Inspection Reports for Ascension Living Bethlehem Woods Village
1571 Ogden Ave, La Grange Park, IL 60526, IL, 60526
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Inspection Report
Annual Inspection
Deficiencies: 3
Oct 14, 2025
Visit Reason
Annual Licensure Survey conducted to assess compliance with state regulations including disaster preparedness, service plans, and Alzheimer's and dementia program requirements.
Findings
The facility failed to orient residents to emergency and evacuation plans within 10 days of move-in, conduct required fire and tornado drills, and properly document these activities. Service plans were not signed timely by all parties and were not revised after significant resident condition changes. Dementia-specific staff training requirements were not met for several newly hired direct care employees.
Severity Breakdown
Type 2 Violation: 2
Type 3 Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to orient residents to emergency and evacuation plans within 10 days, lack of signed documentation, and incomplete fire and tornado drills. | Type 2 Violation |
| Service plans not signed timely by all involved and not revised after significant changes in residents' conditions including falls and injuries. | Type 2 Violation |
| Failure to ensure dementia-specific orientation and on-the-job training for direct care staff prior to assuming job responsibilities. | Type 3 Violation |
Report Facts
Residents reviewed for emergency orientation: 5
Fire drills conducted since last annual survey: 2
Tornado drills required: 3
Residents reviewed for service plan issues: 5
Staples applied to resident's head laceration: 5
Newly hired employees reviewed: 8
Direct care employees lacking dementia orientation: 3
Direct care employees lacking on-the-job training: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Certified Nurse Aide | Did not complete required dementia-specific orientation and on-the-job training |
| E2 | Licensed Practical Nurse | Did not complete required dementia-specific orientation and on-the-job training |
| E3 | Nurse Aide | Did not complete required dementia-specific orientation and on-the-job training |
| E4 | Certified Nurse Aide | Did not complete required on-the-job training |
| E7 | Certified Nurse Aide | Did not complete required on-the-job training |
| E8 | Director of Facilities | Reported missing fire drills and conducted a mock drill |
| E9 | Executive Director | Acknowledged missing fire drills and dementia training issues |
| E10 | Director of Clinical Services | Interviewed regarding resident orientation and service plans |
| E5 | Memory Care Director | Responsible for dementia training; unable to confirm training completion for new hires |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 23, 2025
Visit Reason
The inspection was conducted as a Facility Reported Incident Investigation Survey following a fall incident involving residents at risk for falls.
Findings
The facility failed to implement fall prevention interventions and update service plans annually and after falls for residents R1, R2, and R3. Service plans lacked timely revisions after significant changes in residents' physical and functional conditions, contributing to repeated falls.
Complaint Details
The visit was complaint-related, investigating a fall incident reported on 4/30/25 involving resident R1. The complaint was substantiated as the facility failed to update service plans and implement fall prevention interventions.
Severity Breakdown
Type 2 Violation (Repeat Violation): 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to revise service plans for residents at risk of falls annually and after falls, including lack of interventions for residents R1, R2, and R3. | Type 2 Violation (Repeat Violation) |
Report Facts
Residents with falls reviewed: 3
Fall dates for R2: 7
Plan of Correction Completion Date: Jun 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Clinical Services | Investigated R1's fall and verified lack of updated service plans. |
| E3 | Certified Nursing Assistant | Witnessed circumstances of R1's fall and provided statements about staff assistance. |
| E6 | Caregiver | Failed to assist R1 during fall incident as required by service plan. |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 23, 2025
Visit Reason
The inspection was conducted as a Facility Reported Incident Investigation Survey following a fall incident involving resident R1 on 4/30/2025.
Findings
The facility failed to implement fall prevention interventions and did not update service plans annually or after falls for 3 of 3 residents (R1, R2, and R3) reviewed for falls. Specifically, staff failed to assist R1 properly during ambulation, leading to a fall, and service plans lacked required updates after multiple falls.
Complaint Details
The complaint investigation was substantiated based on interviews and record reviews showing failure to update service plans and implement fall prevention measures after resident falls.
Deficiencies (1)
| Description |
|---|
| Failed to implement fall prevention interventions and update service plans annually and after falls for residents at risk. |
Report Facts
Fall incidents: 7
Date of fall: Apr 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Clinical Services | Investigated R1's fall and confirmed failure to assist and update service plans. |
| E3 | Certified Nursing Assistant | Witnessed the fall incident and confirmed lack of assistance by caregiver E6. |
| E6 | Caregiver | Failed to assist resident R1 during ambulation leading to fall. |
Inspection Report
Annual Inspection
Deficiencies: 3
Oct 30, 2024
Visit Reason
The document is an Annual Licensure Survey conducted to assess compliance with residency requirements, disaster preparedness, communicable disease policies, and other regulatory standards for an assisted living and memory care facility.
Findings
The facility was found non-compliant with several regulations including residency requirements, disaster preparedness, and communicable disease policies. Specific deficiencies included failure to properly transfer or discharge a resident requiring total assistance, inadequate fire safety training for new employees, and failure to investigate and document a skin infestation affecting multiple residents.
