Inspection visit
Inspection
33 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 33 deficiencies, 3 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 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure a resident, dependent upon staff for
cares, had a call light system in place to meet the needs of the resident. This applies to 1 of 20 residents
(R4) reviewed for accommodation of needs in the sample of 20.
Residents Affected - Few
The findings include:
R4's Minimum Data Set (MDS) dated [DATE] shows R4 is dependent upon staff for oral hygiene, toileting
hygiene, showering/bathing, lower body dressing, personal hygiene, putting on/taking off footwear, rolling
left to right in bed, and for all transfers.
On 6/2/24 at 10:51 AM, R4 was lying in bed watching television. R4's call light rope was hanging from a
switch above R45's (R4's roommate) bed. R4, although nonverbal, was able to say yes when asked if she
had a difficult time asking for help from staff.
On 6/3/24, direct observations from the third-floor nurse's station were made from 12:07 PM until 12:24 PM.
During that time, R4 was making intermittent audible verbal sounds at 12:07 PM, 12:10 PM, 12:13 PM,
12:14 PM, 12:17 PM. R4's audible noises became louder and R4 would continue with the noises for roughly
15 seconds at a time. At 12:18 PM, R45 (R4's roommate) returned to the room and stated that R4 makes
those noises when she needs help. R45 proceeded to communicate with R4 to determine the level of help
she required. During this time, R4's call light was still not within reach.
On 6/3/24 at 12:20 PM, R45 left the room to go alert staff that R4 required assistance.
On 6/3/24 at 12:22 PM, R4's audible noises turned into what sounded like a painful howl. V16 Registered
Nurse (RN) entered R4's room at 12:24 PM with another staff member to address R4's needs.
On 6/4/24 at 1:42 PM, V16 RN stated that R4 is nonverbal but will make audible noises when she requires
assistance. There are no other ways for R4 to request assistance from staff. V16 stated they have tried
using the call light rope and that it should always be within reach but does not know if R4 can use it. V16 is
not aware of any other methods for R4 to alert staff when she requires assistance. V16 stated staff would
be responsible for checking on R4 more frequently to make sure R4's needs are met.
Facility Call Light, Use of policy dated 7/10 states, . 7. When providing care to residents be sure to position
the call light conveniently for the resident to use. Tell the resident where the call light is and show him/her
how to use the call light.
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 46
Event ID:
145434
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure a resident was provided
privacy during wound dressing changes. This applies to 1 of 20 residents (R6) reviewed for privacy in the
sample of 20.
Residents Affected - Few
The findings include:
On June 2, 2024, at 11:39 AM, R6 was sitting in his reclining wheelchair in the dining room. V15 Registered
Nurse (RN) changed R6's right heel dressing while he was sitting in the dining room. There were
approximately 20 residents in the dining room. They could see/watch V15 change his dressing.
On June 2, 2024, at 12:48 PM, R6 was lying in bed. V15 RN was changing the dressing to R6's buttocks.
The bedside curtain and door to his room was open. R6 is the first bed in the room. You could see R6 from
the hallway.
One June 5, 2024, at 12:36 PM, V3 Assistant Director of Nursing stated, staff should not be doing dressing
changes in the dining room, and they need to provide privacy for the residents.
The facility's residents right to personal privacy dated September 1, 2011, shows, Policy: Facility staff must
examine and treat residents in a manner that maintains the privacy of their bodies. A resident must be
granted privacy when treatments are given . Staff should pull privacy curtains, close doors, or otherwise
remove residents from public view and provide clothing or draping to prevent unnecessary exposure of
body parts during the provision of personal care and services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 2 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure staff-dependent residents were bathed,
their nails were cut, and facial hair was groomed for 3 of 20 residents (R1, R24, R64) reviewed for activities
of daily living (ADL's) in the sample of 20.
Residents Affected - Few
The findings include:
1. On 6/2/24 at 11:39 AM, R24, who is nonverbal, was lying in bed. His nails, on both hands, were
approximately 1/2-1 inch in length, with some curling back. R24's shower schedule shows he should
receive showers/baths on Monday and Thursday. The facility shower sheets for R24 showed he had a bed
bath on 5/6/24 and not again until 6/3/24. R24's active care plan shows he has diagnoses of dementia,
communication deficit, and requires extensive to total staff assistance with his Activities of Daily Living.
On 6/2/24 at 11:57 AM, V24 (Certified Nursing Assistant/CNA) stated residents should be given showers or
baths 2 times a week, nails should be cut, and facial hair shaved during that time.
On 6/3/24 at 10:10 AM V3 (Assistant Director of Nursing/ADON) was in the room providing cares to R24
with V24. V24 said I thought the nail doctor cuts nails (R24's) nails? V3 ADON replied, No the doctor comes
for toenails.
On 6/5/24 at 9:00 AM, R24 was observed to still have long nails.
2. On 6/2/24 at 11:40 AM, R1 was sitting up in a chair in his room. R1 had long stubbly facial hair, and very
long nails with a visible black thick substance under the nail beds. R1 said, Yes these nails are very long. I
need them cut. The facility shower schedule showed R1 should be given showers on Mondays and
Thursdays.
On 6/5/24 at 9:01 AM, R1 was observed to still have long dirty nails and facial stubble.
R1's active care plan shows he has a self-care deficit and requires extensive staff assistance with his
ADL's.
3. On 6/2/24 at 10:10 AM, R64 stated she has only gotten one shower since she was admitted about a
month ago, and she only got that because her mom came to the facility and threw a fit. The facility shower
schedule showed R64 should receive a shower on Mondays and a second shower was not listed for R64.
Facility shower sheets indicate that R64 refused a shower on 5/6/24, and 5/13/24 but was given one on
5/20/24, which was her last documented shower.
On 6/5/24 at 9:55 AM, R64 stated she does not and did not refuse to take showers at the facility, she wants
showers.
On 6/5/24 10:07 AM, V27 (CNA) stated residents are supposed to receive showers two times a week. V27
stated usually they can get to them on his shift, but he cannot speak for the evening shift.
R64's face sheet shows she was admitted to the facility on [DATE]. R64's active care plan shows she has a
self-care deficit and requires staff assistance with ADL's.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 3 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0677
Level of Harm - Minimal harm
or potential for actual harm
The facility provided policy on Nail Care dated July 2010, shows that nails should be kept clean, trimmed
and smooth and be completed at bath time or shortly after. The facility's Shower for the Resident policy
(undated) does not address a time frame that showers should be given.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 4 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based
observation, interview, and record review the facility failed to ensure the residents were provided activities.
This applies to 3 of 20 residents (R48, R65, R74) reviewed for activities in the sample of 20.
Residents Affected - Some
The findings include:
On June 2, 2024, at 10:11 AM, 11:26 AM, 11:39 AM, 11:46 AM, 12:03 PM and 12:58 PM, R48 and R65
were sitting in the dining room in reclining wheelchairs. There were no activities going on. The television
was the only thing on.
On June 2, 2024, at 10:30 AM, R74, the facility's resident council president stated, there isn't any activities.
They have to entertain themselves.
On June 3, 2024, at 10:03 AM, R48 and R65 were sitting in the dining room in their reclining wheelchairs.
There were no activities going on. The television was the only thing on. At 10:21 AM, V22 Certified Nursing
Assistant (CNA) started playing BINGO with the residents that could play (5 residents). R48 and R65 did
not play bingo but remained in the dining room watching everyone else play.
On June 4, 2024, at 12:25 PM, V3 Assistant Director of Nursing (ADON) stated, there is no activity director
and only 1 activity assistant.
On June 4, 2024, at 1:58 AM, V22 CNA stated, only on certain days they do stuff with the residents. It's too
much for one person. She stated, she is trying to watch the residents that stand up and do activities and
she can't by herself.
R48's activities quarterly/annual participation review dated March 18, 2024, shows, The resident is alert but
not oriented and likes to sit with her peers in the group. She is interested to do building blocks .
R48's activities care plan dated November 30, 2021, shows, Focus: Resident is alert/oriented but
confused/forgetful at times with impaired cognition due to Dementia Has interest in religious r/t (related to)
programs. Interventions: 2. Encourage to attend/participate in interim activity program as tolerated and
increase socialization. 3. Inform the resident when programs of interest occur. Orient to the activity
calendar. 5. Offer the resident independent leisure materials with options addressing areas she might like to
pursue. 14. Do daily round/short pop-up visit.
R65's care plan dated May 4, 2023, shows, Interventions .The resident needs a variety of activity types and
locations to maintain interests.
R74's Minimum Data Set, dated [DATE], shows, he is cognitively intact.
The facility's activity calendar for June 2024 shows, June 2nd: 10:00 AM- Documentary, 1:30 PM Classic
Music. June 3rd: 10:00 AM- Exercise, 1:30 PM Rock & Roll. None of these activities were done during the
survey.
The facility did not provide an activity policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 5 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0680
Ensure the activities program is directed by a qualified professional.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to employ a qualified, full time activity director.
This failure applies to all 84 residents residing in the facility.
Residents Affected - Many
The findings include:
The CMS-671 form dated June 2, 2024, shows, there was 84 residents residing in the facility.
On June 2nd and 3rd, 2024, no activities were observed.
On June 2, 2024, at 10:30 AM, R74, the facility's resident council president stated, there isn't any activities.
They have to entertain themselves.
R74's Minimum Data Set, dated [DATE], shows, he is cognitively intact.
On June 4, 2024, at 12:25 PM, V3 Assistant Director of Nursing stated, there is no activity director and one
activity assistant.
On June 5, 2024, at 9:14 AM, V2 Director of Nursing stated, she does not have a activity director. She has
been gone since March 2024. There is only 1 activity assistant for the entire building. She does not have the
qualifications of an activity director.
The facility's job description and performance standards for the activity director shows, Purpose of this
position: The purpose of this position is to develop and implement an activity program in compliance with
requirements to meet residents' needs.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 6 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure a resident with a skin rash
was assessed and failed to ensure a skin treatment was applied according to standards of practice, for 1 of
20 residents (R17) reviewed for quality of care in the sample of 20.
Residents Affected - Few
The findings include:
On 6/2/24 at 11:06 AM, R17 stated she has a terrible rash, that has been there for over 2 weeks, on her
back and in her groin. R17 proceeded to pull down her pants and show this surveyor the rash, that was
bright red in color, between her legs and spreading down both thighs. R17 also pulled up her shirt and
showed this surveyor a spotty pinpoint rash on her back with some scabbed areas from itching. In R17's
shirt pocket was a bottle of Nystatin powder. R17 stated she has told the nurses about the rashes, but no
doctor has seen her. The nurses gave her the powder and told her to put it on herself. R17 stated she told
the nurse again today (V16 Registered Nurse) who stated she would come and take a look at it.
On 6/3/24 at 12:32 PM, V16 RN stated she had not been in to see R17's rash yet but she would look at it
today and have the wound physician see it as well. V16 said she was not aware of a rash to R17's back.
V16 was asked about the Nystatin that was left in R17's room for her to apply herself and V16 stated that
should not have happened, the nurses need to apply the powder and assess the rash.
On 6/3/24 at 12:40 PM, R17 stated no one had been in to see her yet, the Nystatin powder was still in
R17's shirt pocket.
R17's Treatment Administration Record shows an active order, with a start date of 5/24/24, for Nystatin
powder to her groin two times a day. There was no order for an ointment for the rash to R17's back.
The only documented assessment prior to 6/3/24, provided by the facility for R17's rashes, was a nursing
note completed by V16 RN on 5/28/24 that states skin check every Tuesday for skin monitoring, redness to
groin.
On 6/3/24 at 1:25 PM, V35 (Wound Nurse Practitioner) stated he was not aware of the rashes to R17 until
today. V35 believes the rash on R17's back is a form of an allergic reaction, and the rash in her groin is a
fungal infection.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 7 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure a sacral pressure injury was
assessed, reported to the physician, and a treatment for the injury was in place. The facility also failed to
follow physician orders for pressure injuries. This applies to 1 of 3 residents (R6) reviewed for pressure
injuries in the sample of 20.
