Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Admiral At The Lake, The during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of falls was not accurately assessed for fall risk, resulting in a lack of appropriate care planning and interventions. After a fall, required 72-hour post-fall monitoring and documentation were not completed, and the resident was not promptly sent to the hospital, later being diagnosed with multiple acute cervical fractures. Staff interviews confirmed failures in assessment, care planning, and post-fall supervision.
A resident with cognitive impairment and multiple medical conditions experienced two falls, but the care plan addressing fall prevention was not updated until months after the incidents. Staff interviews and record reviews confirmed that the care plan should have been revised promptly following each fall, in accordance with facility policy.
The facility failed to maintain safe food temperatures, as observed when breakfast items lacked recorded temperatures and barbeque beef was served at 90°F, below the recommended 130-135°F. The 8th floor steamer was non-functional, leading to reliance on microwaving food before serving. The Director of Culinary Services and the Supervisor for Dining acknowledged the importance of proper temperature monitoring to prevent food-related illnesses.
The facility failed to store and label food items according to professional standards, with expired and improperly stored food found in the refrigerator and freezer. Uncovered food items were left unattended, and a server was observed without a hairnet. These actions violate the facility's food safety protocols, as outlined in their documents.
A facility failed to follow proper PPE protocols, affecting resident safety. A caregiver for a resident on contact precautions for C. diff was observed without PPE, despite facility policy requiring it. Additionally, a housekeeping staff member wore gloves outside a resident's room, risking germ spread. The facility's policy mandates PPE to prevent infection transmission, but lapses were noted in adherence.
The facility failed to ensure a hazard-free environment for 15 residents on the eighth floor, as four screws were found on the hallway floor. Two staff members walked past the screws without addressing the hazard, which was later removed by a maintenance staff member. The Director of Nursing confirmed that the facility's policy is to maintain clear passageways and address safety risks promptly.
A facility failed to update a resident's care plan to reflect her hospice care status, despite her being admitted to hospice in November 2024. The resident, who is cognitively intact, was unaware of the hospice services provided, and staff interviews confirmed that care plans should be updated quarterly or as needed. This oversight indicates a deficiency in the facility's care planning process.
A resident with secondary Parkinsonism, muscle weakness, and dementia was not provided with restorative therapy, despite the facility's policy and the potential benefits of such a program. The resident's care plan and physician orders lacked restorative therapy interventions, and the resident was not listed in the facility's restorative program documentation. The Director of Nursing acknowledged the oversight but could not provide a rationale for the deficiency.
The facility failed to secure controlled substances for two residents, as observed when an LPN accessed an unlocked narcotic lock box containing Lorazepam without using a key or code. The DON confirmed that narcotics should be double locked, and the facility's policy requires controlled substances to be locked in permanently affixed compartments.
Failure to Accurately Assess Fall Risk and Implement Post-Fall Interventions
Penalty
Summary
A deficiency occurred when the facility failed to perform an accurate fall risk assessment, develop and implement appropriate post-fall interventions, and provide adequate monitoring and documentation for a resident with a known history of falls. The resident, who was cognitively impaired and had multiple medical diagnoses including a previous fall, was found on the floor after attempting to get out of bed. Despite being on anticoagulation therapy (Eliquis) and having a high fall risk score on previous assessments, the resident's most recent fall risk assessment inaccurately reflected a low risk. This led to a lack of appropriate care planning and interventions to prevent further falls. Following the fall, there was no evidence of the required 72-hour post-fall monitoring or documentation, and the resident was not sent to the hospital until several days later when he exhibited neck pain and was found to have multiple acute cervical fractures. Interviews with staff, including the LPN, DON, MDS Coordinator, and Medical Director, confirmed that the fall risk assessment was not accurately completed, the care plan was not updated with effective interventions, and post-fall monitoring was not performed as required by facility policy.
