficiency, and hyperlipidemia. Order

Summary

Artificial Tears Ophthalmic solution. Order Status: Active. Order Date: 03/15/2025. Resident R50's (Active Order as of: 06/10/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) hypoxemia, personal history of covid-19, and Gastroesophageal reflux disease. Order

Summary

Fluticasone allergy relief. Order date: 09/05/2023. Resident R64's (Active Order as of: 06/09/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) cerebrovascular disease, primary hypertension, and Type 2 Diabetes Mellitus. Order

Summary

insulin glargine inject 10 units subcutaneously at bedtime. Order Date: 05/16/2025. Resident R67's (Active Order as of: 06/09/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) Type 2 Diabetes Mellitus, primary hypertension, and benign prostatic hyperplasia. Order

Summary

Latanoprost Ophthalmic solution. Order date: 05/02/20255. Resident R74's (Active Order as of: 06/09/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) hemiplegia and hemiparesis, cerebral infarction, and blepharoconjunctivitis. Order Summary: Artificial Tears Ophthalmic solution. Order Date: 10/08/2024. Resident R97's (printed on: 06/12/2025) completed Order Summary Report documented that Resident R97's Diagnoses: (include but not limited to) acute respiratory failure, primary hypertension, and personal history of Covid-19.

Order summary documented Resident R97 was ordered Prevnar 20 on 04/09/2025 and on 04/13/2025. Resident R100's (printed: 06/12/2025) Completed Order Summary Report documented Resident R100's Diagnoses: (include but not limited to) convulsion, dysphagia, and anemia. Order Summary documented Resident R100 was ordered Prevnar 20 on 04/09/2025 and 04/13/2025.

The (06/11/2025) email correspondence with V34 (Clinical Nurse Consultant) documented, in part, We don't have specific policies as you requested but please see below our expectations. We expect nurses to follow

the pharmacy labels on the multi dose vial medications. For insulins, they should be refrigerated upon receipt from the pharmacy. Artificial tears expire 30 days after opening. Also, if there are vaccines in the med-room refrigerators, refrigerator temps should be monitored twice daily. For refrigerators with no vaccines, it will be once daily temp monitoring. Should Artificial Tears and Fluticasone be labeled with Open Date? V34 responded 'They should be dated when opened.

The (May 2024) Medication Storage in the facility documented, in part Policy: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure: 11. Medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept in the refrigerator. Medications requiring storage in cool place are refrigerated unless otherwise directed on the label. 14. Outdated drugs will be immediately withdrawn from the stock by the facility. 18. Facility staff will assure that the multidose vial is stored following manufacturer's suggested storage conditions. 08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32338 Based on observation, interview, and record review, the facility failed to ensure that a wet kitchen sanitation cloth is kept in the sanitizing bucket and failed to discard expired milk cartons from the walk-in cooler of the kitchen. These failures have the potential to cause food borne illness in residents with a potential to affect all 150 residents that receive food from the facility's kitchen.

On [DATE REDACTED] after the entrance conference, V1 (Administrator) presented the facility census as 150.

On [DATE REDACTED] at 10:15 am during observation of the Walk-in cooler in the kitchen with V33 (Dietary Manager from Corporate Office), the following were observed: Two 8-ounce cartons of Skim Milk with expiration dates [DATE REDACTED].

One 8-ounce carton of Skim Milk with expiration date [DATE REDACTED].

V33 stated the two dietary aides on duty were supposed to look through the walk-in cooler and throw out expired food items.

On [DATE REDACTED] at 10:19 am, a white wet rag was observed on the food preparation counter in the kitchen. V33 stated that one of the kitchen staff used it to wipe the counter and that it was supposed be kept in the sanitizing solution in the red bucket. V33 added, I will in-service all of them to remind them.

On [DATE REDACTED] at 11:0 0 AM, V33 presented a Facility Document titled In-Service Sheet dated [DATE REDACTED] states: All towels must be put back into sanitation bucket after use. Another Inservice sheet dated [DATE REDACTED] states Look at all dates on milk. are rotated. Food products are used by the expiration date. Food products not used by the expiration dates are discarded.

in sink and areas of production. #5 states: When in use, sanitation clothes (wipes) can be left in sanitation bucket. #6 states: When not in use, sanitation buckets and clothes are stored clean and dry. 08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Have a policy regarding use and storage of foods brought to residents by family and other visitors. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49572 Based on observation, interview, and record review, the facility failed to provide thermometers and maintain refrigerator logs for four residents' personal refrigerators. These failures affected four (Resident R112, Resident R120, Resident R132, Resident R550) of four residents reviewed for safe storage of personal food in a sample of 64.

