3 Reports
Inspection Report — Sep 2, 2025
Annual Inspection
Date: Sep 2, 2025
Visit Reason
Annual Licensure Survey combined with Facility Reported Incidents IL196366 (substantiated) and IL197047 (unsubstantiated). Violations cited: 295.5000 c) 1) 2) 3) 4) 5) 6) 7) d) f) 4) 5) and 295.6000 a) 13).
Findings
The facility failed to maintain medication administration records for one resident, resulting in a high probability of missed medications. The facility also failed to provide adequate supervision to prevent elopement of one resident, which posed a high risk to resident safety.
Deficiencies (2)
A5000 (295.5000 Medication Reminders, Supervision of Self Med) - The facility failed to maintain medication administration records for one resident (R3), including documentation of medication administration and proper evaluation of self-administration ability.
A6000 (295.6000 Resident Rights) - The facility failed to provide adequate supervision to prevent elopement by one resident (R6), resulting in injury and delayed recognition of the elopement.
Report Facts
Residents affected: 1
Residents affected: 1
Residents reviewed for medications: 3
Residents reviewed for elopement: 7
Inspection Report — Sep 12, 2024
Annual Inspection
Date: Sep 12, 2024
Visit Reason
Annual Licensure Survey conducted to determine compliance with licensure requirements and standards, focusing on resident issues, quality improvement, and complaint and incident report reviews.
Findings
The facility failed to provide reliable access to resident electronic medical records, impeding completion of required resident record reviews during the annual licensure survey.
Deficiencies (2)
A1070 (295.1070 Annual on-Site Review and Complaint Procedure) - The facility failed to provide functioning usernames and passwords for access to resident electronic charts, impeding completion of required resident record reviews for nine residents.
A7000 (295.7000 Resident Records) - The facility failed to provide reliable computer access to resident electronic medical records, interfering with completion of resident medical record reviews during annual licensure activities for nine residents.
Report Facts
Residents affected: 9
Inspection Report — Sep 12, 2024
Annual Inspection
Date: Sep 12, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility failed to provide functioning usernames and passwords and reliable computer access to resident electronic medical records. The Executive Director consulted with the IT team to create and test a Yardi username and password for surveyors and obtained a direct contact number for further assistance.
Deficiencies (2)
A1070 (295.1070) - The facility failed to provide a functioning username and password for access to the resident’s electronic chart.
A7000 (295.7000) - The facility failed to provide reliable computer access to resident electronic medical records.
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