Failure to Timely Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to review and revise the comprehensive, resident-centered care plan for one resident following significant changes in condition, specifically after two documented falls. The resident, who is cognitively impaired and has multiple complex diagnoses including heart failure, atrial fibrillation, chronic kidney disease, and a history of falls, was admitted with a high risk for further falls. Despite the occurrence of falls on two separate occasions, the care plan addressing fall prevention was not updated until several months after the incidents. Interviews with the Director of Nursing and the MDS/Care Plan Coordinator confirmed that the expectation is for care plans to be updated promptly after a fall with appropriate interventions. However, documentation showed that the fall care plan was not initiated until long after the falls had occurred, contrary to facility policy which requires ongoing assessment and timely revision of care plans when a resident's condition changes. This lapse was identified through record review and staff interviews, which revealed a lack of timely action in updating the care plan to address the resident's increased fall risk.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to adhere to its policies and procedures for safe food preparation and service, which could potentially affect all residents receiving nutrition from the kitchen. On the morning of January 21, 2025, a review of the facility's hot holding temperature log revealed that no temperatures were recorded for breakfast items such as scrambled eggs, breakfast meat, oatmeal, and cheese omelets, including their pureed versions. The Director of Culinary Services, identified as V6, acknowledged the importance of recording food temperatures to ensure they are safe for consumption and to prevent food-related illnesses. Further observations on the same day revealed that the steamer on the 8th floor was not operational, and a work order had been placed for repairs. The Supervisor for Dining, identified as V8, reported that food was being microwaved before serving to residents, but a temperature check of the barbeque beef showed it was only 90 degrees Fahrenheit, below the recommended holding temperature of 130 to 135 degrees Fahrenheit. Additionally, it was noted that food should be covered to prevent contamination. The Director of Culinary Services stated that servers were instructed to serve food directly from insulated food carriers due to the non-functional steamer table, and V8 was responsible for monitoring dining services.
Improper Food Storage and Handling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage and labeling of food items. During an inspection, it was observed that the refrigerator contained approximately 20 slices of cheese, 15 slices of turkey, and cured Italian meat, all of which were past their use-by dates. Additionally, three 5-pound containers of cottage cheese were found to be expired. In the walk-in freezer, blue cheese butter and prepared chicken were also found with expired use-by dates. The Director of Culinary Services acknowledged that these items should have been discarded and mentioned ongoing efforts to in-service the kitchen staff. Further observations revealed several food handling and sanitation issues. Uncovered zucchini and lemon bars were left unattended, posing a risk of contamination. Soup containers were found uncovered on a table with ice, and a server was noted to be serving food without wearing a hairnet. Additionally, pans on the steam table were uncovered, exposing barbeque beef and peas and carrots to potential contamination. Facility documents from 2020 and 2024 outline the importance of proper labeling, dating, and storage of food to prevent foodborne illnesses, but these standards were not followed, leading to the identified deficiencies.
Failure to Adhere to PPE Protocols in Infection Control
Penalty
Summary
The facility failed to adhere to proper Personal Protective Equipment (PPE) protocols, which has the potential to affect all residents. On January 21, 2025, a private caregiver for a resident on contact precautions for Clostridioides difficile (C. diff) was observed without wearing the required PPE, such as a gown and gloves, while inside the resident's room. The caregiver stated that they were informed by a nurse that PPE was only necessary when changing the resident after a bowel movement. However, the Director of Nursing and the Infection Control Prevention Nurse clarified that PPE should be worn by anyone entering the room, as C. diff can be transmitted through contact with objects in the room. Additionally, on January 23, 2025, a housekeeping staff member was observed wearing disposable gloves outside of a resident's room, which is against the facility's infection control policy. The staff member admitted to wearing gloves while using the elevator and stated that they were in a rush to assist other workers. The Assistant Director of Nursing and the Infection Control Nurse confirmed that wearing gloves outside of resident rooms poses a risk of spreading germs throughout the facility. The Environmental Service Housekeeping Manager also stated that housekeepers are trained to remove gloves after cleaning a resident's room to prevent contamination. The facility's policy on isolation and transmission-based precautions requires staff and visitors to wear gloves and gowns upon entering rooms of residents on contact precautions. The policy aims to prevent the spread of infections through direct or indirect contact with contaminated surfaces. The failure to consistently implement these precautions, as observed in the cases of the private caregiver and housekeeping staff, indicates a lapse in adherence to infection control protocols, potentially compromising resident safety.
