Inspection Reports for Lexington Square Retirement Community of Lombard

IL

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Inspection Report Summary

The most recent inspection on September 19, 2025, identified deficiencies related to failure to provide necessary care and medical attention to one resident experiencing pain and vomiting. Earlier inspections in 2025 included substantiated complaints about controlled medication misappropriation and issues with medication storage and supervision, including missing Morphine and Lorazepam from residents’ comfort kits. Inspectors cited failures to follow medication policies, store narcotics securely, and perform consistent shift-to-shift counts. The facility reported these incidents to police and has since implemented enhanced security measures and monitoring protocols for medications. The inspection history shows ongoing challenges with medication management and resident care, with some corrective actions taken after the complaint investigation.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

14% worse than Illinois average
Illinois average: 3.5 deficiencies/year

Deficiencies per year

4 3 2 1 0
2025

Inspection Report

Original Licensing
Deficiencies: 1 Date: Sep 19, 2025

Visit Reason
Original investigation of facility FRI IL 197269 to assess compliance with resident rights regulations.

Findings
The facility was found to have neglected one of three residents experiencing pain and vomiting, resulting in a Type 2 violation due to failure to provide necessary care and medical attention overnight.

Deficiencies (1)
Failure to address one of three residents experiencing pain and vomiting, resulting in substantial probability of harm.

Employees mentioned
NameTitleContext
E3CaregiverNamed in failure to follow protocol leading to resident pain and vomiting overnight.
E1Executive DirectorExpressed concerns about failure to follow protocol and stated termination of E3.

Inspection Report

Complaint Investigation
Deficiencies: 2 Date: Feb 5, 2025

Visit Reason
The inspection was conducted as a complaint investigation following substantiated incidents involving controlled medication misappropriation and failure to follow medication storage and supervision policies.

Complaint Details
The complaint investigation was substantiated with findings of missing controlled substances from residents R16 and R17. The investigation revealed missing Morphine and Lorazepam, with evidence of tampering and missing narcotic sheets. The incidents were reported to police.
Findings
The facility failed to follow its policy and procedure on controlled medication storage and supervision, resulting in missing controlled substances (Morphine and Lorazepam) from residents' comfort kits. Narcotic lock boxes were stored in unlocked resident refrigerators, accessible to others, and shift-to-shift counts of controlled substances were not consistently performed. The incidents were reported to police but the establishment could not identify who took the medications.

Deficiencies (2)
Failure to follow policy and procedure on controlled medication storage and supervision, including storing narcotic lock boxes in unlocked resident refrigerators accessible to others.
Failure to prevent misappropriation of controlled medications paid for by residents, resulting in missing Morphine and Lorazepam from residents' comfort kits.
Report Facts
Milliliters of Morphine missing: 28.75 Milliliters of Lorazepam missing: 19.25 Milliliters of Morphine missing: 30 Milliliters of Morphine in lock box: 29.75 Milliliters of Lorazepam in lock box: 30

Employees mentioned
NameTitleContext
E3Director of Assisted Living and Memory CareProvided information about medication storage practices and missing Morphine for resident R17
E4NurseProvided information about narcotic counts and medication administration during the investigation

Inspection Report

Plan of Correction
Deficiencies: 1 Date: Feb 5, 2025

Visit Reason
Investigation of a self-reported incident related to medication administration at Lexington Square of Lombard.

Findings
A violation of Section 295.5000 & 295.6000 regarding medication administration was cited. The facility has implemented enhanced security and monitoring protocols for hospice comfort kit medications, including weekly audits and a double-lock security system.

Deficiencies (1)
Violation of Section 295.5000 & 295.6000 Medication Administration

Employees mentioned
NameTitleContext
Carlos BernalExecutive DirectorSigned the plan of correction letter addressing medication administration violation.

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