Inspection visit

Health inspectionSeptember 22, 2023

LAKEFRONT NURSING & REHAB CTRCMS #1452353 citations on this visit

3 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 3 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse by another resident for one (R4) out of three residents reviewed for abuse. This incident resulted in one (R4) resident feeling emotionally and psychologically traumatized. Findings include: R4 is a [AGE] year-old female with a BIMS (Brief Interview for Mental Status) score (4/20/2023) of 15, which means R4's cognition is intact. Per Face sheet, R4 has diagnosis of major depression. R4's abuse care plan documents: History of sexual abuse. On 09/19/2023 at 11:32 AM, R4 was inside her room, alert and able to express her thoughts very well. R4 stated a male resident who she has never seen before, touched her arm and shoulder, tried to wake her up and solicited unilateral aggressive sexual contact. R4 stated that she screamed upon realizing the situation that is transpiring. R4 stated that she screamed for help and then V6 (Registered Nurse) came right away. R4 stated that she was traumatized with the incident and unable to sleep because she had past sexual abuse experience. R4 stated that she was afraid that the unidentified male person would come back into her room. On 09/19/2023 at 11:08 AM V3 (Registered Nurse) stated that he is familiar with R2. V3 stated that when R2 was admitted to the facility on [DATE], on (floor different than R4). V3 stated that R2 is a wanderer. V3 stated that on 08/08/2023 R2 went into R4's room (R4's room is located on a different floor than R2) and made aggressive sexual inappropriate comments to R4. V3 stated that he went into R2's room and saw V6 (Registered Nurse) telling R2 that he cannot make inappropriate comments like that, and it was wrong. V3 stated that he talked to R4. V3 stated that R4 told V3 that she was shocked because R2 touched her arm and neck. V3 stated that R4 told him that she was scared and worried and concerned. R4 told V3 that R2 made inappropriate comments. V3 stated that R4 told him that R2 was trying to wake her up. On 09/19/2023 at 02:01 PM, V6 (Registered Nurse) stated that he was working the 3:00 PM to 11:00 PM shift on (R4's floor) on 08/08/2023. V6 stated that R4 is a resident residing (stated floor location). V6 stated that he did not notice R2 going into R4's room. V6 stated that R4 told him saying, somebody, who she did not recognize, came in her room, and made an inappropriate/sexual proposal. She said no and he left. V6 stated that he went into R2's room and talked to R2. V6 asked R2 if he went into R4's room. R2 stated he did and was looking for R4 to have sex with her. V6 stated that he called R2 outside his room and R4 identified the resident. V6 stated that R2 admitted that he made (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 145235 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 inappropriate sexual comments to R4. R4 stated that she was anxious. V6 stated, R4 told him, I hope he doesn't come down to my floor and into my room again. V6 assured her that R2 won't come down. Level of Harm - Actual harm Residents Affected - Few R4's progress note by V6 on 08/08/2023 at 07:40 PM documents: Around 7:40pm, resident reported that a male resident came into her room and made an inappropriate verbal proposal to her; she refused. According to Face sheet, R2 is a [AGE] year-old male. R1 has medical diagnosis of schizoaffective disorder, homicidal ideation, and bipolar disorder. On 09/20/2023 at 09:47 AM, V4 (Clinical Manager) stated that at admission we have 72-hour constant observation and monitoring by the interdisciplinary team including social worker, CNA and nurses also watches him. It's our practice to constantly monitor them because we need to understand their behavior. On 09/20/2023 at 10:37 AM, V5 (Social Services Director) stated the resident must be watched for 72 hours by the social worker. We do not have any behavior interventions in place for R2 to monitor and watch him from going into another resident's room. On 09/20/2023 at 2:13 PM, V9 (Nurse Practitioner) stated that schizoaffective is derived of two words. Schizo- meaning prominent psychotic symptoms such as hallucinations, delusions, auditory symptoms, disorganized speech. Affective which means mood such depression, anxiety, and mania. Homicidal Ideation means that there is an intent to harm others. Thought to harm others or specific plan. For example, I want to hurt the nurse with the knife. Intentional motivation to harm others. Schizoaffective disorder can make you sexual aggressive. It's not always but usually. V9 stated, you can google this information. It is the same. Progress Note by V4 (Clinical Manager) for R2 documents in part: R2 presents as danger to self & others and requires immediate hospitalization due to sexually inappropriate behavior. Resident solicited sexual behavior (to) other resident and touched another resident's arm and neck. Resident is