3 Reports
Inspection Report — Mar 21, 2026
Complaint Investigation
Date: Mar 21, 2026
Visit Reason
Original Investigation of FRI# IL200333 - The survey was conducted to investigate a facility reported incident involving resident R1 who sustained multiple falls and injuries.
Complaint Details
Facility Reported Incident (FRI) IL200333: multiple falls and injuries to resident R1 investigated.
Findings
The establishment failed to revise and escalate R1's service plan to address ongoing fall risks despite multiple serious injuries. Staffing was insufficient to meet R1's scheduled and unscheduled needs, and there was no documented family involvement regarding care level decisions.
Deficiencies (2)
A4010 (295.4010 Service Plan) - The establishment failed to ensure the service plan was effectively revised and interventions escalated to address R1's ongoing fall risk despite nine falls and serious injuries from 2/1 to 3/21/26.
A4060 (295.4060 Alzheimer's and Dementia Programs) - The establishment failed to provide appropriate care and sufficient skilled staff to meet the 24-hour needs of R1, resulting in nine falls including serious injuries.
Report Facts
Falls: 9
Inspection Report — Dec 10, 2025
Annual Inspection
Date: Dec 10, 2025
Visit Reason
Annual Licensure Survey. The survey covered multiple regulatory sections including personnel requirements, health evaluations, background checks, Alzheimer's and dementia programs, resident rights, physical plant, and environmental requirements.
Findings
The facility was found deficient in multiple areas including personnel records and training, initial health evaluations, healthcare worker background checks, staffing and medication administration, resident abuse investigation, fire drill evacuations, and environmental safety hazards. The facility failed to provide sufficient nursing staff on 5/11/25 evening shift resulting in missed medications for many residents. An alleged abuse incident was not properly investigated or reported. Fire drills did not include full evacuations outside the building. Hazardous chemicals were accessible in the memory care unit posing a risk to residents.
Deficiencies (8)
A3000 (295.3000 Personnel Requirements, Qualifications and Training) - The establishment failed to adequately supervise and coordinate transfer of healthcare worker background checks, employee physicals, and training records during a management change and failed to ensure nurses staffed the 5/11/25 evening shift.
A3030 (295.3030 Initial Health Evaluation for Direct Care and Food Service Employees) - The facility failed to provide documentation of initial health evaluations and tuberculosis screening for 9 employees reviewed.
A3040 (295.3040 Health Care Worker Background Check) - The facility failed to provide healthcare worker background check documentation for 5 of 6 employees reviewed, impeding verification of eligibility for employment.
A4060 (295.4060 Alzheimer's and Dementia Programs) - On 5/11/25 evening shift, no nurse was present in memory care to administer medications, resulting in 28 residents missing important medications. Additionally, one resident (R3) with aggressive behavior was not properly assessed or managed according to residency requirements.
A6000 (295.6000 Resident Rights) - The facility failed to ensure sufficient nursing staff to administer medications on 5/11/25 evening shift, affecting 40 residents and placing them at risk of harm.
A6010 (295.6010 Abuse, Neglect, and Financial Exploitation Prevention and Reporting) - The facility failed to investigate, document, and report an alleged abuse incident involving resident R3 on 7/5/25 and failed to ensure agency staff were oriented to abuse reporting procedures.
A9000 (295.9000 Physical Plant) - The facility failed to provide credible documentation of a full evacuation outside the building since the last annual licensure and lacks sufficient personnel on night shift to perform such evacuation, placing all 105 residents at risk.
A9040 (295.9040 Environmental Requirements) - Hazardous chemicals including acetone, hand sanitizer, and perineal cleanser were accessible in unlocked cabinets in the memory care unit, posing a swallowing hazard to 2 cognitively impaired residents.
Report Facts
Residents affected: 3
Residents affected: 28
Residents affected: 39
Residents affected: 105
Employees reviewed: 9
Employees affected: 6
Agency nurses scheduled: 3
Inspection Report — Jan 16, 2025
Date: Jan 16, 2025
Visit Reason
Licensure Survey. 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.
Findings
The establishment was found in compliance with all applicable regulations; no violations were cited.
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