6 Reports
Inspection Report — Mar 11, 2026
Complaint Investigation
Date: Mar 11, 2026
Visit Reason
Complaint investigation survey: IL200476 found no violations. Facility Reported Incident surveys IL199647/FRI 12.23.25, IL199907/FRI 1/25/26, and IL200480/FRI 2.13.26 cited sections 295.6000 a) 1) 13) and 295.2000 a) 3) 5).
Complaint Details
Complaint IL200476: no violations cited. Facility Reported Incident IL199647/FRI 12.23.25 cited 295.6000 a) 1) 13). Facility Reported Incident IL199907/FRI 1/25/26 cited 295.6000 a) 1) 13). Facility Reported Incident IL200480/FRI 2.13.26 cited 295.2000 a) 3) 5).
Findings
The establishment failed to reassess a resident for continued admission after physical decline and failed to ensure resident rights by allowing physical abuse and unsafe wandering. One resident was punched by an employee and another eloped into extreme cold, resulting in hospitalization and death.
Deficiencies (2)
A2000 (295.2000 Residency Requirements) - The establishment failed to reassess one resident for continued admission after showing physical decline and increased care needs.
A6000 (295.6000 Resident Rights) - The establishment failed to prevent physical abuse of one resident who was punched by an employee and failed to ensure the safety of another resident who eloped into extreme cold conditions.
Report Facts
Residents reviewed: 4
Residents involved: 3
Inspection Report — Dec 20, 2025
Complaint Investigation
Date: Dec 20, 2025
Visit Reason
Facility Reported Incident IL199049. For this survey, the establishment is in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Complaint Details
Facility Reported Incident IL199049: No violations cited.
Findings
The establishment was found in compliance with all applicable regulations during this facility reported incident investigation.
Inspection Report — Sep 30, 2025
Annual Inspection
Date: Sep 30, 2025
Visit Reason
Annual Licensure survey: 295.2040 5) c) d) e), 295.4000 a), 295.4010 a) b) 1) 2) 3) c), 295.4050, 696.140 b) 1) 2), 295.9000 a). Facility Reported Incident: IL196629 - 295.4010 a) b) 1) 2) 3) c). Complaint Investigation IL196663 - 295.4010 a) b) 1) 2) 3) c).
Findings
The facility failed to orient residents timely to emergency plans, conduct required tornado drills, and properly document fire drills. Deficiencies were found in physician assessments, service plans, TB screening, and physical plant fire drill compliance.
Deficiencies (5)
A2040 (295.2040 Disaster Preparedness) - The facility failed to orient 6 of 7 residents on emergency and evacuation plans within 10 days of admission, conduct tornado drills on each shift in February 2025, involve residents in fire drills, identify residents needing assistance during drills, and properly evaluate drill dates and times.
A4000 (295.4000 Physician/s Assessment) - The facility failed to ensure admission assessment was completed by a physician for 1 of 7 residents reviewed.
A4010 (295.4010 Service Plan) - The facility failed to ensure service plans included signatures and dates for 6 of 7 residents, revise plans to address pain management for 1 resident, update plans for outside services and care coordination for 1 resident, and address use of a mechanical lift for 1 resident who is nonverbal.
A4050 (295.4050 Tuberculin Skin Test Procedures) - The facility failed to provide TB screening documentation for 1 of 7 residents and provided a TB record without resident name for another.
A9000 (295.9000 Physical Plant) - The facility failed to meet time constraints for fire drills, ensure all residents attend and participate, and list residents needing assistance during fire drills, with multiple drills exceeding 13 minutes and lacking required documentation.
Report Facts
Residents affected: 6
Residents reviewed: 7
Residents affected: 1
Residents affected: 6
Residents affected: 1
Inspection Report — Jul 7, 2025
Complaint Investigation
Date: Jul 7, 2025
Visit Reason
Complaint Investigation 2575154/IL194004 found no findings. Facility Reported Incident to 5/7/25 IL193620-295.6000a)1) cited.
Complaint Details
Complaint Investigation 2575154/IL194004: no findings. Facility Reported Incident to 5/7/25 IL193620-295.6000a)1) cited.
Findings
The facility failed to ensure residents were treated with dignity; one resident experienced inappropriate communication from a nurse. The nurse received an in-service on communication and tone following the investigation.
Deficiencies (1)
A6000 (295.6000 Resident Rights) - The facility failed to ensure residents were treated in a dignified manner for 1 of 3 residents reviewed for dignity.
Report Facts
Residents affected: 1
Residents reviewed for dignity: 3
Residents in sample: 6
Inspection Report — Jul 3, 2025
Plan of Correction
Date: Jul 3, 2025
Visit Reason
This plan of correction answers the Complaint Investigation IL194004 and Facility Reported Incident IL193620 surveys conducted on 7/3/2025.
Findings
The facility committed to staff training on abuse, neglect, exploitation, and residents' rights, including mandatory in-service sessions and ongoing monitoring led by the Executive Director and Wellness Leader.
Inspection Report — May 30, 2025
Complaint Investigation
Date: May 30, 2025
Visit Reason
Complaint Investigation Survey 2572511/IL188629 found no violations. Facility Reported Incident Investigation Surveys on 4/20/25 IL190941, 5/6/25 IL192277 found no violations. The investigation from 5/13/25-5/22/25 IL193422 cited 295.6000a)13). Several other complaints and incidents were unsubstantiated or unable to be completed due to subjects not residing in the facility.
Complaint Details
Complaint Investigation Survey 2572511/IL188629: No Violations. Facility Reported Incident Investigation Surveys 4/20/25 IL190941, 5/6/25 IL192277: No Violations. Facility Reported Incident Investigation Survey 5/13/25-5/22/25 IL193422: 295.6000a)13) cited. Several other complaints and incidents unsubstantiated or unable to be completed.
Findings
The facility failed to ensure residents were free from theft of personal property involving five residents. The facility is cooperating with police investigations and has suspended suspected staff pending investigation.
Deficiencies (1)
A6000 (295.6000 Resident Rights) - The facility failed to ensure residents were free from theft of their personal property, affecting 5 of 5 residents reviewed.
Report Facts
Residents affected: 5
Residents reviewed: 13
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