On [DATE REDACTED] at 10:54am during observation of Resident R120's personal refrigerator the following was observed: Resident R120's Refrigerator Temperature Log Month/Year ,d+[DATE REDACTED] had missing initials and temperatures on [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED]. Resident R120's Refrigerator Temperature Log Month/Year ,d+[DATE REDACTED] with missing initials and temperatures on [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED].

On [DATE REDACTED] at 10:54 am, Resident R120 said, Yes, this is my (Resident R120) fridge. My friend brings me food in all the time.

They (staff) don't check my fridge every day. Only certain staff check it. Unless they're (staff) checking it (personal refrigerator) when I'm (Resident R120) not here but doubt that. Resident R120's face sheet documents diagnosis that include but are not limited to weakness, abnormalities of gait and mobility, repeated falls, and mononeuropathies of bilateral lower limbs. Resident R120's Brief Interview of Mental Status (BIMS) score, dated [DATE REDACTED], documents, in part, a score of 15 which indicates Resident R120 is cognitively intact.

On [DATE REDACTED] at 11:08am, during observation of Resident R112's personal refrigerator the following was observed: Resident R112's Refrigerator Temperature Log Month/Year : (Blank) had no documentation of temperature checks and employees' initials. There were no other Refrigerator Temperature Log Month/Year observed.

Surveyor attempted to interview Resident R112 but was unable to complete interview due to Resident R112's altered mental status. Resident R112's face sheet documents diagnosis that include but are not limited to weakness, abnormalities of gait and mobility, repeated falls, and mononeuropathies of bilateral lower limbs. Resident R112's Brief Interview of Mental Status (BIMS) score, dated [DATE REDACTED], documents, in part, a score of 99 which indicates Resident R112 was unable to complete the interview.

On [DATE REDACTED] at 1:50 pm, V2 (Director of Nursing/DON) said, Yes, residents' personal refrigerator's temperature should be checked daily. The purpose of checking the temperatures is to make sure foods are stored correctly and so bacteria doesn't build up. Each resident's personal refrigerator should have a temperature log and a thermometer. The temperature should be checked every shift by housekeeping.

On [DATE REDACTED] at 10:47 am, V16 (Housekeeping Director) said, My staff (housekeeping) and maintenance take care of residents' personal refrigerators, but usually us (housekeeping staff). We (housekeeping staff) check whether or not temp (temperature of refrigerator) is 40 degrees, and if not we (housekeeping staff) adjust it.

We (housekeeping staff) tell all the staff and patients to properly label outside food with dates and if (outside food) more than 3 days old we (housekeeping staff) toss (dispose of) the items. Expiration dates are checked so all the items aren't spoiled and kept at healthy temps (temperatures) and not freeze or get too warm to a point that the food is not healthy to eat. If patients (residents) eat foods past expiration they (residents) can get sick like a stomach illness. Temperatures of personal fridges are checked daily. Staff should put temp (temperature reading) and their (staff) initials on the refrigerator log sheet daily. All personal fridges should have thermometers and if not they (staff) should notify me (V16). facility to assure that perishable food requiring refrigeration is stored at the proper temperature . All unit refrigerators will be maintained regarding temperature and cleanliness . Each refrigerator will be provided with a thermometer to ensure that the refrigerator is maintained between 35 degrees and 40 degrees and environment that enhances or promotes your quality of life . You have the right to receive services with reasonable accommodations to individual needs and interests . The facility must provide a safe, clean, comfortable, home-like environment, allowing you the opportunity to use your personal belongings to the extent possible. The facility will provide housekeeping and maintenance services .

On [DATE REDACTED] at 11:46 AM, in Resident R550's room, surveyor observed personal refrigerator had a missing log sheet form. Inside of the fridge the food items observed with no concerns.

