Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakefront Nursing & Rehab Ctr during CMS and state inspections, most recent first.
A dumpster lid was observed left open due to an unbroken box, contrary to facility policy requiring lids to remain closed to prevent pest entry. This was confirmed by the dietary manager and regional operations director during the survey.
Staff did not consistently wear required PPE, such as gowns and gloves, while providing high-contact care to residents on Enhanced Barrier Precautions, and a laundry aide failed to prevent cross contamination by moving soiled linens near clean linens. These actions occurred despite clear facility policies, posted instructions, and prior staff education.
A resident with multiple medical diagnoses did not have a code status or advance directive documented in the medical chart or physician order sheet. An LPN was unable to confirm the resident's code status, and facility leadership acknowledged that code status should be documented for all residents. Facility policy requires this documentation, but it was not present for the affected resident, potentially impacting all residents in the facility.
A resident with multiple psychiatric diagnoses was administered Depakote without updated consent reflecting a change in dosage, contrary to facility policy requiring new consent forms for each change in psychotropic medication regimen. Staff interviews confirmed the outdated consent and the requirement for updated documentation.
A resident with multiple medical conditions did not receive prescribed wound care because new physician orders for packing gauze and dressing changes with betadine were not entered into the medical record. Staff interviews revealed assumptions and lack of follow-up after the resident's doctor visit, leading to a delay in treatment despite facility policies requiring prompt documentation and implementation of orders.
Two residents did not receive their prescribed therapeutic diets and nutritional supplements due to failures in communication, documentation, and supply management. One resident missed double entree portions and peanut butter and jelly sandwiches, while another did not consistently receive ordered Ensure supplements, with staff and dietary management unaware of the lapses until identified by surveyors.
Surveyors identified failures in medication labeling and storage, including an insulin pen used past its 28-day expiration, insulin and eye drops lacking open dates, and expired house stock medication that had not been discarded. Nursing staff and the DON confirmed that these items should be labeled and disposed of according to policy and manufacturer guidelines.
Staff did not allow the blender used for pureeing food to air dry after sanitizing and before preparing food for two residents on a puree diet, despite facility protocols and staff expectations requiring this step to prevent food contamination. The affected residents had medical conditions requiring a puree diet, and the deficiency was confirmed by both dietary management and operations staff during observation.
Six multiple occupancy bedrooms did not meet the required 80 square feet per resident, with each of these rooms housing three residents in 226 square feet, resulting in only 75.3 square feet per resident. Facility leadership acknowledged the deficiency and confirmed no changes had been made to the room sizes.
A physical altercation occurred between two residents after a disagreement over a beverage, resulting in one resident sustaining a scrape above the eyebrow. The facility's investigation concluded that the incident was a behavioral issue rather than abuse, with conflicting accounts from the residents involved.
A resident with dysphagia and other health issues did not receive the prescribed mechanical soft diet and nutritional supplements, posing a potential choking hazard and hindering weight maintenance. The Dietary Manager and Registered Dietician confirmed the oversight, noting the importance of adhering to the meal ticket instructions for the resident's health.
Dumpster Lid Left Open, Allowing Potential Pest Access
Penalty
Summary
During an observation of the facility's outside dumpster, it was found that one of the three dumpster lids was being held open by an unbroken box. This observation was made in the presence of the Dietary Manager and the Aramark Regional Director of Operations. The facility's documented expectations for the outside dumpster specify that lids should remain closed at all times to prevent rainwater entry, littering, and pest infestations. The Dietary Manager confirmed that the dumpster lid should be closed at all times to prevent rodents from accessing the dumpster and potentially entering the facility. At the time of the observation, the facility census was 90 residents.
Failure to Adhere to Enhanced Barrier Precautions and Laundry Cross-Contamination Prevention
Penalty
Summary
Staff failed to consistently don appropriate Personal Protective Equipment (PPE) while providing care to residents under Enhanced Barrier Precautions (EBP) and did not follow proper procedures to prevent cross contamination in the laundry area. Certified Nursing Assistants (CNAs) were observed transferring and repositioning residents in EBP rooms without wearing gowns, despite EBP signage and care plans specifying the need for gown and glove use during high-contact care activities such as transferring, feeding tube care, and changing linens. The CNAs involved stated they did not believe gowns were required for transfers, even though their education and the posted EBP instructions indicated otherwise. A physical therapist was also observed providing therapy to a resident in an EBP room while only wearing gloves and no gown, with her uniform and arms coming into contact with the resident's bed. The therapist admitted to becoming desensitized to the EBP signage and not consistently wearing gowns as required. The residents involved had significant care needs and were dependent on staff for transfers and repositioning. Their care plans and physician orders documented the use of EBP due to conditions such as gastrostomy tube feeding, indwelling catheters, and wounds, all of which increase the risk of infection transmission. The facility's policies and posted EBP signs clearly instructed staff to wear gowns and gloves during high-contact care activities for these residents. Despite this, staff did not adhere to these requirements during observed care activities. Additionally, in the laundry area, a laundry aide was observed moving a dirty linen bin past a cart containing clean linens, contrary to facility policy and training that require separation of clean and soiled items to prevent cross contamination. The laundry aide acknowledged awareness of the correct procedure but stated she was rushing and forgot to move the clean linen cart out of the way before bringing in the soiled bin. Interviews with supervisory staff confirmed that all staff had been educated on EBP and laundry procedures, and that the expectation was for strict adherence to these protocols.