Residents Affected - Few
The findings include:
On June 2, 2024, at 11:39 AM, V15 Registered Nurse (RN) was changing R6's right heel dressing. R6 had
an approximate 1-inch abrasion to his left knee. V15 RN stated, they are leaving it open to air and then put
betadine on it.
On June 2, 2024, at 12:48 PM, V15 RN was changing R6's sacral wound dressing. R6 had a large, ping
pong ball size, purple/red open area on his right buttock. He (R6) had the same size/color wound on his left
buttock that was connected to the right buttock. V15 RN stated, she first saw the wound on Wednesday of
that week. She was waiting for the wound doctor to come in and evaluate the wound. He was supposed to
come that day (June 2, 2024) but wasn't coming now. She (V15) stated, the wound was worse than what
she saw on Wednesday. There were no physician orders/treatments in place for the wound. She was just
putting betadine on it and covering it with a foam dressing.
R6's medical record does not show any assessments of the sacral wound by V15 RN or other nursing staff.
R6's progress notes dated April 28, 2024, shows, Resident readmitted from local hospital . Has skin issues
on left knee, right heel, both bottom with form dressings on them .
R6's progress notes dated June 2, 2024, shows, .Wound dr/doctor supposed to come and evaluate the
wound today, but he didn't make it. DON/ADON (Director of Nursing/Assistant Director of Nursing) made
aware the sacral wound.
R6's Treatment Administration Record (TAR) for the month of June 2024 shows, Left knee, every day shift
every Tue, Thu, Sat for treatment, cleanse with normal saline, apply adaptic and foam island (dressing).
R6's TAR for the month of June 2024 shows, Cleanse sacral wound with normal saline and put medi-honey
with dry-foam dressing on it every shift until healed . The start date for this physician order is June 3, 2024.
R6's wound doctor evaluation dated June 3, 2024, shows, sacral pressure wound measuring 6 x 6 x 0.3 (6
cm (centimeters) X 6 cm X 0.3 cm) with 50% purple ecchymosis. Date treatment initiated: 6/3/2024.
R6's care plan dated February 25, 2024, shows, The resident may be at risk for skin breakdown related to
the following factors which have a causal relationship or complicate the condition: lack of mobility, bowel
and/or bladder incontinence, presence of one or more risk factors but no current ulcers, skin problems or
lesions. Approaches/Interventions: .Administer prescribed medications and treatments per doctor's orders.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 8 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0686
R6's care plan does not address his current pressure injuries.
Level of Harm - Minimal harm
or potential for actual harm
The facility's management/treatment of pressure ulcer(s) dated November 1, 2012, shows, Purpose: The
facility will have protocols in place in the even a newly identified pressure ulcer is noted the direct care staff
will initiate an appropriate treatment to the wound until that time it is further assessed by the wound care
nurse. Any newly identified pressure ulcer must have treatment initiated at the time of discovery.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 9 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0688
Level of Harm - Minimal harm
or potential for actual harm
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.
Based on interview and record review the facility failed to provide restorative services to 2 of 5 residents
(R24, R64) reviewed for restorative cares in the sample of 20.
Residents Affected - Few
The findings include:
1.) On 6/2/24 at 11:37 AM, R24 who is nonverbal, was lying in bed with contractures noted to both hands.
R24's active care plan shows he has diagnoses including dementia and right sided weakness due to a
cerebral vascular accident with contractures to his upper body. R24's Restorative Care Plan shows he
requires extensive staff assistance with his Activities of Daily Living and should receive PROM (passive
range of motion) to his affected extremities for 15 minutes a day. R24's restorative documentation for the
last 30 days showed he was provided range of motion for 15 minutes on 8 out of 30 days 5/9/24, 5/10/24,
5/11/24, 5/16/24, 5/20/24, 5/24/24, 5/29/24 and 6/1/24.
On 6/3/24 at 1:42 PM V3 (Assistant Director of Nursing) stated they have a restorative CNA (Certified
Nursing Assistant) who should be doing range of motion, and working with residents but he gets pulled to
work the floor a lot and then restorative is left up to the CNAs on the floor to complete.
On 6/5/24 at 9:13 AM, V32 (Restorative CNA) stated he just covered another CNA's vacation and was
pulled to the floor to work for the last 8 days. V32 stated when he is pulled to the floor, he cannot get his
restorative job done and the CNA's have to do their own restorative and that may not always be done.
On 6/5/24 at 9:20 AM, V24 (CNA) stated she tries to do range of motion for R24 but cannot always get to it
when she is the only CNA on that hall.
2.) On 6/2/24 at 10:11 AM, R64 stated she was receiving physical therapy however the therapist (V30
Physical Therapist) went out of the country so she was supposed to be walked by the nursing staff but that
has not been getting done. R64 additionally stated they are claiming that I always refuse to walk, and I
don't. If someone wakes me up, I will go walk with them.
On 6/5/24 at 9:25 AM, R64 stated she was walked by her mom yesterday and when her son comes in, he
will also walk her. R64 stated one day last week she was too tired to walk because a medication she was
on was making her sleepy and did refuse to go but that was the only time that has happened.
On 6/5/24 at 9:13 AM, V32 (Restorative CNA) stated R64 is supposed to be walked to the bathroom and
back, with a walker, and she can do that with stops to rest, but he is not sure if that is being done when he
is pulled to work the floor.
On 6/5/24 at 9:35 AM, V27 (CNA) stated he cannot always get time to walk residents when V32
(Restorative CNA) is not there.
R64's Physical Therapy Plan of Treatment shows she was discharged from skilled physical therapy on
5/10/24 but there was no indication on the treatment plan to indicate how often R64 should be walked by
the restorative department.
R64's ADL (Activity of Daily Living) record for the month of May shows she was not walked at all.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 10 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
A restorative care plan was requested for R64, and what was provided by the facility was a self-care deficit
care plan which lists range or motion to be done but no mention in that care plan of walking her.
The facility provided Restorative Nursing Program policy (undated) shows that restorative care should be
done to prevent a resident from declining. Restorative programs include range of motion, bed mobility and
ambulating residents which should be documented daily.
Event ID:
Facility ID:
145434
If continuation sheet
Page 11 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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.
Based on observation, interview, and record review the facility failed to ensure residents at risk for falls
were supervised and interventions were in place to prevent falls. The facility also failed to ensure residents
were transferred in a safe manner. These failures apply to 2 of 20 residents (R21, R65) reviewed for
safety/supervision in the sample of 20.
The findings include:
1. On June 2, 2024, at 10:08 AM, R21 was sitting in her wheelchair in the dining room. Her (R21) left eye
was yellow/green with sutures to her eyebrow.
R21's incident/occurrence report dated May 26, 2024, shows, Resident fell forward in the bed after night
CNA (certified nursing assistant) put her back to bed after falling. Noted bleeding on her left forehead d/t
(due to) laceration.
R21's hospital records dated May 26, 2024, shows, she had a fall with a cut on her face. Chin and left
eyebrow laceration, stitches or tape. The same records continue to show, Pt (patient) arrives via EMS
(emergency medical services) with c/o (complained of) mechanical fall and facial lacerations. Pt resides at
the facility assisted living facility with hx (history) of dementia . Per staff at the facility, pt was wheeling
herself around in her wheelchair when she struck a corner and fell out of the chair, lacerating her chin and
forehead. This occurred at 0700 (7:00 AM) and was unwitnessed but staff heard the fall and assisted the
patient up and called EMS.
R21's progress notes dated May 26, 2024, shows, Resident sent out to local hosp.(hospital) for fall and hit
her head with bleeding d/t forehead laceration via 911 .
She was diagnosed as below at local hospital; 1. CHIN LACERATION 2. MILD TRAUMATIC BRAIN INJURY
3. PELVIC FRACTURE. She came back from local hosp. after having been 9 stitches done on left forehead
without dressings on it.
On June 2, 2023, at 12:58 PM, R21 wandered out of the dining room in her wheelchair and was sitting in
another resident's room down the hall. No one was watching her. At 1:29 PM, she tried opening the exit
door and set off the alarm. No one was watching her.
On June 3, 2024, at 10:32 AM, R21 was sitting in her wheelchair in the dining room. She was standing up
and sitting down. Her wheelchair was not locked. V22 Certified Nursing Assistant (CNA) was in the dining
room but attending to another resident. R21 stood up again and realized she couldn't stand well and tried to
sit back down but her wheelchair was unlocked so it moved away from her, and she fell on her right side.
V22 CNA was on the other side of the dining room. V22 CNA stated, this is why you can't take your eyes off
anyone and do games. She also stated, you cannot take your eyes off R21. It is too much for one person.
She will stand up and fall.
R21's incident report dated June 3, 2024, shows, Resident was trying to get up from w/c (wheelchair) when
she fell and landed on her left side . wheelchair was unlocked.
R21's care plan date-initiated April 9, 2024 shows, The resident is high, risk for falls r/ t
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 12 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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
(related to) confusion, gait/balance problems, incontinence, psychoactive drug use, unaware of safety
needs. Interventions: Review information on past falls and attempt to determine cause of falls. Record
possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT
(interdisciplinary team) as to causes. The care plan has not updated since April 9, 2024.
On June 4, 2024, at 12:25 PM, V4 Assistant Director of Nursing (ADON) stated, she reviews the falls. She
reviews them and puts an intervention in place but does not put that information anywhere except her
office. She has not added any new interventions for R21. R21 has to be watched. She is everywhere and
will stand up and fall.
The facility's falls and fall risk, managing policy dated 2001 shows, Policy Statement: Based on previous
evaluations and current data, the staff will identify interventions related to the resident's specific risks and
causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy
Interpretation and Implementation: Prioritizing Approaches to Managing Falls and Fall Risk: 1. The staff,
with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a
systematic evaluation of a resident's fall risk identifies several possible interventions, the staff my choose to
prioritize interventions (i.e., to try one or a few at a time, rather than many at once) .
The facility's falls-clinical protocol policy dated 2001 shows, Cause Identification: 1. For an individual who
has fallen, staff will attempt to define a possible cause within 24 hours of the fall . Treatment/Management:
1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to
prevent subsequent falls and to address risks of serious consequences of falling .
2. On June 3, 2024, at 10:47 AM, V21 CNA transferred R65 from one reclining wheelchair to another
reclining wheelchair. R65 did not have a gait belt on. R65 tried to sit down before he got to the chair and
almost fell.
R65's care plan last updated December 31, 2023, shows, July 30, 2023, Staff to use gait belt during
transfers.
On June 6, 2024, at 12:36 PM, V4 Assistant Director of Nursing stated, staff should be transferring R65
with a gait belt.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 13 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure the Registered Dietician was immediately notified of
a significant weight loss for a resident receiving enteral feedings. This failure resulted in a delay in a
resident (R24) being assessed by the dietician to implement interventions to prevent further weight loss.
The facility failed to ensure weekly weights were completed for a resident (R1) on enteral feedings with
insidious weight loss. This applies to 2 of 3 residents (R24, R1) reviewed for enteral feedings in the sample
of 20.
Residents Affected - Few
The findings include:
1. R24's active care plan shows he requires enteral feedings through a Gastrostomy tube (G tube). Hospital
records from a local community hospital show he was hospitalized from [DATE] through 3/12/24 for
placement of a gastrostomy tube.
R24's nutritional assessment completed by V7 (Registered Dietician/RD) on 3/25/24 show he was
re-admitted from the hospital with tube feeding orders for a continuous tube feeding of Glucerna 1.2 at 60
(ml) milliliters per hour. These orders were changed by V7, at the request of the facility, to bolus feedings
QID (four times a day).
R24's weight summary shows on 4/1/24, R24's weight was 101.0 lbs. (pounds). On 4/4/24 R24's weight
was 91 pounds, a 10 lb., 9.9% weight loss in 4 days. On 4/15/24, R24's weight had dropped from 91 lbs. to
87.8 lbs, another 3.2 lbs in 11 days. R1's nursing progress notes do not show that V7(RD) or V29 (R24's
Physician and Medical Director) were notified of R24's significant weight loss.
