3 Reports
Inspection Report — Apr 24, 2026
Annual Inspection
Date: Apr 24, 2026
Visit Reason
Annual Licensure survey
Findings
The establishment was found to have multiple deficiencies including failure to implement an effective quality improvement program, failure to verify professional licenses, incomplete health care worker background checks, inadequate service plans for residents at high risk of falls, and insufficient Alzheimer's and dementia training for staff.
Deficiencies (5)
A2060 (295.2060 Quality Improvement Program) - The establishment failed to address dining service issues including incorrect orders, service delays, and food unavailability, and did not develop or implement a process to resolve these issues as evidenced by resident council meeting minutes and staff interviews.
A3000 (295.3000 Personnel Requirements, Qualifications and Training) - The establishment failed to verify the professional licenses of 16 of 17 licensed staff by contacting the Illinois Department of Financial and Professional Regulation and placing verification in personnel files.
A3040 (295.3040 Health Care Worker Background Check) - The establishment failed to complete required health care worker background checks including initial and annual employment verification for 3 of 4 unlicensed employees providing resident care or service.
A4010 (295.4010 Service Plan) - The establishment failed to integrate end-of-life hospice care into R1's service plan, develop individualized service plans for R2 and R6 identifying high fall risk, and implement interventions such as skin protection for R2, resulting in multiple falls and injuries.
A4060 (295.4060 Alzheimer's and Dementia Programs) - The establishment failed to ensure 8 employees with direct resident contact received required on-the-job and annual training hours related to Alzheimer's disease and dementia care.
Report Facts
Personnel files affected: 16
Personnel files affected: 3
Residents affected: 3
Employees affected: 8
Inspection Report — May 8, 2025
Date: May 8, 2025
Visit Reason
Licensure Survey - No deficiency. Facility Reported Incident (FRI) IL189202 (3/28/25) 295.3000 cited 295.4010 cited
Findings
The survey found multiple violations related to personnel qualifications and training, and service plan development and implementation. The facility failed to follow its elopement policy, document elopement assessments, monitor wounds and nephrostomy care, and develop individualized service plans for residents at risk.
Deficiencies (2)
A3000 (295.3000 Personnel Requirements, Qualifications and Training) - The facility failed to follow its elopement policy, did not document elopement assessments for two residents, failed to document staff assessments of a resident's nephrostomy site and tubing, failed to document care of a resident's leg wound, and failed to adequately monitor a resident assessed as an elopement risk who eloped and was injured.
A4010 (295.4010 Service Plan) - The facility failed to develop and implement individualized goals and interventions for three residents assessed as elopement risks, one resident with a vascular wound, and one resident with a nephrostomy, causing harm and substantial probability of harm.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 1
Inspection Report — May 8, 2025
Plan of Correction
Date: May 8, 2025
Visit Reason
This plan of correction answers the Annual Licensure Survey and Facility Reported Incident Survey of the licensing inspection conducted on 5/8/2025.
Findings
The facility committed to updating service plans for residents with specific goals and interventions, completing audits of residents with elopement risks, wounds, and nephrostomy tubes, and retraining staff on relevant policies and care responsibilities. Monitoring will be conducted through weekly interdisciplinary meetings and quality assurance reviews to ensure ongoing compliance.
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