Inspection Reports for
Willow Falls Senior Living

IL, 60403

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6 Reports

2024–2026

Inspection Report — Apr 21, 2026

Annual Inspection
Date: Apr 21, 2026

Visit Reason
Annual Licensure Survey conducted citing violations in Disaster Preparedness, Personnel Requirements, Qualification and Training, and Healthcare Worker Background Check Code.

Findings
The establishment failed to orient new residents to emergency and evacuation plans within 10 days, conduct required fire and tornado drills including night shifts, maintain documentation of resident participation in drills, ensure timely initial health evaluations for newly hired employees, and comply fully with the Health Care Worker Background Check Act.

Deficiencies (3)
A2040 (295.2040 Disaster Preparedness) - The establishment failed to orient new residents to emergency and evacuation plans within 10 days, conduct at least six fire drills per year including two night drills, and include resident participation details in drill evaluations.
A3000 (295.3000 Personnel Requirements, Qualification and Training) - The establishment failed to ensure 3 of 8 newly hired employees received initial health evaluations within 30 days of hire and one employee had an evaluation 6 months prior to hire.
A3040 (295.3040 Health Care Worker Background Check) - The establishment failed to comply with the Health Care Worker Background Check Act for 5 of 8 newly hired employees by not maintaining background check results.
Report Facts
New residents not oriented: 4 Newly hired employees without timely health evaluation: 3 Newly hired employees without background check compliance: 5

Inspection Report — Mar 6, 2026

Complaint Investigation
Date: Mar 6, 2026

Visit Reason
Complaint Investigation IL199695, IL200408 - Unsubstantiated. Facility Reported Incident IL200502 - Unsubstantiated.

Complaint Details
Complaint IL199695: Unsubstantiated. Complaint IL200408: Unsubstantiated. Facility Reported Incident IL200502: Unsubstantiated.
Findings
The establishment was found in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.

Inspection Report — Oct 14, 2025

Complaint Investigation
Date: Oct 14, 2025

Visit Reason
Facility Reported Incident 9/13/25 - IL197929 - Substantiated. See Complaint #IL 197444/2578639 & IL 197541/2578839 exited on 9/16/25 for violations cited.

Complaint Details
Facility Reported Incident IL197929: Substantiated. See Complaint #IL 197444/2578639 and #IL 197541/2578839 exited on 9/16/25 for violations cited.
Findings
This document is a summary statement referencing a substantiated facility reported incident and related complaints exited for violations. No specific deficiencies are detailed in this form.

Inspection Report — Sep 18, 2025

Complaint Investigation
Date: Sep 18, 2025

Visit Reason
Complaint Investigation IL00197541 and IL00197444. The survey found multiple violations related to residency requirements, resident rights including verbal abuse, and failure to timely report alleged abuse incidents.

Complaint Details
Complaint IL00197541 and IL00197444: multiple Type 1 violations cited including residency requirements, resident rights, and abuse reporting.
Findings
The establishment failed to ensure residency requirements for one resident with inappropriate sexual behavior, failed to protect one resident from verbal abuse by staff, and failed to report alleged sexual/mental abuse incidents to the Department within 24 hours as required.

Deficiencies (3)
A2000 (295.2000 Residency Requirements) - The establishment failed to ensure residency requirements for one resident (R1) who exhibited inappropriate sexual behavior of self-exposure.
A6000 (295.6000 Resident Rights) - The establishment failed to ensure residents are free from verbal abuse, evidenced by one resident (R3) being yelled at by an employee (E4).
A6010 (295.6010 Abuse, Neglect, and Financial Exploitation Prevention and Reporting) - The establishment failed to report alleged sexual/mental abuse incidents involving one resident (R1) to the Department within 24 hours.
Report Facts
Residents reviewed: 3 Residents in facility: 86

Inspection Report — Aug 19, 2025

Annual Inspection
Date: Aug 19, 2025

Visit Reason
Annual Licensure Survey conducted including review of residency requirements, service plans, Alzheimer's and dementia program training, and a facility reported incident (FRI IL196705) on 7/17/25.

Complaint Details
Facility Reported Incident IL196705/FRI 7/17/25: Section 295.6000 a) 1) 13) cited.
Findings
The survey found deficiencies in residency requirements, service plan completeness, dementia-specific staff training, and resident rights related to abuse prevention. The facility failed to ensure one resident met residency requirements, did not revise service plans adequately for fall incidents, lacked required dementia training for new staff, and failed to prevent physical abuse of a resident.

Deficiencies (4)
A2000 (295.2000 Residency Requirements) - The establishment failed to ensure prior to admission that one resident met all residency requirements, including appropriate service and staffing for total assistance needs.
A4010 (295.4010 Service Plan) - The establishment failed to revise service plans to address unwitnessed falls, physical therapy services, and coordination of care for one resident.
A4060 (295.4060 Alzheimer's and Dementia Programs) - The establishment failed to ensure six newly hired direct care and one non-direct care employees completed required dementia-specific orientation and on-the-job training within required timeframes.
A6000 (295.6000 Resident Rights) - The establishment failed to prevent physical abuse of one resident during incontinence care, resulting in the termination of the caregiver involved.
Report Facts
Residents reviewed: 5 Residents reviewed: 3 Newly hired employees: 8 Direct care employees: 6 Direct care employees: 5

Inspection Report — Aug 26, 2024

Plan of Correction
Date: Aug 26, 2024

Visit Reason
This plan of correction answers the Follow-up to Annual Survey conducted on 08/08/2024.

Findings
The facility committed to in-service all current staff on the Eden Fire Policy and Procedure, orient new hires on fire safety and incident reporting policies, conduct monthly training and monitoring, assign leadership for Quality Improvement Program, and ensure dementia training for direct care employees. Additional corrective actions include coaching on documentation of isolation for COVID-positive residents and proper storage of hazardous materials.

Report Facts
Employees affected: 4 Employees affected: 3

Employees mentioned
NameTitleContext
Executive Director who signed the plan and was instructor for trainings
Instructor for Resident Records training
Instructor for Storage of Hazardous Material training

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