A Nutrition/Dietary note completed by V7 (RD) on 4/29/24 shows, Patient with significant weight loss noted,
10% in 1 month, Discussed with RN will change to a continuous tube feeding to meet the needs of the
patient. A physician's order dated 4/29/24 shows R24's tube feeding was changed from bolus to a
continuous feeding of Glucerna 1.2 at 50 ml. per hour.
On 6/4/24 at 10:32 AM, V7 (RD) stated she is only at the facility 16 hours per month. V7 stated she is not
immediately notified of weight loss as she finds out by notes left in her mailbox when she comes to the
facility. V7 stated she could not recall exactly when she was told of R24's weight loss but she did not see
him until 4/29/24 so she assumes it was that day. R24 stated she made immediate changes to the tube
feeding orders to be a continuous feeding to try to prevent further weight loss.
On 6/5/24 at 7:50 AM, V2 (Director of Nursing) stated she was aware of R24's weight loss and she expects
the nurses to call the Dietician and Physician right away for significant weight loss and to chart that in the
resident's medical record. V2 stated she was not aware that V7 (RD) was only contracted to come to the
facility 2 times per month.
On 6/5/24 at 10:35 AM, V29 (R24's Physician) stated he was notified of R24's weight loss but not sure of
the date. V29 stated he was also unaware that the nursing staff were only leaving notes in the mailbox for
V7 (RD) and not calling her to notify her of significant weight loss. V29 state they will have to fix that
process because the Registered Dietician should be notified immediately.
On 6/5/24 at 11:41 AM, V16 (Registered Nurse/RN) stated they do not call the Dietician directly
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 14 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0692
they let V3 (Assistant Director of Nursing) know and then put a note in the Dieticians mailbox. V16 stated
they should call the residents physician who usually tells them to notify the Dietician.
Level of Harm - Actual harm
Residents Affected - Few
The facility provided Weight Monitoring policy dated 2017 describes significant weight loss as 5% in one
month, 7.5% in 3 months, and 10% in 6 months. The policy shows that the physician and dietician should
be notified but fails to indicate a time frame.
2. R1's Medication Administration Record shows he receives enteral feedings via a G-tube of Jevity 1.2,
300 ml at breakfast and lunch, and 600 ml. at dinner.
R1's 2/12/24 Nutrition note completed by V7 (RD) shows the resident has had a significant weight loss of
8% in 6 months and she recommended weekly weights for 4 weeks to monitor his weight.
R1's Weight Summary report shows on 2/5/24 he weighed 132.0 lbs. but, no further weight is documented
until 3/12/24. One month after V7 ordered weekly weights for R24.
On 6/4/24 at 10:32 AM, V7 (RD) stated R1 has a history of refusing the bolus feedings so he can consume
his regular diet order. V7 stated she ordered the weekly weights to keep track of his weight and she expects
the facility to do the weights when it is ordered.
The facility provided Weight Monitoring policy dated 2017 describes significant weight loss as 5% in one
month, 7.5% in 3 months, and 10% in 6 months. The policy shows that the physician and dietician should
be notified but fails to indicate a time frame. The policy additional shows that a client's body weight is
monitored to maintain acceptable parameters of nutritional status.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 15 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure oxygen tubing was dated
and failed to change humidifier containers on the oxygen concentrator for 2 of 4 residents (R23, R61)
reviewed for oxygen administration in the sample of 20.
Residents Affected - Few
The findings include:
On 6/2/24 at 10:42 AM, R23 was in bed with a portable oxygen concentrator next to the bed. R23 stated I
am not using it right now because they don't change the filter on the back of the machine or the water
container. R23's nasal cannula tubing was not dated, and the humidifier container was dated 4/18/24.
On 6/2/24 at 11:10 AM, R61 was in her room with her portable oxygen concentrator running. The nasal
cannula tubing was also not dated, and the humidifier container was dated 4/18/24.
Both R23 and R61's May 2024 Treatment Administration Record (TAR) shows their oxygen tubing and
humidifier container are to be changed every week on Sundays. R23 and R61's TAR is initialed as the
oxygen tubing and humidifiers being changed however the date on the humidifier for both residents was
4/18/24, and the tubing was not dated.
On 6/3/24 at 8:30 AM, V3 (Assistant Director of Nursing) stated the oxygen tubing and humidifiers should
be dated and changed weekly.
The facility Oxygen Administration policy dated 2018 shows that humidifiers should be dated and initialed
when changed and should be changed according to facility protocol.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 16 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in
charge on each shift.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to provide sufficient nursing staff to meet the
needs of the residents. This failure has the potential to affect all 84 residents in the facility.
The findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a
resident census of 84.
1. R4's Minimum Data Set (MDS) dated [DATE] shows R4 is dependent upon staff for oral hygiene, toileting
hygiene, showering/bathing, lower body dressing, personal hygiene, putting on/taking off footwear, rolling
left to right in bed, and for all transfers.
On 6/2/24 at 10:51 AM, R4 was lying in bed watching television. R4's call light rope was hanging from a
switch above R45's (R4's roommate) bed. R4, although nonverbal, was able to say yes when asked if she
had a difficult time asking for help from staff.
On 6/3/24, direct observations from the third-floor nurse's station were made from 12:07 PM until 12:24 PM.
During that time, R4 was making intermittent audible verbal sounds at 12:07 PM, 12:10 PM, 12:13 PM,
12:14 PM, 12:17 PM. R4's audible noises became louder and R4 would continue with the noises for roughly
15 seconds at a time. At 12:18 PM, R45 (R4's roommate) returned to the room and stated that R4 makes
those noises when she needs help. R45 proceeded to communicate with R4 to determine the level of help
she required.
On 6/3/24 at 12:20 PM, R45 left the room to go alert staff that R4 required assistance.
On 6/3/24 at 12:22 PM, R4's audible noises turned into what sounded like a painful howl. V16 Registered
Nurse (RN) entered R4's room at 12:24 PM with another staff member to address R4's needs.
2. On 6/2/24 at 11:39 AM, R24, who is nonverbal, was lying in bed. His nails, on both hands, were
approximately 1/2-1 inch in length, with some curling back.
R24's shower schedule shows he should receive showers/baths on Monday and Thursday. The facility
shower sheets for R24 showed he had a bed bath on 5/6/24 and not again until 6/3/24.
R24's active care plan shows he has a diagnosis of dementia, communication deficit, and requires
extensive to total staff assistance with his Activities of Daily Living.
On 6/5/24 at 9:00 AM, R24 was observed to still have long nails.
3. On 6/2/24 at 11:40 AM, R1 was sitting up in a chair in his room. R1 had long stubbly facial hair, and very
long nails with a visible black thick substance under the nail beds. R1 said, Yes these nails are very long. I
need them cut. The facility shower schedule showed R1 should be given showers on Mondays and
Thursdays.
On 6/5/24 at 9:01 AM, R1 was observed to still have long dirty nails and facial stubble.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 17 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0725
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
R1's active care plan shows he has a self-care deficit and requires extensive staff assistance with his
ADL's.
4. On 6/2/24 at 10:10 AM, R64 stated she has only gotten one shower since she was admitted about a
month ago, and she only got that because her mom came to the facility and threw a fit. The facility shower
schedule showed R64 should receive a shower on Mondays and a second shower was not listed for R64.
Facility shower sheets indicate that R64 refused a shower on 5/6/24, and 5/13/24 but was given one on
5/20/24, which was her last documented shower.
5. On 6/2/24 at 11:37 AM, R24 who is nonverbal, was lying in bed with contractures noted to both hands.
R24's active care plan shows he has diagnoses including dementia and right sided weakness due to a
cerebral vascular accident with contractures to his upper body.
R24's Restorative Care Plan shows he requires extensive staff assistance with his Activities of Daily Living
and should receive PROM (passive range of motion) to his affected extremities for 15 minutes a day. R24's
restorative documentation for the last 30 days showed he was provided range of motion for 15 minutes on 8
out of 30 days 5/9/24, 5/10/24, 5/11/24, 5/16/24, 5/20/24, 5/24/24, 5/29/24 and 6/1/24.
On 6/3/24 at 1:42 PM V3 (Assistant Director of Nursing) stated they have a restorative CNA (Certified
Nursing Assistant) who should be doing range of motion, and working with residents but he gets pulled to
work the floor a lot and then restorative is left up to the CNAs on the floor to complete.
On 6/5/24 at 9:13 AM, V32 (Restorative CNA) stated he just covered another CNA's vacation and was
pulled to the floor to work for the last 8 days. V32 stated when he is pulled to the floor, he cannot get his
restorative job done and the CNA's have to do their own restorative and that may not always be done.
On 6/5/24 at 9:20 AM, V24 (CNA) stated she tries to do range of motion for R24 but cannot always get to it
when she is the only CNA on that hall.
6. On 6/2/24 at 10:11 AM, R64 said she was receiving physical therapy however the therapist (V30 Physical
Therapist) went out of the country so she was supposed to be walked by the nursing staff but that has not
been getting done. R64 additionally stated they are claiming that I always refuse to walk, and I don't. If
someone wakes me up, I will go walk with them.
On 6/5/24 at 9:25 AM, R64 stated she was walked by her mom yesterday and when her son comes in, he
will also walk her. R64 said one day last week she was too tired to walk because a medication she was on
was making her sleepy and did refuse to go but that was the only time that has happened.
On 6/5/24 at 9:13 AM, V32 (Restorative CNA) stated R64 is supposed to be walked to the bathroom and
back, with a walker, and she can do that with stops to rest, but he is not sure if that is being done when he
is pulled to work the floor.
On 6/5/24 at 9:35 AM, V27 (CNA) stated he cannot always get time to walk residents when V32
(Restorative CNA) is not there.
On 6/3/24, during the resident meeting, R11 and R40 each stated there was not always a nurse assigned
to the third floor on the night shift (11 PM-7 AM). R11 stated, There are nights we don't have a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 18 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0725
Level of Harm - Minimal harm
or potential for actual harm
nurse. I get scared because what if I choke and no one is there to help me? When we don't have a nurse at
night, my 6 AM meds (medications) are late. They aren't given until after 7 AM when the day nurse arrives.
On 6/4/24 at 10:00 AM, R28 stated, There has been nights when we haven't had a nurse on the floor. One
night I needed a pain pill but there was no one to tell.
Residents Affected - Many
On 6/3/24 at 2:00 PM, the facility's nursing schedules dated 5/19/24-6/2/24 were reviewed and showed the
following:
a. On 5/19/24 (Sunday), V34 Registered Nurse (RN) was assigned to both the second and third floors of
the facility from 11 PM-7 AM. A daily census form dated 5/19/24 showed 1 Nurse (V34) was responsible for
87 residents from 11 PM-7 AM.
b. On 5/20/24 (Monday), No nurse was assigned to the second floor of the facility from 11 PM-7 AM. V2
Director of Nursing (DON) was assigned to the third floor from 11 PM-7 AM. A daily census form dated
5/20/24 showed 1 Nurse (V2 DON) was responsible for 87 residents from 11 PM- 7 AM.
c. On 5/27/24 (Monday), V34 RN was assigned to both the second and third floors of the facility from 11
PM-7 AM. A daily census form dated 5/27/24 showed 1 Nurse (V34) was responsible for 85 residents from
11 PM-7 AM.
d. On 5/28/24 (Monday), V34 RN was assigned to both the second and third floors of the facility from 11
PM-7 AM. A daily census form dated 5/28/24 showed 1 Nurse (V34) was responsible for 86 residents from
11 PM-7 AM.
e. On 6/2/24 (Sunday), No nurse was assigned to the second floor of the facility from 11 PM-7 AM. V34 RN
was assigned to the third floor from 11 PM-7 AM. A daily census form dated 6/2/24 showed 1 Nurse (V34)
was responsible for 85 residents from 11 PM-7 AM.
On 6/4/24 at 7:43 AM, V19 RN stated, I always work the second floor. We are sometimes short-staffed.
There have been nights when I am the only nurse for the whole building . If I work both floors, I don't pass 6
AM meds on the third floor. I don't have time. I will pass PRN (as needed) meds to residents on the third
floor if they need them .I tell the CNAs on the third floor to call me if there is an emergency.
