Lemont Nursing & Rehab Center

In the surveyor’s words

From the most serious findings on record at Lemont Nursing & Rehab Center, in the surveyor’s own words.

• Actual harm, isolatedF692Jan 17, 2025

  Based on observations, interview and record review, the facility failed to serve pureed diet as ordered by a Physician to a resident (R1) that has had a recent history of swallowing problems. This failure contributed to the resident having a significant weight loss. This applies to 1 of 3 residents (R1) reviewed for improper nursing in the sample of 6. The findings include: R1's EMR (electronic medical records) included diagnoses of osteomyelitis, pressure ulcer of sacral region, stage 4, pressure ulcer of right buttock, stage 4, unspecified severe protein-calorie malnutrition, adult failure to thrive, other cerebral palsy, dysphagia, oropharyngeal phase, anorexia nervosa. […]

• Actual harm, isolatedF684Feb 16, 2022

  Based on interview and record review the facility failed to notify the physician of an elevated White Blood Cell Count. This applies to 1 of 4 residents (R1) reviewed for change in condition in a sample of 4. This failure resulted in R1 being admitted to the hospital Intensive Care Unit for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R1's Resident Progress Notes dated [DATE] documents R1 with increased confusion and cloudy urine. The Physician was notified, and orders were received to obtain a urinalysis and urine culture. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's final Laboratory Report dated [DATE] at 5:07 PM documented a White Blood Cell Count (WBC) of 20.8 (normal range 4.,d+[DATE].8). […]

• Actual harm, isolatedF689Jan 13, 2022

  Based on interview and record review, the facility failed to ensure a resident was transferred in a safe manner using a mechanical total transfer lift device. This failure resulted in R1 sustaining a fractured fibula of the left lower leg. This applies to 1 of 3 residents (R1) reviewed for falls in a sample of 3. The findings include: The Face Sheet shows R1 had multiple admissions and readmissions to the facility. R1 was originally admitted to the facility for short term rehabilitation on 01/08/2013. R1's readmission to the facility for long term placement was on 09/01/2020. […]

• No harm, potential for more than minimal, widespreadF812Jan 9, 2026

  Based on observation, interview and record review the facility failed to maintain the kitchen in a manner that prevents food borne illness.This applies to all 135 residents receiving dietary services.Findings include:The CMS 671 start date of 01/06/2026 shows a total of 135 residents residing in the facility. On 01/07/2026 at 2:35 PM, V1 Administrator confirmed all 135 residents received meal services from the dietary department.On 01/06/2026 at 1:51 PM, R108 stated he did not want to eat from the facility cutlery because it isn't clean when he receives it. […]

• No harm, potential for more than minimal, widespreadF947Jan 9, 2026

  Based on interview and record review, the facility failed to provide the required twelve (12) hours per year of continuing competence training for Certified Nursing Assistants (CNA's), including dementia management training. This failure has the potential to affect all 135 residents in the facility. The findings include: The facility's January 6, 2026, Centers for Medicare and Medicaid Services (CMS) Form 671, Long-Term Care Facility Application for Medicare and Medicaid, showed 135 residents live in the facility. On 01/07/26 at 2:19 PM, V5 (Human Resources Director) said V2 (Director of Nursing) is responsible for in-service trainings and competencies of the CNAs. V5 stated she did not know who tracks the CNA yearly hours and did not know how many hours are required. […]