On [DATE REDACTED] at 11:47 AM, Resident R550 stated, when Resident R550 got admitted , the staff cleaned the fridge and put Resident R550's food items inside and must have forgotten to put the log sheet on the side of the fridge. Resident R550's face sheet documents in part diagnosis included but not limited to Type 2 Diabetes Mellitus, Pyoderma Gangrenosum, Weakness, Atherosclerosis, Peptic Ulcer, Abdominal pain, Atherosclerotic Heart Disease, Cardiac Pacemaker, Hyperlipidemia, Hypertension. Resident R550's Minimum Data Sheets (MDS), dated [DATE REDACTED], in section C -Cognitive Patterns, documents Brief

Interview for Mental Status (BIMS) Summary Score of 15, which indicates intact cognitive function.

On [DATE REDACTED] at 12:05 PM in Resident R132's personal refrigerator, surveyor observed no thermometer inside and missing refrigerator' s daily log sheet. Items inside a fridge observed without concerns.

On [DATE REDACTED] at 12:06 PM Resident R132 stated, that Resident R132 is not sure where the thermometer is, or why the log sheet is missing, the staff should be maintaining it. Resident R124'S Face sheet documented diagnosis that included but are not limited to Centrilobular Emphysema, Nephropathy, Liver disease, Weakness, Nasal Congestion, Primary Insomnia. Resident R124's Minimum Data Sheets (MDS), dated [DATE REDACTED], in section C -Cognitive Patterns, documents Brief

Interview for Mental Status (BIMS) Summary Score of 15, which indicates intact cognitive function.

On [DATE REDACTED] at 13:51 PM V2 (DON) stated that the refrigerators in the resident's rooms should have thermometers and temperature's log sheets. V2 stated that refrigerator's temperatures should be checked and documented on the forms. These log sheets should be checked daily every shift and should be the housekeeping's responsibility. The reason for the checks is to make sure that the food in the refrigerators don't get spoiled, or expired and so residents won't get sick, or the food won't spread infection. should be provided with a thermometer to ensure that the refrigerator is maintained in proper temperatures and that the temperatures should be checked and documented daily. 08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Dispose of garbage and refuse properly.

Based on observation, interview, and record review, the facility failed to ensure that the outside garbage waste dumpsters are closed with the lids to prevent pest infestation and foul odor. This failure affects all 150 residents residing in the facility.

On 6/10/2025 at 1:10 pm with V33 (Dietary Manager from Corporate Office), 2 of the 3 outside dumpsters were observed to be overfilled with garbage and the lids were left partially opened. V33 stated that it's not only dietary staff, but other departments at the facility also dump garbage into the dumpsters and was not sure who left the dumpsters open. V33 added that some of the items in those dumpsters are also recyclables.

On 6/11/25 at 9:48am, V2 (Director of Nursing) stated that housekeeping staff dump garbage in the dumpsters and all staff will be in-serviced.

On 6/11/25 at 10:47am, V16 (Housekeeping Director) stated all housekeeping staff throw garbage into the outside dumpster, and he (V16) would in-service all of the staff. garbage and refuse properly to reduce the risk of foodborne illness. #1: Keep dumpster closed at all times. #2: Keep the dumpster and surrounding area clean and free of debris. If the dumpster becomes full, contact

the garbage service for removal. 08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide and implement an infection prevention and control program. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45196 Based on observation, interview, and record review, the facility failed to follow infection control protocols by not providing trash receptacles in transmission-based precaution rooms and not maintaining contact/droplet isolation for COVID-19 positive residents. These failures affected two (Resident R20 and Resident R126) of two residents reviewed for infection control and has the potential to place all 150 residents at risk for the spread of infection. Resident R126's Brief Interview Mental Status (BIMS) dated 03/26/25 shows Resident R126 with a score of 14 which indicates Resident R126 is cognitively intact. Resident R126's face sheet has a diagnosis which includes but not limited to COVID-19. Resident R126's Physician Order Sheet (POS) dated 06/03/25 shows Resident R126 has orders for Contact/Droplet Isolation Precautions COVID positive every shift for infection prevention for 10 days. Resident R126's care plan dated 06/04/25 documents in part: Focus Resident R126 is on isolation related to (R/T) COVID.

Interventions: Set up isolation per facility protocol.