On 6/4/24 at 10:07 AM, V16 RN stated, Yes, there have been days that I have come in for day shift and
there has not been a night nurse. Sometimes residents haven't gotten their 6 AM meds.
On 6/4/24 at 11:56 AM, V2 DON stated she was responsible for completing the nursing schedule and
ensure sufficient staffing. V2 stated she was aware the facility was short-staffed, specifically on nights (11
PM-7 AM). V2 stated, We are supposed to have one nurse assigned to the second floor and one nurse
assigned to the third floor on nights. There are nights we only have one nurse for both floors, but I sleep
here in case they need anything.
The facility's Facility Assessment Tools revised 7/31/23 showed the second floor and third floors were to
each have their own nurse assigned from 11 PM- 7 AM as part of the facility resources needed to provide
competent support and care for resident population every day and during emergencies.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 19 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0744
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to monitor behaviors and provide
stimulation for residents with a diagnosis of dementia. This applies to 3 of 3 residents (R21, R53, R138)
reviewed for dementia in the sample of 20.
Residents Affected - Few
The findings include:
1. R21's face sheet list diagnoses to include dementia.
On June 2, 2024, at 10:08 AM, R21 was sitting in the dining room in her wheelchair. There were no
activities going on and she was just sitting there. At 11:15 AM, she was trying to leave the dining room. V22
Certified Nursing Assistant (CNA) brought her back into the dining room and put her at the table. At 12:03
PM, she was standing up and down in her wheelchair trying to take food off other resident's trays. She
wheeled herself over to the lunch cart and was trying to take food off the cart. At 12:58 PM, she wandered
out of the dining room in her wheelchair and was sitting in another resident's room down the hall. No one
was watching her. At 1:29 PM, she tried opening the exit door and set off the alarm. No one was watching
her.
On June 3, 2024, at 9:17 AM, R21 was sitting in the dining room doing nothing. At 10:21 V22 CNA started
playing bingo with other residents. R21 was not offered to play bingo or played bingo. At 10:32 AM, she kept
standing up and down. She ended up falling out of her wheelchair, on her right side.
R21's care plan dated August 8, 2023, shows, The resident has impaired cognitive function/dementia or
impaired thought processes r/t Dementia, difficulty making decisions, impaired decision-making, long-term
memory loss, neurological symptoms.
R21's care plan does not address her behaviors.
2. R53's face sheet list diagnoses to include dementia.
On June 2, 2024, at 10:20 AM, R53 was sitting in a reclining wheelchair in the dining room doing nothing.
There were no activities going on and she was just sitting there. She was fidgeting with a blanket and trying
to get out of her wheelchair. At 10:59 AM, she was still sitting in the dining room doing nothing trying to get
out of her wheelchair. At 12:58 PM and 1:29 PM, she was still sitting in her reclining wheelchair doing
nothing. There was staff in the dining room, but they were not engaging with the resident.
On June 3, 2024, at 9:17 AM, R53 was sitting in the dining room in her reclining wheelchair. There were no
activities going on and she was just sitting there. At 10:21 AM, V22 CNA started playing bingo with other
residents. R53 was not offered to play bingo or played bingo. She continued just sitting in her wheelchair
fidgeting with her shoes and trying to get out of her wheelchair.
R53's care plan does not address her dementia or behaviors.
3. R138's face sheet lists his diagnoses to include dementia. His face sheet also shows R138 is a Korean
speaking resident.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 20 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0744
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On June 2, 2024, at 10:08 AM, 10:20 AM, 10:59 AM, 11:38 AM and 12:58 PM, R138 was sitting in a chair
in the dining room. He keeps standing up. V22 CNA would tell him to sit back down. There were no activities
going on and he was just sitting there doing nothing.
On June 3, 2024, at 9:17 AM, R138 was sitting in a chair in the dining room. There were no activities going
on and he was just sitting there. At 10:21 AM, V22 CNA started playing bingo with other residents. R138
was not offered to play bingo or played bingo. He continued just sitting in the chair doing nothing.
R138's medical record does not have a care plan or address his dementia or behaviors.
On June 4, 2024, at 1:58 PM, V22 Certified Nursing Assistant stated, on certain days she tries to do stuff
with the residents but it is too much for one person to do. She is trying to watch the residents that are
standing up. She has asked for help because it is too much for one person to do.
The facility's dementia-clinical protocol dated 2001 shows, Treatment/Management: 1. For the individual
with confirmed dementia, the IDT (Interdisciplinary team) will identify a resident-centered care plan to
maximize remaining function and quality of life 4. Direct care staff will support the resident in initiating and
completing activities and tasks of daily living. a. Bathing dressing, mealtimes, and therapeutic and
recreational activities will be supervised and supported throughout the day as needed
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 21 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0745
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to provide medically related social
services to meet the needs of the residents. This failure has the potential to affect all 84 residents in the
facility.
Residents Affected - Many
The findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a
resident census of 84.
1. R21's face sheet list diagnoses to include dementia.
On June 2, 2024, at 10:08 AM, R21 was sitting in the dining room in her wheelchair. At 11:15 AM, she was
trying to leave the dining room. V22 Certified Nursing Assistant (CNA) brought her back into the dining
room and put her at the table. At 12:03 PM, she was standing up and down in her wheelchair trying to take
food off other resident's trays. She wheeled herself over to the lunch cart and was trying to take food off the
cart. At 12:58 PM, she wandered out of the dining room in her wheelchair and was sitting in another
resident's room down the hall. No one was watching her. At 1:29 PM, she tried opening the exit door and
set off the alarm. No one was watching her.
On June 3, 2024 at 9:17 AM, R21 was sitting in the dining room doing nothing. At 10:21 V22 CNA started
playing bingo with other residents. R21 was not offered to play bingo or played bingo. At 10:32 AM, she kept
standing up and down. She ended up falling out of her wheelchair, on her right side.
R21's care plan dated August 8, 2023, shows, The resident has impaired cognitive function/dementia or
impaired thought processes r/t Dementia, difficulty making decisions, impaired decision-making, long-term
memory loss, neurological symptoms.
R21's care plan does not address her behaviors.
2. R53's face sheet list diagnoses to include dementia.
On June 2, 2024, at 10:20 AM, R53 was sitting in a reclining wheelchair in the dining room doing nothing.
She was fidgeting with a blanket and trying to get out of her wheelchair. At 10:59 AM, she was still sitting in
the dining room doing nothing trying to get out of her wheelchair. At 12:58 PM and 1:29 PM, she was still
sitting in her reclining wheelchair doing nothing. There was staff in the dining room, but they were not
engaging with the resident.
R53's care plan does not address her dementia or behaviors.
3. R138's face sheet lists his diagnoses to include dementia. His face sheet also shows R138 is a Korean
speaking resident.
On June 2, 2024, at 10:08 AM, 10:20 AM, 10:59 AM, 11:38 AM and 12:58 PM, R138 was sitting in a chair
in the dining room. He keeps standing up. V22 CNA would tell him to sit back down. There were no activities
going on and he was just sitting there doing nothing.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 22 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0745
R138's medical record does not have a care plan or address his dementia or behaviors.
Level of Harm - Minimal harm
or potential for actual harm
4. On 6/3/24, during the resident meeting, R11, R55, and F74 each stated the facility did not have a
full-time social worker. R55 stated, They have a part-time woman that comes a couple of hours in the
evening a few days a week, but we hardly ever see her. R55 stated she had an ongoing conflict with her
new roommate with no resolution due to no one here to deal with it. R55 stated she needed someone's
assistance to help her work with my insurance so I can find a dentist but there's no one to help do that
either. R11 stated, I see my counselor (contracted psychiatric social worker) once a week when she comes
in but, I have no one to talk to if I am upset and need to talk to someone when she isn't here.
Residents Affected - Many
5. R28's Social Service note dated 4/17/24 showed R28 was seen upon admission to the facility by social
services. The note showed R28 was admitted to the facility for subacute rehab after a flare-up of her
Multiple Sclerosis. R28's medical records dated 4/18/24-6/3/24 showed no other social services notes for
R28.
On 6/4/24 at 10:00 AM, R28 stated, I was admitted here for rehab. I have a MS (Multiple Sclerosis) flare-up
and broke a rib. The plan was never for me to stay here long term. I have a cat and my own apartment. I
need to go home. No one has talked to me about my discharge. I haven't talked to anyone in social services
in months.
On 6/3/24 at 8:44 AM, V3 Assistant Director of Nursing (ADON) stated, We have not had a full-time social
worker in a long time. We have (V18 part-time Social Services) that comes in a few hours during the
evenings, but she is part-time.
On 6/3/24 at 12:12 PM, V18 (part-time Social Services) stated, I work very part-time there. I am under
social services, but I am just helping out. I come in for 3-4 hours during the evening; 3-4 days a week. I help
do care plans and MDS's (Minimum Data Set), but I am a little behind on the care plans. V18 stated, I don't
do any discharge planning. I don't handle grievances unless someone complains to me. I don't do anything
with resident council. I don't help set up appointments or counsel residents unless someone stops me when
I'm there. I don't do any behavior management counseling unless I see behaviors happening when I'm
there. V18 stated R55 did ask her to help R55 find another dentist but told R55 that she does not help with
medical referrals. V18 stated, I told her to tell nursing about it.
On 6/3/24 at 11:44 AM, V1 Administrator of the facility stated they had not had a full-time social worker in a
while.
On 6/3/24 at 11:47 AM, V2 Director of Nursing stated, We haven't had someone in full-time in Social
Services for a long time. V2 stated social services is responsible for handling resident problems, problems
with roommates, resident's grievances, help with behavior management, helping schedule and set-up
monthly resident council meetings, and doing discharge planning for residents.
On 6/3/24 at 12:15 PM, V17 Human Resources stated the last time the facility had a full-time social
services employee was last year. V17 stated, We have never had a Social Service Director that I am aware
of. We used to have a consultant for social services but that hasn't been since last year.
On 6/4/24 at 11:05 AM, V17 Human Resources stated, I am responsible for providing the yearly abuse,
harassment, and privacy education to our nursing staff. Social services usually does the staff
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 23 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0745
dementia training every year but we don't have anyone in social services to do it.
Level of Harm - Minimal harm
or potential for actual harm
On 6/4/24 at 8:31 AM, V3 ADON was asked for the facility's grievance logs from 3/1/24-6/4/24. V3 stated, I
don't think we have any. We don't have anyone to complete the logs and always follow up on them. That
would be done by social services.
Residents Affected - Many
A facility form dated 6/4/24 showed no documented grievances from March 2024-June 2024.
The facility's Social Service Director (Designee) job description (undated) showed, The purpose of this
position is to provide social services to meet the social and/or emotional needs that affect the residents'
ability to achieve their highest level of function; participate in the development of residents' comprehensive
care plans; develop policies and procedures to provide social services to residents in compliance with
federal, state and local regulations The job description showed the Social Service Director was responsible
for developing and coordinating family and resident activities designed to promote social interaction .
develop one-to-one professional relationships with residents and families as needed for counseling .
assess, plan, and document residents' discharge needs . document the social service component of the
Comprehensive Care Plan for each resident in a timely manner . refer residents to social, health and
community resources and complete accurate documentation in residents' records concerning the results of
such referrals .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 24 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0755
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 observation, interview, and record review the facility failed to ensure medications were dispensed
according to standards of practice for 1 of 20 residents (R26) reviewed for pharmacy services in the sample
of 20.
The findings include:
On 6/2/24 at 11:52 AM, on R26's bedside table was a pill cup containing 1 blue pill. R26 stated sometimes
when he is in the bathroom, they just leave his medication for him to take. R26 was not able to indicate
what pill was in the cup or what time it was left for him. R26 took the pill while this surveyor was in the room.
On 6/2/24 at 12:22 PM, V16 (Registered Nurse/RN) stated residents should be supervised taking their
medication and R26 does not have an order that he can self-administer his own medication. V16 also
stated if the pill was blue, she believes it was probably his Levothyroxine.
On 6/3/24 at 8:30 AM, V3 (Assistant Director of Nursing/ADON) stated medications should not just be left
for residents to take they should be supervised.
