Mistreatment in nursing facilities can take on many forms including negligence by the nursing staff, resident-to-resident assault, or bad hiring practices. Many nursing homes in Illinois are understaffed or fail to provide adequate training to their Nurses and Nurse’s Aides.
If your loved one was injured while residing in a Cook County nursing home, the Illinois Nursing Home Law Center attorneys can help. Our team of nursing home negligence lawyers has successfully handled and resolved cases just like yours. Contact us now so we can begin working on your case today.
This Medicare/Medicaid-participating nursing facility is a "for profit" home providing services to residents of Chicago and Cook County, Illinois. The 244-certified bed long-term care center is located at:
725 West Montrose Avenue
Chicago, Illinois, 60613
(773) 929-1700
In addition to providing around-the-clock skilled nursing care, the Carlton at the Lake also offers:
The federal government has the legal authority to penalize any nursing home that has violated rules and regulations that harmed or could have harmed a nursing facility resident. These penalties include denial of payment for Medicare services or an imposed a monetary fine.
Within the last three years, The Carlton at the Lake has received twenty-four formally filed complaints due to substandard care. Additional information about fines and penalties can be found on the Illinois Department of Public Health Nursing Home Reporting Website concerning this nursing facility.
To ensure families are fully informed of the services and care that the long-term care facility offers in their community, the state of Illinois routinely updates their comprehensive database. This information contains a list of health violations, opened investigations, safety concerns, incident inquiries, dangerous hazards, and filed complaints of nursing homes statewide. The data is posted on the IL Department of Public Health website and Medicare.gov.
According to Medicare, this facility maintains an overall rating of one out of five stars, including one out of five stars concerning health inspections, two out of five stars for staffing issues and four out of five stars for quality measures. The Cook County neglect attorneys at Nursing Home Law Center have found serious deficiencies and safety concerns at The Carlton at the Lake that include:
In a summary statement of deficiencies dated March 16, 2017, the state survey team noted that the nursing home had failed to “follow policy to make alternative methods before using restraints and failed to obtain a physician’s orders.” The incident involved a patient who “was seated in a specialty chair at the end of the third-floor hallway for activities.” At that time, the Activity Director and Activity Aide “were supervising the activity, which [the Activity Director] described as a Morning Mixer, consisting of music and ball playing.”
At that time, the resident “was alert, sitting up in his wheelchair with [good] posture and body alignment.” The resident’s “hands are partially contracted [and their] seatbelt was fastened during the activity.” On March 15, 2017, at 11:35 AM, the resident “was again seen seated in his specialty wheelchair, alone in his room, his seatbelt fastened, and his call light was not within his reach.”
It was then that the surveyors asked the resident “if he could unfasten a seatbelt.” However, the resident “did not follow this command request.” A nurse providing the resident care said that the resident “was totally dependent on staff to eat, bathe, dress, and for hygiene needs.” The survey team reviewed the resident’s assessment that indicates that no alternatives to the restraint had been tried and that the resident’s “seatbelt use is not a focus in his care plan.”
A second resident was observed in the Third Floor Dining Room during the lunchtime with a “seatbelt fastened around her waist and another belt fastened around her chest.” At that time, the second resident was “alert, nonverbal, and had hand contractures.” The resident “was again seen seated in the third-floor dining room” the following morning at 9:46 AM during an art activity “conducted by [three Certified Nursing Assistants (CNAs)] again, the resident’s chest and waist seatbelt were fastened. On both occasions, [the resident] was sitting still.”
During a discussion with a nurse providing the resident care, it was revealed that the resident “is developmentally delayed, has profound intellectual disabilities, is nonverbal, and requires total assistance to eat, bathe, dress, transfer and for incontinence care.”
The nurse said that the patient “has a chest and waist belt fastened at all times when up in her specialty wheelchair.” A review of the resident’s Physician Order Sheet indicates that on March 1, 2016, there is an order for a “custom supportive wheelchair hip belt to prevent further deformity and promote cognitive activities – release every two hours – every shift.” However, the Physician’s Order Sheet does not indicate that any other alternative has been tried other than physical restraint.
In a summary statement of deficiencies dated February 8, 2018, the state survey team noted the nursing home had “failed to ensure that residents are dependent on staff assistance for their activities of daily living care are turned and repositioned to help heal or prevent the development of a new or recurring pressure ulcer.” The deficient practice by the nursing staff involved one resident “reviewed for pressure ulcers.”
The state survey team observed the resident on the morning of February 5, 2018 while “lying on his right side with pillows between his knees and bilateral heel protectors in place.” The surveyors interviewed the resident who said, “that he had been lying on his right side since 6:00 AM.” The patient also said that “the staff does an offer to change [the resident’s] position.”
The resident told the surveyors that a family member changes their position before they leave the facility so that the resident “can sleep comfortably. The night shift staff changes [the resident’s] position at 6:00 AM before they leave, they do not offer to change [the resident’s] position during the shift.” The patient said that “the day and evening shift staff member offers to change [their] position.”
The survey team interviewed a Certified Nursing Assistant (CNA) providing the resident care on the morning of February 5, 2018. The CNA said that the resident’s “position is changed when he asks the staff to change his position and did not offer to change the [resident’s] position.”
