Inspection Reports for
Mill Creek Alzheimer‘s Special Care Center

The establishment failed to follow their fall policy for falls for R1, one of three residents reviewed for falls. Incident reports were not generated for R1's two falls on 4-29-26, preventing investigation and updating of the service plan.

Incident IL 199572: Incident can be substantiated. No violations cited.

The establishment was found in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.

Incident IL 197942: Allegation can be substantiated. No violations cited. Incident IL 198034: Allegation can be substantiated. No violations cited.

The establishment was found in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.

Facility Reported Incident Investigation to incident of 09-23-25/IL#197721.

The facility neglected to implement fall prevention interventions for one resident who fell twice on 09/23/25, resulting in a fracture. Staff acknowledged the resident was unsupervised in a hallway despite service plan interventions for increased supervision.

The facility failed to ensure annual physician assessments were completed and signed by a physician for three of five residents. The facility also failed to conduct annual tuberculosis screenings for four of five residents reviewed.

The establishment was found in compliance with all applicable regulations during the original licensing investigation.

The establishment failed to ensure 17 residents received physician ordered evening medications on 06-14-2025. The facility notified all resident power of attorneys and physicians regarding the medication incident and terminated the responsible nurse.

The facility committed to in-service all licensed nursing staff post-incident regarding medication management and medication error policies. The Health Service Director will continue education and monitoring to ensure compliance with medication administration and resident rights.

Complaint 2543924/IL191521: Complaint cannot be substantiated. No violations cited. Incident Report Investigation IL 190944: Allegations cannot be substantiated. No violations cited.

The establishment was found in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.

The facility completed staff in-service training on wandering and elopement, installed door closures and alarms, conducted elopement drills, updated service plans for elopement risk, and implemented ongoing monitoring procedures to ensure resident safety.

Incident Report Investigation IL 189898: Type 2 Violation cited.

The establishment failed to ensure resident safety to prevent an elopement. Staff have since received further training on wandering and elopement prevention, conducted elopement drills, added additional alarms and door closers, and ordered an alarm for the nurse's station door.

Original investigation IL# 182155. Previously investigated under IL# 180886.

The establishment was found in compliance with all applicable regulations during this complaint investigation.