R26's Physician Order Summary (POS) shows an order for Levothyroxine to be given one time a day and
shows no order for him to self-administer his own medications. R26's Medication Administration Summary
shows the Levothyroxine is scheduled to be given at 6:00 AM.
The facility provided pharmacy policy titled Medication Administration (undated) shows that residents can
only administer their own medication with a physician order and all residents should be observed during
medication administration to ensure a resident takes the medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 25 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0761
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 ensure opened, multi-dose bottles of
medication, inhalers, and insulin pens were labeled with expiration dates for 4 of 4 residents (R64, R20,
R45, R82) reviewed for medication storage in the sample of 20.
The findings include:
1. R64's June 2024 (physician) Order Summary report showed R64 received Advair Diskus (powder)
inhaler, 100-50 mcg (micrograms), one puff, twice a day. The order showed R64 received 30 units of
Glargine insulin, subcutaneous (SQ), daily.
R20's June 2024 (physician) Order Summary report showed R20 received Lispro insulin, as per sliding
scale instructions, SQ (subcutaneous), four times a day.
R45's June 2024 (physician) Order Summary report showed R45 received Lantus insulin, 25 units, SQ,
daily.
On 6/2/2024 at 10:50 AM, the third-floor medication (med) cart was reviewed by this surveyor and V16
Registered Nurse (RN). Upon inspection of the cart, the following medications were found opened and not
dated with an opened or expiration date:
a)
A Lantus insulin pen and Advair Diskus inhaler for R64.
b)
A vial of Lispro insulin for R20.
c)
A Lantus insulin pen for R45.
On 6/2/24 at 11:00 AM, V17 RN stated all medication vials/bottles are to be dated when opened so staff
know when the medication expires.
2. R82's June 2024 (physician) Order Summary report showed R82 received Latanoprost 0.005% eye
drops, one drop to both eyes as needed.
On 6/2/24 at 10:35 AM, the second-floor med cart was reviewed by this surveyor and V15 RN. A medicine
cup, containing 6 pills of different sizes and colors was noted in the top drawer of the med cart. When asked
about the cup of pills, V15 stated, They have been there since yesterday. I don't know who they are for. They
should be labeled with a name, so we know who they are for. One opened/not dated bottle of Latanoprost
eye drops for R82 was noted in the cart. When V15 was asked why medications should be dated when
opened, V15 stated, I know they should be dated but I'm not sure why.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 26 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
The facility's Storage of Medications policy dated 10/25/2014 showed, Medications and biologicals are
stored safely, securely, and properly, following manufacturer's recommendations or those of supplier . When
the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated.
The nurse shall place a date opened sticker on the medication and enter the date opened and the new
expiration date . The expiration date of the vial or container will be 30 days unless the manufacturer
recommends another date or regulations/guideline require different dating .
Event ID:
Facility ID:
145434
If continuation sheet
Page 27 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0801
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the
food and nutrition service, including a qualified dietician.
Based on observation, interview, and record review, the facility failed to ensure dietary staff were
supervised and trained by a qualified dietary manager resulting in R6, R53, R21, and R65 receiving
incorrect physician prescribed diets and resulted in R6 choking, requiring the Heimlich maneuver. R6
required hospitalization for aspiration pneumonia and remains at risk for further episodes of choking and
aspiration due to continuing receiving the incorrect diet.
This failure applies to 4 of 4 residents (R6, R53, R21, and R65) reviewed for mechanical soft diets in the
sample of 20.
This failure resulted in an Immediate Jeopardy.
The Immediate Jeopardy began on 4/22/24, when the facility failed to ensure residents were served a
mechanically soft diet as prescribed by their physician. V1 (Administrator) was notified of the Immediate
Jeopardy on 6/4/24 at 2:30 PM. This surveyor confirmed by observation, interview, and record review that
the Immediate Jeopardy was removed on 6/6/24; however, noncompliance remains at a Level Two because
additional time is needed to evaluate the implementation and effectiveness of the in-service training.
The findings include:
On 6/3/24 at 2:05 PM, V4 (Food Service Manager/FSM) stated he has been in his role as food service
manager for about three years. V4 only has a food protection manager certification that has expired. V4 is
not a certified dietary manager. V4 has not begun the process of signing up to take the certified dietary
manager coursework as of 6/3/24. V4 stated that he doesn't always know exactly what to do in his position.
There isn't someone on site at all times for him to refer to when he has questions.
V4's provided food protection manager certification shows an expiration date of 4/23/24.
On 6/4/24 at 10:37 AM, V7 (Registered Dietitian/RD) stated that she is contracted to provide 16 hours at
the facility per month which mainly includes conducting resident nutrition assessments. V7 has never
attended a face-to-face staff meeting with all of the dietary staff but has provided printed information for the
staff to review.
On 6/4/24 at 8:44 AM, V9 (Cook) stated she has worked here for about eight years. V9 was trained by V4
(FSM) and former cooks on the job. V9 has a current food protection manager certification. V9 stated that a
mechanical soft diet is prepared using a knife and cutting the item into bite-size pieces, roughly the size of
the fingernail on a pinky finger. V9 does not use any type of machine or device to prepare the mechanical
soft diet. V9 stated chopped meats, cooked vegetables, canned fruit, and fresh fruit are allowed on a
mechanical soft diet. V9 stated V7 (RD) does not come to the kitchen and V9 has not received training from
V7. Per V9, the most recent in-service provided by V4 was a few months ago and covered being careful to
send the correct foods for each resident.
On 6/4/24 at 9:03 AM, V8 (Dietary Aide) stated he reads all of the diet cards during service and notifies the
chef as to what to put on each plate. A mechanical soft diet is signified by a green sticker on the diet card.
Mechanical soft diets are to receive soft and chopped foods, roughly the size
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 28 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0801
Level of Harm - Immediate
jeopardy to resident health or
safety
of the fingernail on a pinky finger. V8 stated that residents receiving a mechanical soft diet can receive a
lettuce salad as long as the contents of the salad are chopped finely, similar in size to the chopped meats. If
tomatoes are a part of the salad, those need to be chopped up as well; they cannot be large pieces.
Facility provided dietary staff certificates indicate that V10 (Dietary Aide), V11 (Dietary Aide), V13 (Dietary
Aide), and V14 (Dietary Aide) do not have current food handler's certifications.
Residents Affected - Some
V12's (Cook) Food Protection Manager's certificate has an expiration date of 2/13/24 and is not currently
active.
R6's current diet card shows R6 should receive a mechanical soft diet.
R6's progress note dated 4/22/24 shows, Writer was called to R6's room, resident was choking. 911 was
called. Heimlich maneuver was performed, a piece of tomato was expelled.
On 6/3/24 at 1:02 PM, V5 (LPN) stated that at the time of the choking event, R6 was lying in bed. V5 was
called into R6's room by V6 (Certified Nursing Assistant (CNA)). When V5 entered R6's room, R6 was
purple and could not speak. V5 initiated the Heimlich maneuver on R6 and a tomato piece, approximately
the size of a quarter, came flying out. V5 stated R6 was receiving a mechanical soft diet on 4/22/24 and is
still on a mechanical soft diet.
R6's progress note dated 4/28/24 shows, Resident readmitted from local hospital via local paramedics. He
was on IV (intravenous) antibiotics to treat aspirated pneumonia while at local hospital . On minced moist
diet with thin liquid .
Facility served menu for 4/22/24 shows the meal served for the day includes a tomato wedge, pesto
chicken salad, potato chips, marinated cucumber and onion salad, pudding with whipped topping, and a
dinner roll.
Facility diet spreadsheet for 4/22/24 shows that a mechanical soft diet should have received a diced tomato
rather than a full tomato wedge.
On 6/2/24 at the noon meal, R6 received ham cut into cubes, a baked potato with the skin, spinach, and
fresh cantaloupe cut into chunks.
On 6/3/24 at the noon meal, R6 received meat lasagna, California blend vegetables, garlic bread, and
apple slices.
R53's physician order sheet dated 10/1/23 shows R53 is on a general diet with mechanical soft texture.
On 6/2/24 at the noon meal, R53 received a whole hot dog on a bun, spinach, and fresh cantaloupe cut into
chunks.
On 6/3/24 at 1:43 PM, V7 stated that a hot dog is absolutely not appropriate for a resident on a mechanical
soft diet.
R21's current diet card reads, mech soft (mechanical soft).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 29 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0801
On 6/2/24 at the noon meal, R21 received ham cut into cubes, a baked potato with skin, spinach, and fresh
cantaloupe cut into chunks.
Level of Harm - Immediate
jeopardy to resident health or
safety
On 6/3/24 at the noon meal, R21 received meat lasagna, California blend vegetables, garlic bread, and
apple slices.
Residents Affected - Some
R65's physician order sheet dated 10/1/23 shows R65 is on a general diet with mechanical soft texture.
R65's current diet card reads, Regular diet (with no texture modifications).
On 6/2/24 at the noon meal, R65 received a slice of ham, a baked potato with skin, spinach, and fresh
cantaloupe.
On 6/3/24 at the noon meal, R65 received meat lasagna, California blend vegetables, garlic bread, and
apple slices.
On 6/3/24 at 1:43 PM, V7 (RD) stated that ham would not be the best option for a resident on a mechanical
soft diet. The cut-up squares could be a choking problem. She would also recommend they not serve fresh
fruit unless they could guarantee it is soft enough for them to eat.
Facility diet spreadsheet for 6/2/24 shows mechanical soft residents should have received ground ham and
a chopped baked potato without the skin.
On 6/3/24 at 1:20 PM, V4 (FSM) said the staff should follow the diet spread sheet for altered diets.
On 6/4/24 at 1:13 PM, V29 (Medical Director) stated, They definitely should be serving what is ordered for
the resident's diets.
Facility Food and Nutrition Services Diets and Diet Orders, Mechanical Soft Diet policy dated 2017 states, .
Procedure: The texture may be altered by one of the following methods: Unless otherwise indicated, meat
and meat substitutes will be mechanically ground
On 6/5/24 at 10:40 AM, V29 (Medical Director) stated that he was not familiar with what qualifications a
dietary manager requires and he also did not know that V4 (FSM) did not possess the proper qualifications.
Facility provided job description for Director of Food and Nutrition Services dated 2018 states,
Qualifications: Certified in food safety through an American National Standards Institute (ANSI) accredited
course and has one of the following qualifications: Registered Dietitian, Licensed or Certified Dietitian,
Certified Dietary Manager .
The facility presented an abatement plan to remove the immediacy on 6/5/24. The survey team reviewed
the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was
returned to the facility for revisions. The facility presented a second revised abatement plan on 6/5/24 and
the survey team accepted the abatement plan on 6/6/24.
The Immediate Jeopardy that began on 4/22/24 was removed on 6/6/24 when the facility took the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 30 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0801
following actions to remove the immediacy:
Level of Harm - Immediate
jeopardy to resident health or
safety
1. Immediate Recruitment Efforts: We have placed a Certified Dietary Manager (V31) in this position as of
06/04/24. The current Supervisor (V4) will attend a class dated 08/19/24, to renew his Food Safety
Manager Certificate. All other dietary staff files will be audited for compliance with the current Food
Handler's Certification by Human Resources (V17) by 6/5/24. The Certified Dietary Manager (CDM) (V31)
has started the training for dietary staff on 6/5/24. The Registered Dietitian (V7) will continue with the
training for proper production and serving of mechanical soft diets on 6/6/24. This process will be
completed by 6/6/24. The CDM (V31) will supervise food service production.
Residents Affected - Some
2. Enhanced Training Programs: As of 6/5/24 In-servicing and training have begun for dietary staff by the
CDM (V31) on providing diet as ordered, communication protocol, review diet, and update orders,
in-servicing will continue until all dietary staff is trained before starting their next shift. The ADON (V3)
started in-servicing nursing staff on 6/5/24 on monitoring dietary cards to ensure correct food consistency is
being served; in-servicing will continue until all nursing staff is trained by 6/13/24. We are enhancing our
current training programs to ensure all dietary staff receive continuous education on a yearly basis for food
safety, nutritional guidelines, and regulatory compliance. These programs will be provided by our contracted
Registered Dietitian (V7) or her designee.
