Deficiencies (over last year)
Deficiencies (over last year)
5 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
43% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 28, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse, neglect, and financial exploitation at the facility.
Complaint Details
The complaint investigation was substantiated for one incident (IL00188725) with no deficiency cited, and unsubstantiated for another (IL00196925) with a citation under 295.6010. The deficiency involved failure to timely submit the abuse investigation report.
Findings
The facility failed to submit the final written abuse allegation investigation report to the department within 14 days of the initial report, affecting one resident. The initial report was sent on 2025-07-24, but the final report was not submitted as of 2025-08-26.
Deficiencies (1)
Failure to submit the final written abuse allegation investigation report to the department within 14 days of the initial report.
Report Facts
Days to submit final report: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Stated on 2025-08-26 that the investigation was completed but the final report was not sent to the department. |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jul 15, 2025
Visit Reason
Annual Survey conducted from 7/9/25 to 7/15/25 to assess compliance with state regulations for assisted living and memory care units.
Findings
The facility was found deficient in multiple areas including disaster preparedness orientation for residents, service plan development and updates, dementia-specific staff training, and medication storage and administration practices. Several residents' service plans lacked required updates and signatures, staff failed to complete mandatory dementia training, and medication errors were identified involving unattended medications and failure to administer as ordered.
Deficiencies (4)
Failed to ensure that 4 residents and their responsible parties received orientation on emergency evacuation with signed documentation.
Failed to revise service plans to address unwitnessed falls, include physical therapy details, and ensure plans were signed and dated by residents or POA.
Failed to ensure five newly hired direct care employees and one non-direct employee completed required dementia-specific orientation training prior to assuming job responsibilities.
Failed to ensure oral medications were stored in a locked medication cart inaccessible to residents and failed to administer medications as ordered for 2 residents.
Report Facts
Residents reviewed for falls: 4
Newly hired employees reviewed: 8
Residents reviewed for medication errors: 2
Medication error date: Mar 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E10 | Resident Service Director / RN Resident Care Director | Involved in resident orientation and medication error investigation |
| E11 | Maintenance Director | Meets with new residents and families to show fire safety instructions |
| E12 | Licensed Practical Nurse (LPN) | Left medications unattended and failed to administer medications as ordered, resulting in termination |
| E13 | Human Resources Manager | Provided personnel files and could not explain missing dementia training documentation |
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