Terraces At The Clare
TERRACES AT THE CLARE in CHICAGO, IL — inspection on May 31, 2026.
Found 1 citation. 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
Nursing Assistant) that R1 was a little restless. I told her that's her baseline and sometimes she goes
prior to going on break and I usually do rounds around 3:00 AM, I normally go on break anywhere from
morning, um one of the CNAs (V6) notified me, she asked me to untie the knot. I went to R1's room. I thought at first it (blanket) was stuck. I proceeded to untie it, it was simple over and under knot, I'm not sure what you call it, tied to the top right corner of the bed frame. I can't say for sure if it was tied to the other side, I can't say that I checked the other side.
The blanket was tied to the bed at the level of R1's chest, it covered R1's chest. It (blanket) should not be tied to the bed because that would restrict her movement. We don't do restraints, anything that is tied on the bed is a restraint, anything that impedes her movement from doing what she wants is a restraint.
The CNA could have let me know so that I could spend more time with the resident, that's the only way we make sure she stays safe.5.30. 2026 at 3:57, V2 (DON-Director of Nursing) said, I got a call from V6 (CNA) while I was on my way in to work (incoming call at 7:18 am per cell phone call log). V6 said she needed to speak with me but preferred not to speak with me on the phone. We agreed to meet/speak on the 16th floor. At approximately 8:45 AM, I spoke with V6.
She said when she came in for her shift, a blanket was tied to one side of R1's bed, she couldn't get it untied. I immediately let V1 know.
When I spoke with V4, she said she tied one side of the blanket to the bed, the other side she tucked in to prevent R1 from falling. I immediately told her, You can't do that, it's a restraint. V4 should have notified the nurse that V4 was having trouble redirecting the resident. V5 could have notified the On Call Supervisor to talk about other possible interventions if the behavior continued.Numerous attempts were made to contact V4 via phone and text (5.30.2026 at 2:34 PM,5.31.2026 at 10:18 AM, 5.31.2026 at 10:19 AM. V4 did not respond to surveyor's calls/text.V5?s Employee Behavioral Change Notice (5.23.2026) documents, in part: Behavioral Change Subject: Final Warning.
Reason For Discipline: Safety, Work Performance, Policy Violation. V5 was involved in a review related to an abuse investigation on 5.19.26. It was identified that a CNA engaged in an inappropriate care practice (tying a blanket to one side of the bed) and the nurse (V5) was unaware of the action.
Contributing factors included low visibility (dark room) and lack of direct supervision at the time of care.
This reinforces the nurse's responsibility for supervision and accountability of CNA care delivery.Expectation (proof of awareness of expectations): It is the policy of (facility) to ensure all residents are free from abuse. A key responsibility of leadership and licensed staff is to provide consistent supervision and oversight of resident care to ensure safe, compliant practices are followed at all times.Moving forward, it is expected that you will:-Maintain active supervision and oversight of CNAs during resident care-Remain visibly engaged and aware of care being provided on the floor-Ensure resident care activities are performed safely, appropriately, and in accordance with policy-Intervene immediately when unsafe, noncompliant, or inappropriate practices are observed-Promptly report concerns, incidents, or policy violations to leadership-Promote a culture of accountability, resident safety, and professional supervision through consistent monitoring and leadership presenceStaffIllinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities booklet (undated) documents, in part: Your rights to safety: You have a right to be free from physical or chemical restraints.Facility's Abuse Prevention Policy (Reviewed December 22, 2025) documents, in part: The (Facility) affirms the right of its residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment.
This Community therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.
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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.