3. Policy Review and Updates: A review of our Dietary Policies and Procedures Manual will be reviewed by
the CDM (V31) and our contracted Registered Dietitian (V7) this process will be started on 6/6/24 and
continued yearly to ensure they align with State and Federal Regulations. Any necessary updates will be
implemented by in servicing the Dietary and Nursing Staff to reinforce our commitment to compliance and
high-quality care, this procedure will be given by our contracted Registered Dietitian or her designee.
4. Regular Audits and Monitoring: To prevent future occurrences, we will establish a random weekly audit of
3 meals a week for 90 days done by the CDM (V31); this audit will be focused on food consistency
matching the dietary card. This procedure will help us monitor for compliance, identify potential issues early,
and take corrective actions promptly.
Results will be reported at QA meeting to ensure ongoing compliance.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 31 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0803
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Based on
observation, interview, and record review the facility failed to ensure residents with a history for choking and
at risk for choking were served the correct physician prescribed diets. This failure resulted in R6 choking,
requiring the Heimlich maneuver, going to the hospital, and being treated for aspiration pneumonia. R6
returned to the facility and continued to be served the incorrect diet putting him at risk to choke again. The
facility also failed to ensure R21, R53, and R65 were served the correct physician prescribed diets putting
them at risk to choke. This applies to 4 of 20 residents (R6, R21, R53, R65) reviewed for menus in the
sample of 20.
These failures resulted in an Immediate Jeopardy.
The Immediate Jeopardy began on 4/22/24 when the facility failed to ensure residents were served a
mechanically soft diet as prescribed by their physician. V1 Administrator was notified of the Immediate
Jeopardy on 6/4/24. This surveyor confirmed by observation, interview, and record review that the
Immediate Jeopardy was removed on 6/6/24 however, noncompliance remains at a Level Two because
additional time is needed to evaluate the implementation and effectiveness of the in-service training and
staffing levels.
The findings include:
1. R6's progress notes dated 4/22/24 shows, Writer was called to R6's room, resident was choking. 911
was called. Heimlich maneuver was performed, a piece of tomato was expelled.
R6's local hospital records dated 4/22/24 shows, Medical Screening Exam: s/p (status post) reported
witnessed chocking [SIC (statement is correct)] event earlier today at 1846 (6:46 PM). Local fire department
called by SNF (skilled nursing facility) for witnessed event, Heimlich maneuver perform and fully
resolved/signed off at the scene.
R6's progress notes dated 4/28/24 shows, Resident readmitted from local hospital via local paramedics. He
was on iv antibiotics to treat aspirated pneumonia while at local hospital . On minced moist diet with thin
liquid .
On 6/3/24 at 1:02 PM, V5 Licensed Practical Nurse (LPN) stated, R6 was lying in bed when he choked. It
was dinner time, and the CNA (certified nursing assistant/V6) called her into R6's room. R6 was purple and
couldn't speak when V5 LPN got into the room. She did the Heimlich maneuver on him and a quarter size
tomato came flying out. She couldn't remember what was for dinner that night only that he choked on a
tomato. She also stated, his diet has not changed and was on a mechanical soft diet at the time when he
choked.
The dinner menu for 4/22/24 (the day R6 choked) shows, tomato wedge, pesto chicken salad, potato chips,
marinated cucumber and onion salad, pudding with whipped topping and a dinner roll. The spreadsheet for
mechanical soft diet shows, tomato wedge (diced (garnish)) .
On 6/3/24 at 1:43 PM, V7 Dietitian stated, ham would not be the best option for a resident on a mechanical
soft diet. The cut-up squares could be a choking problem. She would also recommend they steer away from
fresh fruit unless they could guarantee it is soft enough for them to eat.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 32 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0803
Level of Harm - Immediate
jeopardy to resident health or
safety
On 6/4/24 at 9:03 AM, V8 Dietary Aide stated, residents on a mechanical soft diet can receive a salad if it is
chopped fine and the tomato is cut small. They should not receive large pieces of tomato. Mechanical soft
diets should be soft and chopped up to about the size of a pinky nail.
On 6/2/24, at the noon meal, R6 was served a slice of ham cut into cubes, a baked potato with skin,
spinach and fresh cantaloupe cut into chunks. R6 has no teeth.
Residents Affected - Some
On 6/3/24, at the noon meal, R6 was served meat lasagna, California blend vegetables, garlic bread and
apple slices.
R6's physician order sheet dated 4/28/24 shows, Regular diet, soft & bite sized texture, regular/thin
consistency minced and moist diet/thin liquid for dysphagia.
The menu for 6/2/24, at the noon meal shows, orange glazed ham, baked potatoes with sour cream,
seasoned spinach, fresh fruit mix and dinner roll. The spreadsheet for mechanical soft diet shows, orange
glazed ham: grnd (ground), baked potato: no skin/chopped/add [NAME] (margarine (butter)). The
spreadsheet does not show what mixed fruit should be for a mechanical soft diet.
The menu for 6/3/24, at the noon meal shows, home style meat lasagna, Italian blend vegetables, fresh fruit
and garlic bread. The spreadsheet for mechanical soft diet shows, they can have what is on the menu
however it shows they were to get pineapple with the noon meal instead of fresh fruit. The spreadsheet
does not show what a mechanical soft diet should get instead of sliced apples.
R6's diet card shows, mechanical soft diet.
On 6/4/24 at 1:13 PM, V29 (R6's physician/Medical Director) stated, he was aware of him choking during
dinner. They definitely should be serving what is ordered for the resident's diets.
R6's medical record does not show any evaluations by a speech therapist for diet recommendations.
2. On 6/2/24, at the noon meal, R53 was served a whole hot dog on a bun, spinach and fresh cantaloupe
cut into chunks. R53 also has no teeth and was having a hard time eating the hot dog and cantaloupe.
On 6/3/24, at the noon meal, R53 was served meat lasagna, California blend vegetables, garlic bread and
apple slices. R53 was having a hard time eating the apple slices.
R53's physician order sheet dated October 1, 2023, shows, General diet, Mechanical Soft texture,
Regular/Thin consistency.
On 6/3/24 at 1:43 PM, V7 Dietitian stated, A hot dog was absolutely not appropriate for a resident on a
mechanical soft diet.
R53's current diet card shows, regular diet (not the prescribed diet).
3. On 6/2/24, at the noon meal, R21 was served a slice of ham cut into cubes, a baked potato with skin,
spinach and fresh cantaloupe cut into chunks.
On 6/3/24, at the noon meal, R21 was served meat lasagna, California blend vegetables, garlic bread
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 33 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0803
and apple slices.
Level of Harm - Immediate
jeopardy to resident health or
safety
R21's physician order sheet dated October 1, 2023, shows, NAS (no added salt) diet, Mechanical Soft
texture.
R21's current diet card shows, mech soft (mechanical soft).
Residents Affected - Some
4. On 6/2/24, at the noon meal, R65 was served a slice of ham, a baked potato with skin, spinach, and
fresh cantaloupe.
On 6/3/24, at the noon meal, R65 was served meat lasagna, California blend vegetables, garlic bread and
apple slices.
R65's physician order sheet dated October 1, 2024, shows, General diet, Mechanical Soft texture,
Regular/Thin consistency.
R65's current diet card shows, Regular diet (not the prescribed diet).
On 6/3/24 at 1:20 PM, V4 Dietary Manager stated, they follow the spreadsheet for altered diets
(mechanically soft diets).
The facility's food and nutrition services diets and diet orders policy dated 2017 shows, Diet
Standardization: Policy: Food and nutrition services will serve standard diets which correspond to the diet
columns on the menu spreadsheet and are based on the nutrition manual for healthcare communities .
Procedure: Examples of standard diet orders may include: Mechanical soft: The texture and consistency of
the general/regular or therapeutic diet is modified. Food maybe served as ground or chopped. Whole food
may only be served if it is soft in consistency.
The facility's food and nutrition services diets and diet orders, mechanical soft diet policy dated 2017
shows, Policy: Food will be provided in a form designed to meet individual needs. The highest practicable
level of eating will be provided. The texture of the food may be altered to mechanical soft consistency.
Procedure: The texture may be altered by one of the following methods: Unless otherwise indicated, meat
and meat substitutes will be mechanically ground. Plain fish fillet may be flaked. Meat loaf without hard
crust and soft casseroles may be served intact. Foods commonly avoided are fibrous raw vegetables (such
as celery, radishes, cauliflower, broccoli, etc.), whole kernel corn and nuts. If individual tolerance allows,
meat and meat substitutes can by chopped by hand. This will be indicated on the tray card.
The facility presented an abatement plan to remove the immediacy on June 5, 2024. The survey team
reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement
plan was returned to the facility for revisions. The facility presented a second revised abatement plan on
June 5, 2023, and the survey team accepted the abatement plan on June 6, 2024.
The Immediate Jeopardy that began on April 22, 2024, was removed on June 6, 2024, when the facility
took the following actions to remove the immediacy:
1.
Immediate Recruitment Efforts: We have placed a Certified Dietary Manager (V31) in this position as
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 34 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0803
Level of Harm - Immediate
jeopardy to resident health or
safety
of 06/04/24. The current Supervisor (V4) will attend a class dated 08/19/24, to renew his Food Safety
Manager Certificate. All other dietary staff files will be audited for compliance with the current Food
Handler's Certification by Human Resources (V17) by June 5, 2024. The CDM (V31) has started the
training for dietary staff on 06/05/24. The Registered Dietitian (V7) will continue with the training for proper
production and serving of mechanical soft diets on 06/06/24. This process will be completed by 06/06/24.
The CDM (V31) will supervise food service production.
Residents Affected - Some
2.
Enhanced Training Programs: As of 6/5/24 In-servicing and training have begun for dietary staff by the CDM
(V31) on providing diet as ordered, communication protocol, review diet, and update orders, in servicing will
continue until all dietary staff is trained before starting their next shift. The ADON (V3) started in-servicing
nursing staff on 06/05/24 on monitoring dietary cards to ensure correct food consistency is being served, in
servicing will continue until all nursing staff is trained by 6/13/24. We are enhancing our current training
programs to ensure all dietary staff receive continuous education on a yearly basis for food safety,
nutritional guidelines, and regulatory compliance. These programs will be provided by our contracted
Registered Dietitian (V7) or her designee.
3.
Policy Review and Updates: A review of our Dietary Policies and Procedures Manual will be reviewed by the
CDM (V31) and our contracted Registered Dietitian (V7) this process will be started on 6/6/24 and
continued yearly to ensure they align with State and Federal Regulations. Any necessary updates will be
implemented by in servicing the Dietary and Nursing Staff to reinforce our commitment to compliance and
high-quality care, this procedure will be given by our contracted Registered Dietitian or her designee.
4.
Regular Audits and Monitoring: To prevent future occurrences, we will establish a Random weekly audit of 3
meals a week for 90 days done by the CDM (V31), this audit will be focused on food consistency matching
the dietary card. This procedure will help us monitor for compliance, identify potential issues early, and take
corrective actions promptly.
Results will be reported at QA meeting to ensure ongoing compliance.
II. Based on observation, interview, and record review the facility failed to ensure residents receiving a
regular texture diet received a 3-ounce (oz) portion of sliced ham for the noon meal on 6/2/24. This applies
to 4 of 4 residents (R44, R75, R84, R45) reviewed for menus in the sample of 20.
The findings include:
Facility provided Dietary Type Report shows that R44, R75, R84, and R45 all receive a regular texture diet.
On 6/2/24 at 11:27 AM, V12 (Cook) was placing a single slice of sliced ham on each plate receiving a
regular texture diet. The slices of ham appeared small. The slices were approximately one quarter inch thick
and the size of a three inch by five-inch index card or smaller.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 35 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0803
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
On 6/2/24 at 12:10 PM, V12 finished plating all meals and none of the residents received additional ham
during normal meal service.
On 6/2/24 at 12:37 PM, facility provided test tray was received and the portion of ham was similar to the
sizes served during lunch.