Failure to Document Resident Code Status in Medical Chart
Penalty
Summary
The facility failed to ensure that a resident's code status was documented in the medical chart, as required by facility policy. During an investigation, an LPN reported being unsure of the resident's code status because it was not listed in the chart or documented on the unit. A review of the resident's medical chart and physician order sheet confirmed that there was no code status or advance directive recorded. The resident's admission record also lacked this information. Interviews with the Regional Director of Clinical Services and the Director of Nursing confirmed that code status should be established and documented upon admission, and that it is a personal right of the resident and family. Facility policies require that physician orders, including code status and advance directives, be documented in the clinical record and physician order sheet. The failure to document the code status for this resident was identified through record review and staff interviews. The facility census indicated that 90 residents could potentially be affected by this deficiency.
Failure to Obtain Updated Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain updated consent for the use of a psychotropic medication for one resident, as required by its own policy. The resident, who was admitted from an acute care hospital with diagnoses including psychosis, cannabis abuse with psychotic disorder, generalized anxiety disorder, mood affective disorder, and major depressive disorder, had intact cognitive function according to the most recent assessment. The care plan noted behavioral distress related to mental illness, and active physician orders included Depakote at specific dosages. Despite a previous consent form for Depakote being on file, it was signed several years prior and did not reflect the current dosage or regimen. Interviews with the Administrator and DON confirmed that facility policy requires new consent forms to be obtained whenever there is a change in medication dosage, and that the existing consent was outdated. The facility's policy specifically mandates obtaining consent for each psychotropic medication and updating it with any change in dose, which was not followed in this case.
Failure to Enter and Implement Physician Wound Care Orders
Penalty
Summary
A resident with diagnoses including acute osteomyelitis, chronic myeloid leukemia, essential hypertension, and type 2 diabetes mellitus did not receive wound care treatment as ordered by their physician. The resident, who was cognitively intact, reported that new wound care treatments were ordered after a recent doctor's visit, but these treatments had not been initiated at the facility. Documentation showed that the physician's order for packing gauze and dressing change with betadine was not entered into the resident's medical record, and the most recent physician order sheet did not include these orders. Interviews with facility staff revealed a lack of communication and follow-up regarding changes in physician orders after appointments. The Regional Director of Clinical Services indicated that staff sometimes assume there are no new orders if residents do not provide paperwork, while the Administrator and Director of Nursing both stated that staff are expected to follow up with the physician's office and ensure all orders are entered into the medical record. Facility policies require prompt documentation and implementation of physician orders, but these were not followed in this case, resulting in a delay in the resident's wound care treatment.
Failure to Provide Prescribed Diets and Nutritional Supplements
Penalty
Summary
The facility failed to follow prescribed therapeutic diet orders and did not provide required nutritional supplements for two of four residents reviewed for nutritional supplements. For one resident with multiple diagnoses including psychosis, heart disease, and vitamin D deficiency, the facility did not provide the ordered double entree portions and peanut butter and jelly sandwiches as specified in the resident's diet order. Observations showed that the resident's meal tray was missing items listed on the tray ticket, and staff interviews revealed miscommunication and lack of proper documentation transfer between dietary and nursing departments. The dietary manager was unaware of the special diet order due to missing communication and did not check the electronic records, resulting in the resident not receiving the correct diet as ordered. Another resident with diagnoses including adult failure to thrive, depression, and chronic obstructive pulmonary disease did not consistently receive the ordered nutritional supplement (Ensure or Medpass 120 ml twice daily). The resident reported only receiving the supplement three times in a month, despite an active order for twice daily administration. Review of the medication administration record (MAR) confirmed multiple instances where the supplement was documented as unavailable. Staff interviews indicated that there had been issues with supplement availability, improper distribution to residents not on the supplement program, and a lack of communication to ensure the correct residents received their prescribed supplements. Both residents had care plans and active orders specifying the need for specialized diets and supplements to maintain their nutritional status. However, failures in communication, documentation, and supply management led to the residents not receiving their prescribed diets and supplements as ordered by their physicians. Staff, including the dietitian and DON, were not aware of the deficiencies until brought to their attention during the survey.
