Landmark Of Itasca Rehabilitation And Nursing Cent
Landmark of Itasca Rehabilitation and Nursing Cent in ITASCA, IL — inspection on April 29, 2026.
Found 4 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
(Electronic Medical Record) showed R9 diagnoses, including bipolar disorder, schizophrenia, major
02/23/2026, around 12:00 PM, the writer asked V1 for the incident report, and V1 said he hadn't
reviewing the progress notes now, he should have reported, investigated, and planned care appropriately.04/23/2026 at 12:30 PM, V2 (Director of Nursing) stated V1 is the abuse coordinator and that she was unaware that the investigation had not been completed.The facility's policy titled Abuse Prevention Program in part defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish to a resident.
145752 04/29/2026
Landmark of Itasca Rehabilitation and Nursing Cent 535 South Elm Itasca, IL 60143
policy that prohibits and prevents abuse, investigates allegations of abuse, protects residents during
of 10.On 04/23/2026 at 10:56 AM, R4 said that on 12/03/2025, when she returned from dinner, R9, whose room is next door and shares the bathroom, told her that V26 (Certified Nursing Assistant) had taken her dishes, which R4 had left on the bathroom sink. R4 said that when she spoke to V26, she hit her with a garbage bag. R4 said she called the police, who came to the facility.
The next day, V1 (Administrator) spoke with her and did nothing about it.R4's EMR (Electronic Medical Record) showed R4 has diagnoses, that included depression, chronic obstructive pulmonary disease, and gastroesophageal reflux disease. R4's MDS (Minimum Data Set) dated 03/29/2026 showed R4's cognition is intact and that she is independent in her daily activities. On 04/24/2026 at 2:30 PM, R9 said she witnessed V26 hitting R4 with a garbage bag.R9's EMR showed R9's diagnoses included bipolar disorder, schizophrenia, major depressive disorder, and anxiety disorder. R9's MDS dated [DATE] showed that R9's cognition was intact and that she was independent in her activities of daily living.On 02/23/2026, at 12:00 PM, this writer asked V1 (Administrator/Abuse Coordinator) if he reported this incident. V1 said he did not report the incident to the Illinois Department of Public Health (IDPH) at that time because he did not believe it met the facility's definition of abuse. V1 acknowledged the incident was not reported to IDPH until 04/22/2026 and indicated an internal investigation had been initiated. V1 said V26 (CNA) continued to work after the allegation an investigation had not been initiated.On 04/24/2026, V2 (Director of Nursing) and V3 (Assistant Director of Nursing) stated the facility overlooked the incident and the abuse allegation should have been addressed in a timely manner.
The facility's policy titled Abuse Prevention Program with a revised date of 01/2019 in part showed the facility will not tolerate resident incidents of abuse, the policy will define how the investigations of abuse allegations will be conducted, outline the process of reporting, investigating, and arriving at a conclusion of allegations.
145752 04/29/2026
Landmark of Itasca Rehabilitation and Nursing Cent 535 South Elm Itasca, IL 60143
authorities.
investigate and report employee abuse to the State Agency and to protect a resident from further
10.On 04/23/2026 at 10:56 AM, R4 said that on 12/03/2025, when she returned from dinner, R9, whose room is next door and shares the bathroom, told her that V26 (Certified Nursing Assistant) had taken her dishes, which R4 had left on the bathroom sink. R4 said when she questioned V26, she hit her with a garbage bag. R4 said she called the police, who came to the facility.