On 6/2/24 at 12:54 PM, V4 (Dietary Manager) used a calibrated food scale to weigh the ham slice provided
on the test tray. The ham slice weighed 1.75 ozs (ounces), providing approximately 88 calories and 11
grams (g) protein. V4 stated the residents were to receive a 3 oz portion of ham, which would provide
approximately 150 calories and 20g protein. Residents received approximately 60 calories and 9g less
protein than the written menu.
On 6/2/24 at 12:55 PM, V9 (Cook) confirmed that V12 cut the ham into slices to serve for lunch on 6/2/24.
Facility Diet Spreadsheet shows the portion size for the regular texture diet is to receive a 3 oz portion of
ham.
On 6/2/24 1:47 PM, R44 said there are sometimes he receives enough food, but he stated the ham
received on 6/2/24 was small and he was still hungry after lunch.
On 6/2/24 at 1:58 PM, R84 state that he believes the portion sizes served are small.
On 6/3/24 at 9:05 AM, R75 stated that she does not believe the food portions served are always large
enough. R75 was unable to eat the ham on 6/2/24 and was still hungry after the end of the meal. R75
stated there have been other times that she was still hungry after meals and this was not the first time.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 36 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0812
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.
Based on observation, interview, and record review the facility failed to ensure a serving spoon was
sanitized and air dried to prevent foodborne illness. This has the potential to affect all 82 residents in the
facility receiving food from the kitchen.
The findings include:
The CMS 671 dated 6/2/24 shows there are 84 residents residing in the facility.
On 6/2/24 at 11:53 AM, V12 (Cook) handed V10 (Dietary Aide) a serving spoon that became soiled during
service. V10 took the serving spoon to the three-compartment sink, and quickly dipped the spoon through
each individual sink. At the sanitizer sink, V10 dipped the spoon a few times, removed the spoon from the
sink, and proceeded to dry the spoon with brown disposable paper towels. V10 returned the spoon to V12
and V12 continued to use the spoon for the remainder of service.
On 6/2/24 at 10:01 AM, V4 stated that all dishes are currently being done using the three-compartment
sink. The dish machine has been broken for a few years and is not currently in use. When using the
three-compartment sink, dishes need to be fully submerged for one full minute in order to sanitize the
items. The items then need to be air dried.
Facility Manual Sanitizing in Three-Compartment Sink policy dated 2017 states, A sink with three
compartments is used for manually washing, rinsing, and sanitizing utensils and equipment that can be
submerged . After washing and rinsing utensils or equipment are sanitized in the third sink by immersion in
either: Hot water (at least 171 Fahrenheit (F) for thirty seconds) or chemical sanitizing solution used
according to manufacturer's instructions. The most common chemical sanitizers are chlorine, iodine, and
quaternary ammonia. The manufacturer's label is referenced for the appropriate concentration of the
sanitizing solution and for length of submersion time.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 37 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0825
Provide or get specialized rehabilitative services as required for a resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure a resident admitted for therapy services received
therapy services. This applies to 1 of 4 residents (R84) reviewed for therapy services in the sample of 20.
Residents Affected - Few
The findings include:
R84's Face sheet shows that R84 was admitted to the facility on [DATE] with a primary admitting diagnosis
of a right femur fracture.
R84's Care Plan shows the resident has a right hip fracture related to a fall from a car accident.
On 6/2/24 at 2:12 PM, R84 stated he was admitted to the facility following surgery after a car accident. He
did not believe he was receiving therapy services. He said that V30 (Physical Therapist) was working with
him to exercise his leg before V30 went on vacation. R84 stated that V32 (Restorative Certified Nursing
Assistant (CNA)) currently works with him on transfers but does not help him walk. On 6/5/24 at 11:08 AM,
R84 stated his goal with therapy is to be able to stand and walk again and discharge back home.
On 6/2/24 at 2:40 PM, V32 (Restorative CNA) confirmed he is only doing transfers with the resident at this
time and not walking with the resident. He believed that the resident has been discharged from therapy.
On 6/5/24 at 2:18 PM, V33 (Physical Therapist) stated that she has been filling in for V30 while he is on
vacation. V33 has not seen R84 during her time at the facility.
R84's Plan of Treatment for Outpatient Rehabilitation form from 5/10/24 states, Pt (patient) is DC
(discharged ) from skilled PT (Physical Therapy) services due to no progress and poor motivation. Pt has
been referred to restorative program at this time. Long term goals states, Pt will safely ambulate using RW
(rolling walker) x 10 feet .
On 6/6/24 at 8:43 AM, R84 stated that V30 never informed him that he was discharged from therapy
services and believed he was still making progress. R84 said that he has not reached his goal of being able
to walk.
A physical therapy policy was requested from the facility but was not received prior to the exit date of
6/6/24.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 38 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0835
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review facility administration failed to manage the facility in
manner to effectively meet the needs of the residents.
Residents Affected - Many
This failure has the potential to affect all 84 residents in the facility.
The findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a
resident census of 84.
1. On June 2, 2024, at 10:11 AM, 11:26 AM, 11:39 AM, 11:46 AM, 12:03 PM and 12:58 PM, R48 and R65
were sitting in the dining room in reclining wheelchairs. There were no activities going on. The television
was the only thing on.
On June 2, 2024, at 10:30 AM, R74 the resident council president stated, there isn't any activities. They
have to entertain themselves.
On June 4, 2024, at 12:25 PM, V3 Assistant Director of Nursing (ADON) stated, there is no activity director
and only 1 activity assistant.
2. On 6/3/24, during the resident meeting, R11, R55, and F74 each stated the facility did not have a
full-time social worker. R55 stated, They have a part-time woman that comes a couple of hours in the
evening a few days a week, but we hardly ever see her. R55 stated she had an ongoing conflict with her
new roommate with no resolution due to no one here to deal with it. R55 stated she needed someone's
assistance to help her work with my insurance so I can find a dentist but there's no one to help do that
either. R11 stated, I see my counselor (contracted psychiatric social worker) once a week when she comes
in but, I have no one to talk to if I am upset and need to talk to someone when she isn't here.
On 6/3/24 at 8:44 AM, V3 Assistant Director of Nursing stated, We have not had a full-time social worker in
a long time. We have (V18 part-time Social Services) that comes in a few hours during the evenings, but
she is part-time.
3. On 6/3/24, during the resident meeting, R11 and R40 each stated there was not always a nurse assigned
to the third floor on the night shift (11 PM-7 AM). R11 stated, There are nights we don't have a nurse. I get
scared because what if I choke and no one is there to help me? When we don't have a nurse at night, my 6
AM meds (medications) are late. They aren't given until after 7 AM when the day nurse arrives.
On 6/4/24 at 10:00 AM, R28 stated, There has been nights when we haven't had a nurse on the floor. One
night I needed a pain pill but there was no one to tell.
On 6/3/24 at 2:00 PM, the facility's nursing schedules dated 5/19/24-6/2/24 were reviewed and showed the
following:
a. On 5/19/24 (Sunday), V34 Registered Nurse (RN) was assigned to both the second and third floors
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 39 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0835
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
of the facility from 11 PM-7 AM. A daily census form dated 5/19/24 showed 1 Nurse (V34) was responsible
for 87 residents from 11 PM-7 AM.
b. On 5/20/24 (Monday), No nurse was assigned to the second floor of the facility from 11 PM-7 AM. V2
Director of Nursing (DON) was assigned to the third floor from 11 PM-7 AM. A daily census form dated
5/20/24 showed 1 Nurse (V2 DON) was responsible for 87 residents from 11 PM- 7 AM.
c. On 5/27/24 (Monday), V34 RN was assigned to both the second and third floors of the facility from 11
PM-7 AM. A daily census form dated 5/27/24 showed 1 Nurse (V34) was responsible for 85 residents from
11 PM-7 AM.
d. On 5/28/24 (Monday), V34 RN was assigned to both the second and third floors of the facility from 11
PM-7 AM. A daily census form dated 5/28/24 showed 1 Nurse (V34) was responsible for 86 residents from
11 PM-7 AM.
e. On 6/2/24 (Sunday), No nurse was assigned to the second floor of the facility from 11 PM-7 AM. V34 RN
was assigned to the third floor from 11 PM-7 AM. A daily census form dated 6/2/24 showed 1 Nurse (V34)
was responsible for 85 residents from 11 PM-7 AM.
On 6/4/24 at 7:43 AM, V19 RN stated, I always work the second floor. We are sometimes short-staffed.
There have been nights when I am the only nurse for the whole building . If I work both floors, I don't pass 6
AM meds on the third floor. I don't have time. I will pass PRN (as needed) meds to residents on the third
floor if they need them .I tell the CNA's on the third floor to call me if there is an emergency.
On 6/4/24 at 10:07 AM, V16 RN stated, Yes, there have been days that I have come in for day shift and
there has not been a night nurse. Sometimes then residents haven't gotten their 6 AM meds.
On 6/4/24 at 11:56 AM, V2 DON stated she was responsible for completing the nursing schedule and
ensure sufficient staffing. V2 stated she was aware the facility was short-staffed, specifically on nights (11
PM-7 AM). V2 stated, We are supposed to have one nurse assigned to the second floor and one nurse
assigned to the third floor on nights. There are nights we only have one nurse for both floors, but I sleep
here in case they need anything.
4. R6's progress note dated 4/22/24 shows, Writer was called to R6's room, resident was choking. 911 was
called. Heimlich maneuver was performed, a piece of tomato was expelled.
On 6/3/24 at 1:02 PM, V5 (LPN) stated that at the time of the choking event, R6 was lying in bed. V5 was
called into R6's room by V6 (Certified Nursing Assistant (CNA)). When V5 entered R6's room, R6 was
purple and could not speak. V5 initiated the Heimlich maneuver on R6 and a tomato piece, approximately
the size of a quarter, came flying out. V5 stated R6 was receiving a mechanical soft diet on 4/22/24 and is
still on a mechanical soft diet.
R6's progress note dated 4/28/24 shows, Resident readmitted from local hospital via local paramedics. He
was on iv (intravenous) antibiotics to treat aspirated pneumonia while at local hospital . On minced moist
diet with thin liquid .
On 6/3/24 at 2:05 PM, V4 (Food Service Manager/FSM) stated he has been in his role as food service
manager for about three years. V4 only has a food protection manager certification that has expired.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 40 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0835
Level of Harm - Minimal harm
or potential for actual harm
V4 is not a certified dietary manager. V4 has not begun the process of signing up to take the certified
dietary manager coursework as of 6/3/24. V4 stated that he doesn't always know exactly what to do in his
position. There isn't someone on site at all times for him to refer to when he has questions.
V4's provided food protection manager certification shows an expiration date of 4/23/24.
Residents Affected - Many
On 6/6/24 at 10:18 AM, V1 Administrator was asked what his responsibilities were as administrator of the
facility. V1 stated, I think of my role as COO (Chief Operating Officer). I overlook the operations of the
facility. (V2 Director of Nursing/DON) hires and fires staff. Both (V2) and I are responsible for making sure
we have staff in key positions. V1 stated, I am aware we haven't had a full-time social service person in a
while. I know (V2) is actively trying to fill that role. V1 stated he wasn't aware that residents' discharge
planning, care plans, and grievances weren't being done in a timely manner or done at all due to not having
dedicated full-time social services staff. V1 stated he was aware that V4 (Food Service Manager) had been
in that role for three years and had never been certified for the position. V1 stated he never gave V4 a
deadline as to when he needed to have his Food Service Manager certification. When V1 was asked if he
was okay with V4 working in the role as food service manager while not being certified, V1 stated, No I am
not okay with (V4) working as the food service manager and not being certified in the role. I can only do so
much for this organization. V1 stated R6's April 2024 choking episode had not been reported to him prior to
the week of 6/2/24. V1 stated, I should have been notified. I also wasn't aware that the kitchen wasn't
serving the right diets until you guys came in for survey. V1 stated he was aware the facility was without an
activity director. V1 stated, I leave the hiring and firing of that position (activity director) to (V2 DON). V1
stated he wasn't aware that there had been nights when the facility only had one nurse for the entire
building. V1 stated he thought (V2 DON) was taking care of any staffing issues. V1 stated he realized the
lack of key staff members and the lack of resident cares associated with a lack of staff falls on him.