Medication Labeling and Storage Deficiencies Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices. Specifically, an opened multi-dose insulin Kwik pen for one resident was found with an open date that indicated it had surpassed the 28-day expiration period, and a registered nurse confirmed it should have been discarded. Another resident's insulin Kwik pen was found without any open date on either the pen or its storage bag. Additionally, an eyedrop bottle for a third resident was observed without an open date, and a bottle of Folic Acid house stock was found to be expired but still contained pills. Interviews with nursing staff and the Director of Nursing confirmed that insulin pens and eye drops are required to be labeled with open dates to determine appropriate discard times, and house stock medications should be discarded according to the manufacturer's expiration date. Facility policies reviewed by surveyors also require proper labeling and timely disposal of medications, including multi-dose vials and house stock, in accordance with manufacturer guidelines.
Failure to Air Dry Puree Equipment Prior to Use
Penalty
Summary
The facility failed to ensure that equipment used to puree food items was properly air dried prior to use, as observed during meal preparation for two residents on a puree diet. During the observation, a cook immersed the pitcher blender into the wash, rinse, and sanitize sinks but did not allow the blender to air dry before using it to puree rice pilaf and then again before pureeing California blend vegetables. Both the Aramark Regional Director of Operations and the Dietary Manager confirmed during the observation that the expectation is for staff to air dry the blender prior to use to prevent food contamination, and expressed concern that this step was not followed. The two residents affected were on regular diet puree texture, with one resident having diagnoses including gastroesophageal reflux disease and chronic obstructive pulmonary disease, and the other with gastroesophageal reflux disease and dysphagia. One resident was cognitively intact, while the other was moderately impaired. Facility documentation, including in-service training materials and the puree process protocol, specified that equipment should be air dried before use for each menu item, but this procedure was not followed during the observed meal preparation.
Failure to Meet Minimum Room Size Requirements for Multiple Occupancy Bedrooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in six multiple occupancy bedrooms, affecting 17 residents. During the entrance conference, the Administrator acknowledged that several rooms did not meet the square footage requirements, and the Assistant Administrator confirmed that rooms 107, 108, 207, 208, 307, and 308 each housed three residents in rooms measuring 226 square feet, resulting in only 75.3 square feet per resident. No construction or modifications had been made to these rooms, and the facility did not have documentation of the current square footage but relied on previous measurements. The facility census confirmed that these six rooms were among the 48 rooms in the building and were occupied by three residents each.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, resulting in a physical altercation between two residents, R2 and R3. The incident occurred when R3 was offered a beverage by a staff member, which R3 declined. R2 insisted that R3 accept the beverage, leading to a verbal disagreement that escalated into a physical confrontation. During the altercation, R2 sustained a scrape above the right eyebrow, and both residents were separated by staff. R2 is a resident with a history of generalized anxiety disorder, insomnia, type 2 diabetes, chronic obstructive pulmonary disease, hyperlipidemia, hypothyroidism, and other chronic pain. R2's cognition is intact, as indicated by a BIMS score of 15. R3, also with a BIMS score of 15, has diagnoses including hypertensive heart disease, generalized anxiety disorder, paranoid schizophrenia, major depressive disorder, schizoaffective disorder, and bipolar type. R3's care plan notes the use of psychotropic medication and a risk for behavioral distress and physically aggressive behavior when agitated. Interviews with staff and residents provided conflicting accounts of the incident. R3 claimed there was no argument, while R2 described being pushed and hit by R3. The facility's investigation concluded that R2 was the aggressor, and both residents were placed on one-to-one supervision. The incident was not substantiated as abuse by the facility, as it was considered a behavioral issue rather than malicious intent.
Failure to Provide Prescribed Mechanical Soft Diet and Nutritional Supplements
Penalty
Summary
The facility failed to adhere to the prescribed dietary plan for a resident with multiple health conditions, including dysphagia and adult failure to thrive. The resident was observed receiving a lunch tray that did not comply with the mechanical soft diet ordered by the physician. Specifically, the ham in the sandwich was not ground, posing a potential choking hazard, and the tray lacked the prescribed whole milk and frozen nutritional treat, which are essential for the resident's weight maintenance and nutritional needs. Interviews with the Dietary Manager and Registered Dietician confirmed the oversight, highlighting that the resident's meal ticket clearly indicated the need for ground meat and specific nutritional supplements. The Dietary Manager acknowledged the deviation from the meal ticket instructions, attributing the issue to a temporary kitchen adjustment. The Registered Dietician emphasized the importance of the nutritional supplements for the resident's weight gain and overall health, noting that the absence of these items could hinder the resident's nutritional progress.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birchwood Plaza | 0.1 mi | ★★★★★ | 0 | 0 |
| Waterford Care Center, The | 0.2 mi | ★★★★★ | 12 | 0 |
| Fargo Health Care Center | 0.2 mi | ★★★★★ | 21 | 0 |
| Chalet Living & Rehab | 0.3 mi | ★★★★★ | 19 | 1 |
| Aperion Care Lakeshore | 0.5 mi | ★★★★★ | 10 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.