4 Reports
Inspection Report — Oct 29, 2025
Complaint Investigation
Date: Oct 29, 2025
Visit Reason
Complaint Investigation: 25910138/IL198097 regarding sections 295.2050 a) and b).
Complaint Details
Complaint #25910138/IL198097: Section 295.2050 a) b) cited.
Findings
The establishment failed to report a fall incident involving resident R1 to the state agency within 24 hours. The fall was documented on video and resulted in injuries, but the incident report was not completed and the responsible staff member was terminated.
Deficiencies (1)
A2050 (295.2050 Incident and Accident Reporting) - The establishment failed to ensure that a fall incident was reported to the state agency within 24 hours as required, found in 1 of 3 residents reviewed.
Report Facts
Residents affected: 1
Residents reviewed: 3
Inspection Report — Sep 2, 2025
Annual Inspection
Date: Sep 2, 2025
Visit Reason
Annual Licensure Survey
Findings
The establishment failed to revise service plans for residents with specific care needs and did not provide required dementia training documentation for some staff.
Deficiencies (2)
A4010 (295.4010 Service Plan) - The establishment failed to revise service plans to address care and responsibility for maintenance of an indwelling urinary catheter for one resident, application and removal of a sling for a resident with a fractured clavicle, and revision of the service plan after fall incidents.
A4060 (295.4060 Alzheimer's and Dementia Programs) - The establishment failed to provide documentation that four of nine newly hired direct care staff completed the required 16 hours of on-the-job dementia-specific training following orientation, and the Reminiscence Care Coordinator lacked documentation of required qualifications.
Report Facts
Residents affected: 1
Residents affected: 1
Personnel files reviewed: 9
Personnel files with deficiencies: 4
Inspection Report — Jun 17, 2025
Plan of Correction
Date: Jun 17, 2025
Visit Reason
This plan of correction responds to the Facility Reported Incident of 3/29/25, IL190058.
Findings
The facility committed to immediate treatment and monitoring of the affected resident, retraining staff on abuse prevention policies, and ongoing weekly interdisciplinary reviews to ensure compliance with resident rights.
Inspection Report — May 31, 2025
Complaint Investigation
Date: May 31, 2025
Visit Reason
Investigation of Facility Reported Incident of 3/29/25, IL190058 - Substantiated.
Findings
The facility failed to ensure a resident was free from abuse. The investigation found a resident had a skin tear consistent with abuse by a staff member, who was removed from the unit.
Deficiencies (1)
A6000 (295.6000 Resident Rights) - The facility failed to ensure a resident was free from abuse for 1 of 3 residents reviewed for abuse, evidenced by a skin tear and staff statements confirming the incident.
Report Facts
Residents affected: 1
Residents reviewed for abuse: 3
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