On 06/09/25 at 10:52 am, Resident R126 was observed in Resident R126's rooms in bed awake, with a conjoining shared bathroom with Resident R63 and Resident R72's room. Resident R126 stated Resident R126 uses Resident R126 bathroom and also the Rehab bathroom

in the hallway available for residents and staff use on the second-floor unit. Resident R126 denied Resident R126's room and bathroom is cleaned daily at the facility and explained housekeeping cleanse Resident R126's room and bathroom [ROOM NUMBER]-3 times per week at the facility. Resident R126's room was observed without a trash receptacle to discard Personal Protective Equipment (PPE).

On 06/09/25 at 11:15 am, V15 (Certified Nursing Assistant, CNA) stated V15 is assigned to Resident R126. V15 explained Resident R126's room does not have a trash receptacle to discard PPE and there is nowhere for V15 or staff to discard PPE when prior to leaving Resident R126's room. V15 explained V15 has asked for a trash receptacle to discard V15's PPE from management at the facility and V15 was not given an answer.

On 06/09/25 at 11:16 am, V13 (Registered Nurse, RN) stated V13 is Resident R126's nurse and has worked at the facility for three weeks. V13 stated V13 has asked where to discard PPE used for Resident R126 and has not received

an answer from management. V13 explained V13 takes V13's used PPE from Resident R126's room and throws the used PPE in a trash receptacle in the hallway outside of Resident R126's room after V13 is finished caring for Resident R126.

V13 is unsure of what bathroom Resident R126 uses at the facility.

On 06/09/25 at 11:28 am, V25 (Housekeeping) stated V25 is responsible for cleaning the residents' rooms and bathrooms on the second floor. V25 stated the residents' rooms and bathrooms should be cleaned once

a day and as needed. V25 stated V25 cleans Resident R126's bathroom once a day at the end of V25's shift and the detachment mop head is then sent to laundry for cleaning. V25 stated V25 was not aware of Resident R126 having orders to only use the Rehab bathroom on the second-floor hallway. V25 stated the Rehab bathroom is unlocked, available for anyone to use, and should be cleaned once a day at the facility. When V25 was asked regarding Resident R126's trash receptacle to discard used PPE, V25 stated, There is not one inside his (Resident R126's) room. It is V5 (Infection Preventionist, IP, Licensed Practical Nurse, LPN) responsibility to ensure there are red bins in the isolation rooms to discard used PPE. I (V25) just remove mine and throw it in the trash can down the hall when I leave the room.

On 06/09/25 at 11:40 am, V2 (Director of Nursing, DON) and V5 (Infection Preventionist/Licensed Practical Nurse IP, LPN) both stated residents on isolation should have a white trash receptacle to discard PPE inside

the residents' room prior to leaving the isolation room. V5 stated if staff do not have trash receptacles to discard PPE, then there is nowhere to discard used PPE. V2 and V5 both stated Resident R126 was instructed and agreed to use the Rehab bathroom on the second-floor unit. V2 and V5 both stated there is no sign posted

on Resident R126 room bathroom to redirect Resident R126 to the Rehab hallway bathroom and they were not aware Resident R126 was using the bathroom inside of Resident R126's room is shared with Resident R63 and Resident R72. V2 and V5 both stated there is a potential for Resident R126 to spread infection to Resident R63 and Resident R72 if Resident R126 is sharing a bathroom with Resident R63 and Resident R72 and

the bathroom is not properly cleaned. V2 and V5 was unaware of the cleaning schedule for Resident R63, Resident R72 and Resident R126's shared bathroom.

V5 (Infection Preventionist/Licensed Practical Nurse), stated the Rehab bathroom on the second-floor unit remains unlocked at all times, and anyone can use the bathroom. V5 stated there is no sign alerting/notifying staff, residents, or visitors to not use the Rehab bathroom on the second-floor hallway. V5 stated if staff, visitors, or other residents use the shared Rehab bathroom with Resident R126 on the second-floor hallway, there is potential to spread infection throughout the entire facility. V2 and V5 was also unaware of the cleaning schedule for the Rehab bathroom on the second-floor hallway.