irrational, unpredictable, acting on impulsiveness, and likely to engage in harmful behavior due to impaired judgment, and mental health decompensation. V9 was notified with new order noted and carried out. Resident on monitoring. Progress Note by V3 (Registered Nurse) for R2 on 08/08/2023 documents: R2 had an incident where he said inappropriate comments to another resident on (location of R4's floor). Administrator made aware. Resident is being monitored on (R2's floor location) and has been instructed to avoid this resident and (R4's floor location). (R4's) Floor Nurse made aware. Resident is on continuous monitoring. R2's baseline care plan does not have behavior interventions related to R2's mental illness diagnosis. Per census, R2 was admitted on the XXX floor and incident happened on the YYYY floor in R4's room. Per incident report, the incident happened inside R4's room located on the YYYY floor. Facility's Abuse Report Final documents in part: R4 did report difficulty sleeping for two nights after the incident. Facility's Abuse Policy (07/14/2023) documents in part: It is the policy of the facility to provide (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. Abuse is the willful infliction of mistreatment, injury, unreasonable confinement, intimidation, or punishment. Abuse assumes to intent harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Even if there is capacity to give consent, consent obtained to intimidation, coercion, or fear is considered sexual abuse. Event ID: Facility ID: 145235 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of records, facility failed to follow their policy to report allegation of abuse within required time frame for one (R4) out of three residents reviewed for abuse. The failure has the potential to affect one resident in addressing abuse incident. Findings include: R4 is a [AGE] year-old female with a BIMS (Brief Interview for Mental Status) score (4/20/2023) of 15. Which means R4's cognition is intact. Per Face sheet, R4 has diagnosis of major depression. R4's abuse care plan documents: History of sexual abuse. On 09/19/2023 at 11:32 AM, R4 was inside her room, alert and able to express her thoughts very well. R4 stated a male resident who she has never seen before, touched her arm and shoulder, tried to wake her up and solicited unilateral aggressive sexual contact. R4 stated that she screamed upon realizing the situation that is transpiring. R4 stated that she screamed for help and then V6 (Registered Nurse) came right away. R4 stated that she was traumatized with the incident and unable to sleep because she had past sexual abuse experience. R4 stated that she was afraid that the unidentified male person would come back into her room. Per incident report, a solicitated inappropriate sexual incident happened by R2 to R4 inside R4's room. According to Face sheet, R2 is a [AGE] year-old male. R1 has medical diagnosis of schizoaffective disorder, homicidal ideation, and bipolar disorder. There was no documentation of interventions related to his (R2) behavior in R2's care plan. On 09/20/2023 at 10:37 AM, V5 (Social Services Director) stated R4's nurse was the nurse who knew about the incident first. On 09/20/2023 at 11:01 AM V1 (Administrator) stated that any time there is an allegation of abuse, we must report to the Department right away. The moment there is an allegation of abuse you report immediately and go in to investigate right away. Initially I got a call from V6 (Registered Nurse) about a proposition that was made. It was told to me that R2 wanted to engage in sexual behavior and R4 said no. V1 stated that V6 talked to him about the proposition. V5 told him the next day that R4 was touched. The story that was initially reported me didn't sound like abuse, so I waited till the next day. R2 did make a proposal for sexual proposal. Just a question, I wouldn't say is an allegation of sexual abuse. The parameters of the story changed the next day. There was a one-on-one CNA placed in front of R4's room. Progress Note by V3 (Registered Nurse) for R2 on 08/08/2023 at 10:36 PM documents: R2 had an incident where he said inappropriate comments to another resident. Administrator made aware. Resident is being monitored and has been instructed to avoid this resident and the (floor R4 was located). Floor Nurse (for R4) made aware. