Inspection Report Summary
The most recent inspection on August 25, 2025, identified deficiencies related to staff conduct, failure to follow service plans, and delayed reporting of an abuse allegation. Earlier inspections also cited issues with abuse, failure to conduct timely background checks, and incomplete service plans, including problems with wound care and resident safety measures. Complaint investigations substantiated multiple abuse allegations and failures to uphold resident rights, with involved staff suspended or terminated, but no fines or license actions were listed in the available reports. Prior corrective action plans addressed these issues through staff education, audits, and monitoring compliance. The facility’s inspection history shows recurring concerns primarily around abuse prevention, staff conduct, and service plan compliance, with ongoing efforts to correct these deficiencies.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
143% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 4
Aug 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of abuse and failure to uphold personnel standards at American House Oak Park.
Findings
The facility failed to ensure staff upheld standards of conduct, resulting in verbal and physical altercations between staff and residents, including an incident of abuse involving resident R1. The facility also failed to follow service plans for residents and did not report the abuse allegation to the state agency within the required timeframe.
Complaint Details
The complaint investigation involved allegations of physical and verbal abuse by staff member E6 towards resident R1 during incontinence care on 8/19/25. The incident included physical altercations and verbal insults. Staff E5 reported the incident but the facility failed to notify the state agency within 24 hours as required. Resident R1 was sent to the hospital with no trauma found. Staff involved were suspended. The investigation found failure to uphold standards of conduct and failure to follow service plans.
Deficiencies (4)
| Description |
|---|
| Failure to ensure employees uphold their Standards of Conduct affecting one resident (R2). |
| Failure to follow service plan intervention for one resident (R1) resistive to care, resulting in combative behavior towards staff. |
| Failure to ensure a resident was free from abuse and follow Abuse Policy and procedure, affecting one resident (R1). |
| Failure to notify the Department within 24 hours of an allegation of abuse affecting one resident (R1). |
Report Facts
Incident time: 1
Resident age: 59
Resident age: 95
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E5 | Resident Assistant | Named in abuse and conduct incident involving resident R1 and R2. |
| E6 | Certified Nursing Assistant | Named as alleged perpetrator of abuse towards resident R1 and involved in conduct issues with resident R2. |
| E3 | Memory Care Director | Provided statements regarding resident R1's condition and staff conduct. |
| E7 | Certified Nursing Assistant | Witnessed and reported staff altercation involving resident R1. |
| Z1 | Agency Nurse | Called to assist with resident R2 and involved in incident report. |
| E4 | Business Office Manager | Reported suspension of staff E5 and E6 due to argument in front of residents. |
| E2 | Wellness Director | Reported that abuse allegation was not timely reported to state agency. |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
Jun 29, 2025
Visit Reason
Complaint investigation triggered by allegations of physical abuse and failure to conduct background checks prior to employee start dates.
Findings
The facility failed to conduct required background checks prior to employee start dates for three employees, potentially affecting all 56 residents. Additionally, the facility failed to keep two residents free from physical abuse, resulting in one resident sustaining a black eye and another a skin tear. The facility also failed to timely report the abuse and did not remove involved staff from resident care promptly.
Complaint Details
Complaint investigation related to physical abuse allegations involving resident R1 who sustained a black eye and resident R4 who sustained a skin tear. The investigation included multiple staff interviews and review of incident reports. The abuse was substantiated, and involved staff were suspended or terminated. The facility failed to report the abuse within 24 hours as required.
Deficiencies (3)
| Description |
|---|
| Failed to conduct health care worker background checks prior to employee start dates for three employees. |
| Failed to keep two residents free from physical abuse, resulting in one resident with a black eye and another with a skin tear. |
| Failed to timely report abuse to the Illinois Department of Public Health and failed to remove alleged perpetrator from resident care promptly. |
Report Facts
Residents affected: 56
Employees with background check failures: 3
Date of incident: Jun 13, 2025
Date of report to IDPH: Jun 16, 2025
Date of skin tear incident: Jun 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E7 | Certified Nursing Assistant | Failed background check prior to start date; reported physical abuse incident involving resident R1. |
| E14 | Certified Nursing Assistant | Failed background check prior to start date; involved in incident with resident R4 resulting in skin tear. |
| E15 | Certified Nursing Assistant | Failed background check prior to start date; involved in physical altercation with resident R1 resulting in resident injury; terminated following investigation. |
| E6 | Business Office Manager/HR Director | Provided statements regarding background check policy and failures. |
| E1 | Senior Executive Director | Provided statements regarding background check policy and abuse investigation. |
| E21 | Memory Care Director | Managed investigation of abuse incidents and staff suspensions. |
| E2 | Clinical Specialist, LPN | Involved in abuse investigation and staff in-service. |
| E10 | Licensed Practical Nurse | Observed resident R1 post-injury and reported findings. |
| E22 | Agency LPN | Provided care to resident R1 during night shift; documented observations of injury. |
| E14 | Certified Nursing Assistant | Involved in incident with resident R4 resulting in skin tear; did not report incident appropriately. |
Inspection Report
Plan of Correction
Deficiencies: 2
Jun 29, 2025
Visit Reason
This document is a Corrective Action Plan submitted in response to a citation dated June 29, 2025, for American House Oak Park.
Findings
The document outlines specific corrective actions taken to address citations related to Healthcare Worker Background Checks and Resident Rights, including audits, education, monitoring compliance, and termination of staff involved in violations.