On 6/5/24 at 10:40 AM, V29 (Medical Director) stated he was not aware the facility did not have an activity
director or full-time social services staff. V29 stated he was not aware V4 Food Services Manager had been
working in the role for three years and had never been certified for the role. V29 stated he was not aware
there were nights the facility only had one nurse scheduled to care for all of the residents. V29 stated, I
speak with (V1 Administrator) at least one-two times a month. He didn't tell me about any of these issues. I
didn't know about any of this. He should have people in place to handle this. I just assumed he did.
The facility's Administrator job description (undated) showed, The purpose of this position is to establish
and maintain systems that are effective and efficient to operate a facility in a manner to safely meet the
residents' needs in compliance with federal, state and local requirements . The job description showed the
administrator's responsibilities included, determining the personnel requirements of the facility and hire or
arrange for sufficient staff to implement facility policies and procedures . supervise the recruitment,
employment, performance, evaluation, promotion, and discharge of all staff . Assume responsibility with
department supervisors to implement effective policies to assure adequate staffing to meet facility needs .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 41 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0850
Hire a qualified full-time social worker in a facility with more than 120 beds.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review the facility failed to provide/employ a qualified, full-time social worker.
This failure has the potential to affect all 84 residents in the facility.
Residents Affected - Many
The findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a
resident census of 84.
The facility's Facility Assessment Tool revised 7/31/23 showed the facility has a maximum bed capacity of
230 beds.
On 6/3/24, during the resident meeting, R11, R55, and R74 each stated the facility did not have a full-time
social worker. R55 stated, They have a part-time woman that comes a couple of hours in the evening a few
days a week, but we hardly ever see her. R55 stated she had an ongoing conflict with her new roommate
with no resolution due to no one here to deal with it. R55 stated she needed someone's assistance to help
her work with my insurance so I can find a dentist but there's no one to help do that either. R11 stated, I see
my counselor (contracted psychiatric social worker) once a week when she comes in but, I have no one to
talk to if I am upset and need to talk to someone when she isn't here.
On 6/3/24 at 8:44 AM, V3 Assistant Director of Nursing stated, We have not had a full-time social worker in
a long time. We have (V18 part-time Social Services) that comes in a few hours during the evenings, but
she is part-time.
On 6/3/24 at 11:44 AM, V1 Administrator state the facility had not had a full-time social worker in a while.
On 6/3/24 at 12:12 PM, V18 (part-time Social Services) stated, I work very part-time there. I am under
social services, but I am just helping out. I come in for 3-4 hours during the evening; 3-4 days a week. I help
do care plans and MDS's (Minimum Data Set). V18 stated, I don't do any discharge planning. I don't handle
grievances unless someone complains to me. I don't do anything with resident council. I don't help set up
appointments or counsel residents unless someone stops me when I'm there. I don't do any behavior
management counseling unless I see behaviors happening when I'm there.
The facility's Social Service Director (Designee) job description (undated) showed, The purpose of this
position is to provide social services to meet the social and/or emotional needs that affect the residents'
ability to achieve their highest level of function; participate in the development of residents' comprehensive
care plans; develop policies and procedures to provide social services to residents in compliance with
federal, state and local regulations The job description showed the Social Service Director was responsible
for developing and coordinating family and resident activities designed to promote social interaction .
develop one-to-one professional relationships with residents and families as needed for counseling .
assess, plan, and document residents' discharge needs . document the social service component of the
Comprehensive Care Plan for each resident in a timely manner . refer residents to social, health and
community resources and complete accurate documentation in residents' records concerning the results of
such referrals .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 42 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4.) On 6/3/24
at 10:10 AM, R24 was in bed with his feeding tube infusing into his gastrostomy tube via a pump. R1 who is
R24's roommate also had a gastrostomy tube. V3 (Assistant Director of Nursing/ADON) completed a
dressing change to R24's stage 2 sacral pressure injury. V24 (CNA) came into the room to assist her with
the dressing change. V3 and V24 did not wear gowns during the dressing change (which are required with
enhanced barrier precautions). There was no sign on the outside door to indicate either resident was on
enhanced barrier precautions and there was no PPE (Personal Protective Equipment) cart outside of the
room.
Residents Affected - Some
On 6/3/24 at 8:30 AM, V3 stated enhanced barrier precautions are for residents who have catheters,
feeding tubes and wounds but the facility has not gotten around to implementing that yet.
On 6/6/24 at 1:10 PM V3 (Assistant Director of Nursing) confirmed the facility does not have an enhanced
barrier policy.
Based on observation, interview, and record review the facility failed to ensure that a resident with a
multi-drug resistant urinary infection was placed on contact isolation. The facility failed to initiate enhanced
barrier precautions on residents with a catheter, tube feeding, and/or wounds. These failures apply to 5 of
20 residents (R51, R4, R84, R1, R24) reviewed for infection control in the sample of 20.
The findings include:
1. R51's Order Summary Report shows R51 is receiving Meropenem-Sodium Chloride (intravenous
antibiotic), two times a day for a UTI (urinary tract infection). This order was started on 5/29/24.
On 6/3/24 at 8:39 AM, R51's door or room had no signs of contact isolation precautions in place. At 9:09
AM, R51 was lying in bed receiving her scheduled intravenous antibiotic.
On 6/3/24 at 8:26 AM, V3 (Assistant Director of Nursing) stated that R51 had ESBL (extended spectrum
beta-lactamase; a multi-drug resistant organism) in the urine and that R51 was not on contact isolation and
there is not an isolation cart of sign outside the room to notify staff. V3 stated R51 should be on contact
isolation.
Facility Isolation-- Initiating Transmission-Based Precautions policy dated 2009 states, . 1. If a resident is
suspected of, or identified as, having a communicable infectious disease, the Charge Nurse or Nursing
Supervisor shall notify the DON (Director of Nursing) and/or the NHA (Nursing Home Administrator) and
the resident's Attending Physician for appropriate Transmission-Based Precautions.
2. On 6/2/24 at 10:51 AM, R4 was lying in bed with a urinary catheter attached. In the corner of R4's room,
next to the head of her bed, a tube feeding bag was suspended from a metal hanger but was not initiated.
There were no enhanced barrier precaution signs on the outside of R4's room.
R4's Minimum Data Set (MDS) dated [DATE] shows R4 has an indwelling catheter and receives 51 percent
or more of her total calories and fluids through a tube feeding.
3. On 6/2/24 at 1:58 PM, R84 was lying in bed with a urinary catheter attached. No enhanced barrier
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 43 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0880
precaution sign was noted outside of R84's room.
Level of Harm - Minimal harm
or potential for actual harm
R84's Care Plan shows that the resident has an indwelling catheter.
Residents Affected - Some
On 6/3/24 at 8:26 AM, V3 (Assistant Director of Nursing) stated they do not currently have a policy or follow
guidance for enhanced barrier precautions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 44 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure residents were screened for and received all
recommended doses of the pneumococcal (pneumonia) vaccine for 2 of 5 residents (R388, R38) reviewed
for the vaccine in the sample of 20.
Residents Affected - Few
The findings include:
1. R388's immunization record (undated) showed R388 was admitted to the facility on [DATE]. The record
showed R388 last received a pneumococcal vaccination on 12/26/2000 which showed R388 was currently
eligible for an additional pneumococcal vaccine. R388's medical record was reviewed and showed no
documentation R388 was screened for or offered a pneumococcal vaccine upon admission to the facility or
at any time during his stay in the facility.
2. R38's immunization record (undated) showed R38 was admitted to the facility on [DATE]. R38's
Authorization and Release for Pneumococcal Vaccine form dated 8/25/2023 showed R38 was screened for
the vaccine and consented to receive the vaccination. R38's medical records dated 8/25/2023-6/2/2024
were reviewed and showed no documentation R38 was administered the vaccine.
On 6/4/2024 at 10:45 AM, V3 Infection Preventionist confirmed R38 had not received a pneumococcal
vaccine in the facility and R388 had not been screened for or offered the vaccine. V3 stated residents
should be screened for the pneumococcal vaccine upon admission to the facility. V3 stated, We should
probably screen residents for the vaccine at least yearly, but we don't do that. I think we only screen
residents when we they get admitted . We don't have a nurse responsible for the immunization program. I
don't monitor any of that.
The facility's Influenza and Pneumococcal Immunizations-Residents policy (undated) showed, All residents
will receive immunizations that aid in preventing infectious diseases unless medically contraindicated or the
resident has already been immunized during this time period . All new residents will be assessed for
pneumococcal vaccine status upon admission. Residents without proof of previous pneumococcal
vaccination should be offered the pneumococcal vaccine(s) unless contraindicated .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 45 of 46
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
145434
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/06/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Claridge Healthcare Center
700 Jenkisson
Lake Bluff, IL 60044
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 0947
Level of Harm - Minimal harm
or potential for actual harm
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in
dementia care and abuse prevention.
Based on interview and record review the facility failed to ensure nursing staff received dementia care
training and education, annually, as required.
Residents Affected - Many
This failure has the potential to affect all 84 residents in the facility.
The findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid form dated 6/2/2024 showed a
resident census of 84.
On 6/4/24 at 11:00 AM, the following employee files were reviewed:
1. V22 Certified Nursing Assistant's (CNA) file showed V22 had been employed by the facility since
4/6/2014. V22's file showed V22 had received no dementia education or training in 2023 or 2024.
2. V28's file showed V28 had been employed by the facility since 8/12/1991. V28's file showed V28 had
received no dementia education or training in 2023 or 2024.
3. V26's file showed V26 had been employed by the facility since 8/7/2015. V26's file showed V26 had
received no dementia education or training in 2023 or 2024.
4. V21's file showed V21 had been employed by the facility since 11/1/2017. V21's file showed V21 had
received no dementia education or training in 2023 or 2024.
5. V6's file showed V6 had been employed by the facility since 1/19/2022. V6's file showed V6 had received
no dementia education or training in 2023 or 2024.
On 6/4/24 at 11:05 AM, V17 Human Resources stated, I am responsible for providing the yearly abuse,
harassment, and privacy education to our nursing staff. Social services usually does the staff dementia
training every year but we don't have anyone in social services to do it. V17 confirmed V22, V28, V26, V21,
and V6 had not received dementia training or education in 2023 or 2024.
The facility's Facility Assessment Tool revised 7/31/2023 showed the nursing staff education and
competencies to be completed, upon hire and as required, included education/training on abuse, resident
rights, and dementia care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145434
If continuation sheet
Page 46 of 46
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Back to topCitations
33 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.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F679 - Activities
Provide activities to meet all resident's needs.
F680 - The activities program must be directed by a qualified professional
Ensure the activities program is directed by a qualified professional.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F688 - Mobility
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.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F725 - Nursing Services
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
F744 - A resident who displays or is diagnosed with dementia, receives the
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
F745 - The facility must provide medically-related social services to attain or
Provide medically-related social services to help each resident achieve the highest possible quality of life.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
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.
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F825 - Specialized rehabilitative services
Provide or get specialized rehabilitative services as required for a resident.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
F850 - Social worker
Hire a qualified full-time social worker in a facility with more than 120 beds.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F947 - Training Requirements
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0006GeneralS&S Fpotential for harm
Conduct risk assessment and an All-Hazards approach.
- 0007GeneralS&S Fpotential for harm
Address patient/client population and determine types of services needed.
- 0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0015GeneralS&S Fpotential for harm
Address subsistence needs for staff and patients.
- 0018GeneralS&S Fpotential for harm
Establish procedures for tracking staff and patients during an emergency.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
FAQ · About this visit
Common questions about this visit
What happened during the June 6, 2024 survey of CLARIDGE HEALTHCARE CENTER?
This was a inspection survey of CLARIDGE HEALTHCARE CENTER on June 6, 2024. The surveyor cited 33 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CLARIDGE HEALTHCARE CENTER on June 6, 2024?
Yes, 33 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Keep residents' personal and medical records private and confidential."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.