Inspection Report
Annual Inspection
Deficiencies: 2
Sep 12, 2025
Visit Reason
The inspection was conducted as an annual licensure survey combined with complaint investigations to assess compliance with regulatory requirements.
Findings
The survey identified a technical infraction related to four new staff members not receiving fire extinguisher training, which was corrected onsite. The facility also failed to provide requested reportable accident/incident reports causing delays, and there was a lack of timely response from facility administration during entrance, resulting in a cited violation.
Complaint Details
Complaint investigations with case numbers 2586277/IL196240 and 2591317/IL196249 were unsubstantiated.
Severity Breakdown
Technical Infraction: 1
General Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Four new staff members did not receive fire extinguisher training. | Technical Infraction |
| Facility entrance was delayed due to absence of administration and failure to provide reportable incidents as requested. | General Violation |
Report Facts
Number of new staff without fire extinguisher training: 4
Dates of survey visits: Initial visit on 2025-08-22 and resumed visit on 2025-09-05
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Interim Health and Wellness Coordinator/Licensed Practical Nurse | Named in relation to delays and lack of timely response during entrance |
| E12 | Associate Executive Director | Named in relation to delays and failure to provide reportable incidents |
| E13 | Receptionist | Named in relation to initial entrance delays |
Loading inspection reports...