The facility policy dated 05/23/23 and titled Post Public Health Emergency - Standard and Guidelines documents, in part: Policy: The facility will follow CDC (Center for Disease Control) guidelines including prompt detection, triage, and isolation of potentially infectious residents to prevent unnecessary exposure of COVID 19 . Resident placement: Residents with suspected or confirmed SARS-CoV-2 infection will be placed in a single person room if possible. The resident should have a dedicated bathroom if possible.

The facility's job description document titled Housekeeper documents, in part: Under the direction of the Director of Housekeeping, the Housekeeper is responsible for cleaning resident rooms and other interior and exterior facility areas and assisting in maintaining a clean and attractive environment for the residents. The person holding this position is delegated responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. Essential Job Functions- Job Knowledge /Duties: D. Role Responsibility- Infection Control: 4. Complies with all established infection control and standard precautions practices when performing housekeeping procedures. 08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

On 6/09/25 at 11:31am, a contact/droplet isolation sign was observed on Resident R20's door. No trash receptacle was observed in or near Resident R20's room for disposal of PPE (personal protective equipment). Resident R20 was observed, in her (Resident R20) room, sitting on the side of her (Resident R20) bed. Resident R20 said, Being on isolation sucks. I have COVID (coronavirus). I (Resident R20) didn't need oxygen until now. I (Resident R20) don't know why my (Resident R20) stuff is on the floor. This place is gross. Everything about this place is gross. I'm (Resident R20) just allowed to go smoke, but not with the other residents. I (Resident R20) have to wear a mask when I (Resident R20) leave my room. A mask, not sure if I (Resident R20) need special one but I (Resident R20) have this one. Resident R20 showed surveyor a multi-colored cloth mask. Resident R20's face sheet documents diagnoses that include but are not limited to Human Immunodeficiency Virus (HIV), anxiety disorder, bipolar disorder, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and pulmonary embolism. Resident R20's Brief Interview of Mental Status (BIMS) score, dated 5/23/25, documents, in part, a BIMS score of 15 which indicates Resident R20 is cognitively intact. Resident R20's Respiratory Panel, result date 6/02/25, documents, in part, Positive for Human Coronavirus. Resident R20's care plan, date initiated 6/02/25, documents, in part, Active Infection (Resident R20) has tested positive for COVID-19. This places resident at high risk for developing Acute Respiratory Distress, Secondary infections such as Pneumonia, and increased risk for Fluid Volume Deficit. The following clinical symptoms have been noted: _Cough, _Fever, _SOB, _Fatigue, _Headache, _Congestion, or _Other . with interventions that document, in part, Encourage resident to remain room . oxygen per order .

On 6/09/25 at 12:06 pm, observed Resident R49 in a wheelchair, wheeling herself (Resident R49) into Resident R20's room.

On 6/09/25 at 12:15 pm, observed Resident R20 smoking on the wheelchair ramp of the facility, with other resident and employees walking by Resident R20.

On 6/09/25 at 12:10pm, V10 (Licensed Practical Nurse/LPN) said, Let me go get (Resident R49) out of (Resident R20's) room.

She 9R49) should not be in there. There should be bigger white trash cans for the PPE equipment. Let me find out where they are.

On 6/09/25 at 12:29 pm, with V2 (Director of Nursing/DON), observed Resident R20 come in through the front door of

the facility, walk through the hallway, with a multi-colored cloth mask not covering Resident R20's nose. V2 said, (Resident R20) please pull your (Resident R20) mask over your (Resident R20) nose.

On 6/10/25 at 10:30 am, Resident R20 was observed at resident council removing her (Resident R20) mask and coughing.

On 6/10/25 at 2:33 pm, V5 (Infection Preventionist/IP) said, (Resident R20) is not supposed to be off isolation today. Resident R20 comes out of isolation on the 12th (6/12/25). Residents with COVID can leave their room with a disposable blue mask, they (residents) should not be wearing linen masks. (Resident R20) can leave her (Resident R20) just to go smoke but must be 6 feet minimum from front of building, with no other residents. No, Resident R20 should not be smoking on the wheelchair ramp. Resident R20 should be in her (Resident R20) room with the door closed. There should be white cans to dispose of the gowns and gloves. (Resident R20) has been told all of this. This can affect everyone at

the facility. Everyone has the potential to get COVID if (Resident R20) isn't following procedure.

08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Objective: To prevent unprotected exposure of residents, visitors and staff to potentially infectious microorganisms or diseases and to decrease the spread of in-house or community acquired infections .