At 9:30 AM the next day, the surveyors observed the resident “lying in bed on his right side.” The resident said that “he had been in the same position since 6:00 AM and the staff still had not come into his room and offered to change his position.” During the interview, the resident said “he “slept on his back all night, last night. None of the staff offered to change his position last night, until 6:00 AM this morning.”
At 10:11 AM that morning, a Certified Nursing Assistant (CNA) said: “that she had not changed [the resident’s] position today and did not offer to change [his] position.” The CNA said that the resident “requests for his position to be changed.”
Less than forty minutes later, the resident said, “he had never refused the offer to change his position from the staff.” A few minutes earlier, the CNA supervisor had said that the “CNA should change the resident’s position every two hours. If the resident refuses, they shall report the refusal to the nurse and still go back in another two hours to change the resident’s position again.”
During an interview with a family member, it was revealed that “the staff does not often change the resident’s position every two hours when [they visit the nursing home].” The state survey team observed the resident on the morning of February 7, 2018, the third day, while “lying on his right side.” The resident said that he had “slept on his back all night. The night shift staff did not change his position all night. He was lying on his back from 6:00 PM yesterday until 6:00 AM this morning.”
The resident said that he had been lying on their side since 6:00 AM and that the nursing staff told the resident “to tell her if [the resident] wanted his position change. The evening shift staff never changes [the patient’s] position.”
The survey team reviewed the resident’s Wound Care Notes dated from January 11, 2018, through February 1, 2018. The report indicates that the resident “currently has a wound on the left posterior thigh that was identified on December 30, 2017.” The resident’s Braden Score dated January 29, 2018, measuring skin integrity, indicates that the resident “is at moderate risk for skin breakdown with a score of 13.”
The resident’s MDS (Minimum Data Set) reveals that the resident “requires extensive assistance with a two-person physical assist for bed mobility – how a resident moves to and from a lying position, turn side to side, and physician’s body while in bed or alternate sleep furniture.” The report also indicates the resident skin condition “is at risk for pressure ulcers and the turning and repositioning program is one of the implemented skin and ulcer treatments for [this resident].”
A review of the resident’s Care Plan with a target date of May 8, 2018, indicates that the resident “currently has a pressure ulcer related to his disease process, history of ulcers, and immobility. Implement interventions include the resident needs monitoring, reminding, and assistance to turn/reposition at least every two hours, and more often as needed and requested.”
The survey team interviewed the facility Assistant Director of Nursing/Acting Director of Nursing who said that “the staff should turn and reposition the resident frequently, near the 2-hour time frame and upon request.” A review of the facility policy titled: Skin Care Treatment Regimen and Formulary reads in part: “Residents who are not able to turn and reposition themselves will be turned and repositioned every two hours.”
In a separate summary statement of deficiencies dated March 16, 2017, the state investigative team documented that the nursing home had failed to follow physician’s orders. The incident involved a female resident who “had a Stage III pressure sore to the coccyx area.”
The state investigators observed a Certified Nursing Assistant (CNA) providing incontinent care to the patient who removed the resident’s “incontinent briefs, which was soiled with watery bowel movement, the wound dressing got halfway soiled with fecal matter.”
The CNA was observed “while continuing to “perform incontinence care on [the resident], cleansed [the resident’s] genital area, groin, rectal area, buttocks and even tried to wipe the fecal matter from the soiled area around the wound dressing.” The CNA “finally finished cleaning [the resident], put on a new incontinence brief and reposition [the resident] on the right side with a pillow placed on the side.”
The state surveyors asked a Registered Nurse (RN) to check the resident’s “wound dressing” at 3:00 PM that same day. The observation showed that “the wound dressing [that was] soiled with fecal matter, almost dried, was still covering [the resident’s] pressure sore.” The RN said that “the dressing is halfway soiled and needs to be changed. The CNAs need to tell nurses if the dressing got soiled so nurses can notify the wound care nurse to change the dressing right away. I was informed that [the resident’s] dressing got soiled with feces. The staff is supposed to tell me this happens.”
The investigators reviewed the facility’s policy titled: Skin Care Treatment Regimen and Formulary that “does not address procedures in soiled wound dressing change.” During the facility presentation on the morning of March 16, 2017, the Nurse Consultant “mentioned that the facility does not have a policy addressing soiled wound dressings.”
Do you believe your loved one was injured or harmed while living at The Carlton at the Lake? If so, call the Illinois nursing home abuse and neglect lawyers at Nursing Home Law Center at (800) 926-7565 for legal help. Our network of attorneys fights aggressively on behalf of Cook County victims of mistreatment living in long-term facilities including nursing homes in Chicago. Contact us now to schedule a free case review to discuss how to obtain justice and resolve a financial compensation claim.
Our attorneys represent clients who have been harmed through nursing home abuse by nursing staff and caregivers. We accept every case concerning wrongful death, nursing home abuse, and personal injury through a contingency fee agreement. This arrangement will postpone the need to make a payment for our legal services until after our attorneys have resolved your case through a jury trial award or negotiated out of court settlement.
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Attorney Jonathan Rosenfeld
Licensed in Illinois
Chicago Nursing Home Injury Lawyer Nursing Home Law Center LLC Home