Deficiencies (2)
| Description |
|---|
| Failure to ensure presence of Healthcare Worker Background Checks in employee files. |
| Violations of Resident Rights and Abuse and Neglect policies. |
Report Facts
Citation numbers: Citation# 295.3040 / 295.6000 / 295.6010
Termination pay out hours: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul P. Zappoli | Executive Director | Named as responsible person and signer of the Plan of Correction |
| Nataly Moreno | Business Office Manager | Responsible for auditing employee files for Healthcare Worker Background Checks and received re-education |
| Mary Joyce Flores | Wellness Director | Responsible for skin assessments and education on Resident Rights and Abuse and Neglect Policy |
| Stacey Williams | Resident Assistant | Termination form and worker's compensation refusal form related to injury and termination |
| Brianna King | Resident Assistant | Termination form indicating termination due to no show or quitting after day 1 |
Inspection Report
Plan of Correction
Deficiencies: 2
Feb 6, 2025
Visit Reason
This document is a Plan of Correction submitted in response to a citation dated February 6, 2025, regarding failure to ensure residency requirements and service plan compliance for one resident who developed pressure ulcers.
Findings
The facility failed to ensure residency requirements were met for one resident who developed stage III and stage II pressure ulcers that progressed to stage VI, and failed to include outside wound care services in the resident's service plan. Corrective actions and monitoring plans were outlined to address these issues.
Deficiencies (2)
| Description |
|---|
| Failed to ensure residency requirement was followed for one resident who developed stage III pressure ulcer and stage II pressure ulcer progressed to stage VI. |
| Failed to ensure that outside services and intervention for wound care were included in the service plan for one resident. |
Report Facts
Citation number: 184173
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul P. Zappoli | Executive Director | Named as responsible person for corrective actions and signer of the Plan of Correction |
| Katrina Aleck | RWD | Instructor for in-service training on residency requirements and wound care |
| Oseloka Okonkwo | Team member involved in in-service training |
Inspection Report
Complaint Investigation
Deficiencies: 2
Feb 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation survey (IL184173/2590248) to determine compliance with residency requirements and service plan regulations following concerns about a resident with progressing pressure ulcers.
Findings
The facility failed to comply with residency requirements by allowing a resident with stage III and progressing pressure ulcers to remain without appropriate services or higher level of care. Additionally, the service plan did not include necessary wound care interventions or outside services despite the resident's documented wounds and physician orders.
Complaint Details
The complaint investigation was substantiated. The resident (R1) developed multiple pressure ulcers progressing in severity, and the facility failed to provide appropriate care or transfer to a higher level of care as required.
Severity Breakdown
Type 2 Violation: 1
Type 3 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residency requirements were met for a resident with stage III and progressing pressure ulcers. | Type 2 Violation |
| Failure to include outside wound care services and interventions in the resident's service plan. | Type 3 Violation |
Report Facts
Resident age: 93
Pressure ulcer stages: 4
Antibiotic dosage: 450
Dates of wound onset: Pressure ulcers onset dates: 1/17/2024, 1/30/2024, 2/3/2024, 2/15/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Noted resident was moved out due to need for higher level of care and acknowledged missing home health services in service plan | |
| Regional Nurse | Reviewed resident notes and confirmed wounds and need for higher level of care | |
| Director of Nursing | Notified and changed wound dressing upon noticing wound size change | |
| Nurse Practitioner | Notified of skin tear and issued wound care orders |
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 15, 2025
Visit Reason
This document is a Plan of Correction submitted in response to a citation dated January 15, 2025, for American House Oak Park.
Findings
The facility failed to address an issue where a resident service plan did not properly account for the resident hiding or misplacing the call pendant. The Plan of Correction outlines auditing current service plans, updating plans for residents missing interventions, re-educating staff, and monitoring compliance over the next twelve weeks.
Deficiencies (1)
| Description |
|---|
| Failed to address one of three sampled residents' service plans where the resident hides or misplaces the call pendant. |
Report Facts
Citation number: 183477
Dates for achieving compliance: 02/28/2025, 03/07/2025, 02/16/2025, 05/23/2025 and ongoing
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul P. Zappoli | Executive Director | Signed letter and named as responsible person for re-education and monitoring compliance |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 13, 2025
Visit Reason
The inspection was conducted as an original investigation of Complaint 2590011 / IL 183477 regarding the facility's failure to address a resident's ongoing issue with hiding or misplacing a call pendent.
Findings
The facility failed to address in the service plan of one sampled resident (R1) the ongoing problem of the resident hiding or misplacing the call pendent. Interviews with the resident's daughter and facility staff confirmed the issue has persisted for several months, but the service plan dated 7/23/24 did not include any interventions to address this problem.
Complaint Details
Original investigation of Complaint 2590011 / IL 183477. The complaint concerned the facility's failure to address a resident's call pendent issue in the service plan. The complaint was substantiated based on record review and interviews.
Severity Breakdown
Type 3 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to address in the service plan the ongoing problem of a resident hiding or misplacing the call pendent. | Type 3 Violation |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Confirmed ongoing problem with resident's call pendent and lack of service plan interventions. |
| E2 | Memory Care Director | Confirmed ongoing issue with resident's call pendent and explained it as part of dementia disease process. |
| Z1 | Resident's daughter who reported the call pendent issue. |
Inspection Report
Plan of Correction
Deficiencies: 2
Dec 12, 2024
Visit Reason
This document is a Corrective Action Plan submitted in response to a citation dated December 12, 2024, for American House Oak Park.
Findings
The plan outlines corrective actions to address deficiencies related to initial health evaluations for direct care and food service employees, and signed service plans for residents. It includes auditing current employee files and resident service plans, re-education of staff, and ongoing monitoring to ensure compliance.
Deficiencies (2)
| Description |
|---|
| Missing initial health evaluation and tuberculosis (TB) testing for employees. |
| Residents' service plans missing required signatures. |
Report Facts
Citation number: 2953030
Citation number: 2954010
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Paul P. Zappoli | Executive Director | Signed the plan of correction and responsible for some corrective actions |
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