The next day, R4 said V1 (Administrator) spoke with her about the incident and did nothing about it. R4 said V26 is still working, and if she did the same thing to V26, the facility would have sent her to the hospital for evaluation, but nothing happened to V26. R4 said that if she thinks about it, she gets very upset.R4's EMR (Electronic Medical Record) showed R4 has diagnoses that included depression, chronic obstructive pulmonary disease, and gastroesophageal reflux disease.R4's MDS (Minimum Data Set) dated 03/29/2026, showed R4's cognition is intact and that she is independent in her daily activities.On 04/24/2026 at 2:30 PM, R9 said she witnessed V26 hitting R4 with a garbage bag.R9's EMR (Electronic Medical Record) shows R9's diagnoses, including bipolar disorder, schizophrenia, major depressive disorder, and anxiety disorder.R9's MDS (Minimum Data Set) dated 01/30/2026 showed that R9's cognition is intact and she is independent in her activities of daily living.On 02/23/2026, at 12:00 PM, this writer asked V1(Administrator/Abuse Coordinator), if he reported the incident to the Illinois Department of Public Health (IDPH). V1 said he did not report the incident at that time because he did not believe it met the facility's definition of abuse. V1 acknowledged the incident was not reported to IDPH until 04/22/2026 and indicated an internal investigation had been initiated.On 04/24/2026, V2 (Director of Nursing) and V3 (Assistant Director of Nursing) stated that the facility overlooked the incident and that the abuse allegation should have been addressed. V2 and V3 said the employee should have been removed from the facility until the investigation was completed. V2 and V3 said the facility should have updated care plans and that the incident should have been reported in a timely manner.
The facility's policy titled Abuse Prevention Program with a revised date of 01/2019 in part showed the facility will report, identify, investigate, remove the employees from the facility during investigation, complete the final investigation within five working days after the review of medical records, personnel records of employees, interview with residents and employees and addressing in quality Performance Improvement Approach, and updating intervention in care plans.
145752 04/29/2026
Landmark of Itasca Rehabilitation and Nursing Cent 535 South Elm Itasca, IL 60143
of 3 residents (R3) reviewed for abuse in a sample of 10.R3's EMR (Electronic Medical Record)
bipolar disorder, major depressive disorder, and anxiety disorder.R3's MDS (Minimum Data Set) dated 04/03/2026 showed that R3's cognition is intact and that she is independent in her activities of daily living.R3's care plan dated 03/24/2026 showed R3 will remain safe, will be treated with respect and dignity, and reside in the facility free of mistreatment, including abuse/neglect.The writer made multiple attempts from 04/21/2026 to 04/24/2026 to speak with R3, but R3 refused to speak. V2 (Director of Nursing) and V3 (Assistant Director of Nursing) said R3 tends not to speak; however, she makes her needs known.On 04/28/2026 at 9:02, V29 (Receptionist) stated that on 04/03/2026, around 7:00 PM, she was near the residents' area by the kitchen, and R3 came by looking for food or coffee.
V29 said she witnessed V17 (Dietary Aide) yelling, pushing, and swearing at R3, then closing the kitchen door. V29 said R3 came to her, said V17 hurt her, and then V29 took R3 to the front desk, gave some cereal, and notified V6 (Social Service Assistant) and V30 (Registered Nurse), who were in the building, and the V1(Administrator)On 04/28/2026 at 12:56 PM, V27 (Social Service Assistant) said she was about to leave around 7:00 PM. V27 said V29 told her that V17 was yelling, pushing R3 away from the kitchen door, and that R3 was crying. V27 said she told V29 to report to the administrator. V6 said all residents have the right to be free from abuse.On 04/28/2026 at 1:49 PM, V3 (Assistant Director of Nursing) stated that V1 (Administrator) asked her to assist the nurses in following up on the incident, and V1 conducted the investigation. On 04/28/2026 at 1:02 PM, V30 (Registered Nurse) said V29 called him to report the incident. V30 said staff then got R3 to the unit, assessed for pain/injury/bruise and then called the police, who came to the facility and met with R3. V30 said R3 complained of pain and refused medication. V3 and V30 said all residents have the right to be free from abuse.On 04/28/2026 at 10:00 AM, V1 (Administrator) stated that V17 (Dietary Aide) is loud by nature and that he did not think abuse occurred.V1 stated that he completed the investigation based on the information he received and acknowledged that residents have the right to be free from abuse.The review of the incident report dated 04/06/2026 lacked the witness's factual statement and signature. V17 was suspended during the investigation, and the incident was not substantiated; no corrective actions were taken.The facility's Abuse Prevention Program, dated 02/2019, in part stated that the final report shall include facts determined during the investigation and a conclusion based on those facts.
Policy further stated that the administrator or Director of Nursing shall review the findings of the investigation and determine whether any further training or corrective action is needed to prevent further actions.
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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.