Severity Breakdown
Level 2: 2
Level 3: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Residency requirements not met due to failure to transfer or discharge a resident requiring total assistance with activities of daily living and emergency evacuation. | Level 2 |
| Disaster preparedness plan deficiencies including failure to ensure all newly hired employees completed fire extinguisher training. | Level 3 |
| Failure to meet communicable disease policies evidenced by failure to inform the department of a skin infestation involving 4 residents and failure to investigate, track, and document the infestation. | Level 2 |
Report Facts
Residents involved: 7
Newly hired employees reviewed: 8
Residents affected by skin infestation: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Director of Nursing | Named in residency requirement deficiency and fall incident involving Resident #7. |
| E2 | Executive Director | Involved in communication regarding Resident #7's discharge and bed assignment. |
| E10 | Director of Nursing | Made aware of skin infestation and communicable disease reporting issues. |
| E11 | Business Office Manager | Responsible for new employee training documentation and fire extinguisher training. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 30, 2024
Visit Reason
The inspection was conducted as a complaint investigation survey (#173844) which was substantiated, focusing on deficiencies related to the service plan requirements for residents.
Findings
The facility failed to ensure that service plans were properly developed, reviewed, and signed for residents, including failure to revise plans after significant changes, address unwitnessed falls, and include interventions for skin infestations. These failures affected multiple residents and posed risks to all residents in Assisted Living and Memory Care units.
Complaint Details
Complaint Investigation Survey #173844 was substantiated based on findings related to service plan violations.
Severity Breakdown
Level 2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Service plan was not reviewed and revised after significant changes in resident's condition, including behaviors of refusing ADL care and medication, unwitnessed falls, and skin infestation. | Level 2 |
Report Facts
Residents reviewed for fall incidents: 7
Residents involved in service plan development: 3
Residents with revised service plans: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E10 | Director of Nursing | Named in findings related to signing service plans and awareness of resident conditions |
Inspection Report
Annual Inspection
Deficiencies: 3
Aug 23, 2024
Visit Reason
Annual Licensure Survey conducted to assess compliance with residency requirements, disaster preparedness, and communicable disease policies at Ascension Living Bethlehem Woods Village.
Findings
The facility failed to transfer or discharge a resident requiring total assistance with activities of daily living and emergency movement, failed to ensure newly hired employees received fire extinguisher training, and failed to report and properly manage a scabies outbreak involving four residents in the Assisted Living area.
Severity Breakdown
Level 2: 2
Level 3: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to transfer or discharge one resident requiring total assistance with 2 or more ADLs and more than minimal assistance in emergency movement. | Level 2 |
| Failed to ensure 8 out of 8 newly hired employees completed fire extinguisher training as part of disaster preparedness. | Level 3 |
| Failed to inform the Illinois Department of Public Health of a scabies infestation involving 4 residents and failed to investigate, track, and document the infestation. | Level 2 |
Report Facts
Residents reviewed for ADL assistance: 7
Newly hired employees reviewed: 8
Residents involved in scabies infestation: 4
Resident R7 age: 93
Resident R1 age: 93
Resident R3 age: 90
Resident R5 age: 93
Resident R6 age: 85
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Director of Nursing | Named in relation to failure to implement interventions for resident R7's multiple falls and fall with injury. |
| E2 | Executive Director | Provided statements regarding family dynamics and resident R7's care. |
| E10 | Director of Nursing | Interviewed regarding fire extinguisher training and scabies outbreak reporting. |
| E11 | Business Office Manager | Interviewed regarding fire extinguisher training documentation for newly hired employees. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Aug 23, 2024
Visit Reason
Complaint Investigation Survey #173844 was conducted to investigate substantiated complaints regarding service plan deficiencies at Ascension Living Bethlehem Woods Village.
Findings
The facility failed to ensure service plans were reviewed and revised after significant changes in residents' conditions, failed to develop interventions for unwitnessed falls and injuries, and did not include necessary interventions for scabies treatment and isolation precautions. Service plans were also not signed and dated by all involved parties. These deficiencies affected multiple residents and had the potential to impact all residents in Assisted Living and Memory Care units.
Complaint Details
Complaint Investigation Survey #173844 was substantiated based on failures in service plan development, review, and implementation affecting multiple residents.
Severity Breakdown
Level 2: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Service plan was not reviewed and revised after significant changes in resident's physical, cognitive, and functional condition. | Level 2 |
| Service plan lacked interventions to address unwitnessed falls and falls resulting in serious injury for multiple residents. | Level 2 |
| Service plan was not signed and dated by all individuals involved in its development for multiple residents. | Level 2 |
| Service plan did not include interventions to address scabies treatment and isolation precautions. | Level 2 |
| Service plans did not include interventions to address behaviors such as refusing ADL care, alcohol consumption, and inappropriate sexual behavior. | Level 2 |
| Service plans did not include interventions to address pacemaker care, Foley catheter care, and multiple falls with and without injury. | Level 2 |
Report Facts
Residents reviewed for fall incidents: 7
Residents with service plan signature issues: 3
Resident ages: 93
Resident ages: 90
Resident ages: 89
Resident ages: 93
Resident ages: 85
Resident ages: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E10 | Director of Nursing | Named in multiple findings including failure to sign service plans and awareness of resident conditions. |
| Z1 | Mentioned in relation to resident evaluations and concerns about facility admissions. | |
| Z2 | Mentioned in relation to removal of liquor and facility admission decisions. |
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