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm R4's progress note by V6 (Registered Nurse) on 08/08/2023 at 07:40 PM documents: Around 7.40pm, resident reported that a male resident came into her room and made an inappropriate verbal proposal to her; she refused, and the male resident left her room immediately. This made resident to be anxious. Administrator notified immediately and suggestion appreciated; resident was reassured that the male resident would be kept off the floor and referred to social service and psych for an eval and counselling. Residents Affected - Few Facility Abuse Report Initial Form confirmation documents facility emailed initial report to IDPH on 08/09/2023 at 01:40 PM. Facility Abuse Initial Form 08/09/2023 documents in part: Date & time when staff became aware of the incident: 08/09/2023 11:39 AM. Name of staff who 1st became aware of the incident: V5 (Social Services Director). Facility's Abuse Report Final documents in part: R4 did report difficulty sleeping for two nights after the incident. Facility's Abuse Policy (07/14/2023) documents in part: All allegation of abuse will be reported to IDPH immediately not exceeding 2 hours after the initial allegation is received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of records, facility failed to follow their policy of completing quarterly fall risk assessments and failed to ensure resident has the right to be free from hazards, accident, and injuries for one (R1) out of three residents reviewed for hazards and accidents. This failure resulted in one resident (R1) sustaining multiple rib fractures. Findings include: On 09/19/2023 at 10:30 AM, surveyor observed R1 rolling around in her wheelchair. R1 stated that she doesn't want to talk. R1 stated that she fell by the bathroom. R1 stated that she demanded to go to the hospital. On 09/20/2023 at 1:00 PM, V2 (Director of Nursing) stated that R1 fell in the bathroom on 07/17 and had multiple rib fractures but we only found out about the fractures later. On 09/20/2023 at 10:12 AM, V7 (Restorative Nurse/Minimum Data Set Coordinator), stated that the nurses are the ones doing the baseline care plan. Me as a care plan coordinator should make sure all of the care plan is updated initially, quarterly and after significant change of condition. V7 stated R1 fell on [DATE]. We sent her out to the hospital on the same day and she returned to us on 07/19/2023. V7 stated R1 fell by going to the bathroom by herself. She will go to the bathroom, hold onto the railing, stand, and pivot herself. But R1 needs extensive assist. R1 is refusing care. We tried to advise her that she needs assistance, but she refuses. At the time she feels she was sick. She went to bathroom, and she fell. The policy is when a resident falls, we must do a risk assessment and update care plan. We found that R1 has fracture of the ribs and femur. R1 also had an infection at that time. She had an upper respiratory infection, I think pneumonia. Fall risk assessment done upon admission, quarterly and any time there is a fall. V7 stated the only fall risk assessments done on the resident was upon admission on [DATE] and then post hospitalization 07/19/2023. There was no fall risk assessment done quarterly for R1. Quarterly assessment is to see if there are any changes to the resident. Per Face sheet, R1 was admitted to facility on 01/23/2023. R1's fall risk assessment (01/23/2023) documents in part: score of 5, which means R1 is a low fall risk. R1's fall risk assessment (07/19/2023) documents in part: score of 13, which means R1 is a high fall risk. R1's care plan (2/10/2023) documents in part: R1 requires assistance from staff to come to standing position due to unsteady gait, poor sequencing, poor coordination and decrease muscle strength. R1's fall care plan (02/10/2023) documents in part: R4 is a high fall risk for falls due to decrease functional mobility and poor safety awareness related to diagnoses. There is no added intervention after the fall. Facility's facility incident report (07/21/2023) documents in part: On 07/17/2023 approximately (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145235 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakefront Nursing & Rehab Ctr 7618 North Sheridan Road Chicago, IL 60626 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 04:50 PM, R1 was observed by nurse on duty in a semi-fetal position on the floor next to the bathroom. R1 verbalized that she hit her head. On 07/18/2023 at around 2:42 PM, facility received the above resident's ed (emergency department) notes, CT chest without contrast resulted in nondisplaced fractures of the anterolateral aspect of the Right fourth, fifth, sixth ribs. Possibly acute or subacute. Facility's Fall Occurrence policy (07/17/2023) documents in part: A fall risk assessment form will be completed by the nurse or the falls coordinator upon admission, readmission, quarterly, significant change and annually. Event ID: Facility ID: 145235 If continuation sheet Page 7 of 7

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Citations

3 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0600SeriousS&S Gactual harm
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
0609GeneralS&S Dpotential for harm
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

FAQ · About this visit

Common questions about this visit

What happened during the September 22, 2023 survey of LAKEFRONT NURSING & REHAB CTR?

This was a inspection survey of LAKEFRONT NURSING & REHAB CTR on September 22, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at LAKEFRONT NURSING & REHAB CTR on September 22, 2023?

Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·September 22, 2023