Droplet Precautions---intended to reduce the risk of respiratory droplet transmission of infectious agents.

This involves contact of the mucous membranes with large-particle droplets generated from the infectious resident. Droplets are generated primarily from coughing, sneezing, talking, or during the performance of certain procedures involving the respiratory tract (e.g., suctioning). Transmission requires close contact because droplets do not remain suspended in the air and generally travel only short distances .F. Droplet Precautions requires the use of surgical/procedural mask when entering the resident's environment/room .

Always use the highest level of PPE if the resident is on multiple isolations (Example: Airborne and Droplet, would call for the use of an N95 even though Droplet only requires a surgical mask) . Droplet Precautions .

Limit resident transport outside of resident's environment/room only for medically necessary reasons .

Ambulating outside of the room: A. Residents on Droplet or Enhanced Isolation Precautions must wear a mask when outside of the room and keep a distance of at least 6 feet from other residents and also from the staff as much as possible. These residents must also be accompanied by appropriate clinical or therapy staff .

SARS-CoV-2 (only) is confirmed: Resident(s) should be placed on Transmission-Based Precautions.

Resident(s) should be placed in a single room, if available, or housed with residents with only SARS-CoV-2 infection. If unable to move a resident (available rooms, refusal to move, etc.), he or she could remain in current room with measures in place to reduce transmission to roommates . Duration of Transmission-Based Precautions for Residents with SARS-CoV-2 Infection: Non-Test Based Strategy: Residents with mild to moderate illness: At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms have improved.

Asymptomatic residents: At least 10 days have passed since the date of their first positive viral test . and environment that enhances or promotes your quality of life . You have the right to receive services with reasonable accommodations to individual needs and interests . The facility must provide a safe, clean, comfortable, home-like environment, allowing you the opportunity to use your personal belongings to the extent possible. The facility will provide housekeeping and maintenance services . 08/26/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 06/12/2025 Lakeview Rehab & Nursing Center 735 West Diversey Chicago, IL 60614 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Based on observation, interview, and record review, the facility failed to empty the lint compartment and filter.

This failure creates an unsafe environment and a fire hazard which has the potential to affect all 150 residents.

On 06/09/25 at 1:03 pm, during tour of laundry area with V16 (Housekeeping/Laundry Director), observed

the lint trap/screen compartment to the dryer for residents personal use not emptied with a large buildup of lint in the lint trap/screen compartment. V16 stated the lint trap does not have a log sheet and there is no procedure or schedule for the laundry staff to clean the lint trap/screen for the residents personal dryer. V16 stated, I check it when I can. I don't know when I'm not here who checks it. V16 explained if the lint trap/screen has lint build up it could overheat the dryer and/or cause a fire.

On 06/09/25 at 1:08 pm, V17 (Housekeeper/Laundry Aide) stated the laundry aides do not check the dryer for residents' personal use. V17 stated the laundry staff only log and check the main dryers in the laundry area after every 2 loads. V17 explained that V17 has never checked the lint trap/screen dryers for residents' personal use when V17 works in laundry.

The facility undated document titled Laundry Policies and Procedures for Laundry Personnel documents, in part: Drying: . All dryer lint screens must be cleaned by laundry staff after every 2 loads and documented on

the Laundry Daily Lint Screen Cleaning Form.

The facility's job description document titled Laundry Aide documents, in part: position summary: the duties of the laundry age shall be insured to ensure facility linen and residence personal clothing are properly collected, sorted, laundered, distributed and or stored according to facility policy. The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with the current existing federal and state regulations and established company policies and procedures.

Essential job functions: C. Role Responsibilities -Safety: use this facility equipment safely.

The facility's job description document titled Director of Housekeeping documents, in part: Under the direction of the Administrator, the Director of Housekeeping, is responsible for daily operations of the housekeeping department, including staffing, supply ordering and supervision. The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures.

Essential Duties and Responsibilities - Job Knowledge/Duties: B. Role Responsibility- Administrative Duties: Maintains pertinent records, manages budgets and supplies, and functions as a working supervisor in all areas of responsibility as the department's budgeted hours and workload. 08/26/2025

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Lakeview Rehab & Nursing Center

Inspection Findings

F-Tag F132's

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