Failure to Maintain Hazard-Free Environment on Eighth Floor
Penalty
Summary
The facility failed to maintain a safe and hazard-free environment for 15 residents residing on the eighth floor. During a tour of the floor, four screws were observed on the hallway floor, posing a potential tripping hazard. Two staff members, a Live Enrichment staff and a Care Partner/CNA, walked past the screws without picking them up. Later, a maintenance staff member picked up the screws, acknowledging the potential risk they posed for accidents, such as slipping or falling. The Director of Nursing confirmed that the facility's policy is to keep the environment free of hazards, ensuring that passageways are clear and equipment is properly stored. The facility's policy emphasizes the importance of identifying and addressing safety risks through employee training and monitoring. Despite these policies, the presence of screws on the floor indicates a lapse in adherence to safety protocols, as staff members failed to address the hazard promptly.
Deficiency in Resident's Hospice Care Plan Documentation
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that reflects the current condition, goals, and services for a resident under hospice care. The resident, who is cognitively intact, was admitted to hospice care on November 16, 2024, but her care plan did not document this significant change in her care needs. Despite being under hospice care, the resident was unaware of the services provided to her, indicating a lack of communication and documentation regarding her care plan. Interviews with facility staff revealed that the care plans should be updated at least quarterly or as needed to reflect the resident's current needs and services, including specialized services like hospice care. However, the resident's care plan was not updated to include her hospice care status, which is a critical component of her current care needs. This oversight was identified during a survey, highlighting a deficiency in the facility's care planning process.
Failure to Provide Restorative Therapy for Resident with Parkinsonism
Penalty
Summary
The facility failed to provide restorative therapy for a resident diagnosed with secondary Parkinsonism, muscle weakness, and dementia, as per their restorative care policy. The resident, who was unable to be interviewed, was observed with a constricted left hand and a tendency to flinch and make fists. Despite the resident's condition and the potential benefits of a restorative program, the Director of Nursing acknowledged that the resident was not receiving restorative therapy services. The Director of Rehab confirmed that the resident was not being followed by therapy, and the resident's care plan and physician order set did not include restorative therapy interventions. The facility's restorative program documentation did not list the resident as a participant, and the Minimum Data Set indicated that the resident received zero days of restorative nursing programs. The Director of Nursing stated that the purpose of the restorative program is to maintain residents at their baseline and that a resident with Parkinson's Disease would benefit from such a program to slow functional decline. However, there was no rationale provided for the lack of restorative therapy services for this resident, indicating a failure to adhere to the facility's policy of providing necessary restorative care.
Failure to Secure Controlled Substances
Penalty
Summary
The facility failed to properly secure controlled substance medications for two residents, R7 and R14, as observed during a survey. On January 21, 2025, a Licensed Practical Nurse (LPN), identified as V23, was observed accessing the refrigerator and narcotic lock box on the 8th floor medication cart without using a key or entering a code. The refrigerator lacked a locking mechanism, and the narcotic lock box inside the refrigerator, which had a coded locking mechanism, was not locked. The unlocked narcotic lock box contained Lorazepam Intensol Oral Concentrate 2mg/ml for residents R7 and R14. The Director of Nursing (DON), identified as V3, confirmed that narcotics should be double locked to prevent unauthorized access and potential misuse. The facility's policy on controlled substances, dated November 2022, requires that controlled substances be separately locked in permanently affixed compartments. The physician order summaries for R7 and R14 indicated active orders for Lorazepam Oral Concentrate for anxiety management, with specific dosages and administration instructions. The failure to secure these medications as per policy and professional standards constitutes a deficiency in medication storage and security protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Selfhelp Home Of Chicago | 0.2 mi | — | 0 | 0 |
| Complete Care At Margate Park | 0.3 mi | — | 10 | 0 |
| All American Vlge Nrsg & Rhb | 0.4 mi | — | 1 | 0 |
| Alden Lakeland Rehab & Hcc | 0.5 mi | — | 13 | 1 |
| Aperion Care Wesley | 0.6 mi | — | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.