Inspection Reports for Carriage Crossing Senior Living of Rochester
1121 Community Dr, Rochester, IL 62563, United States, IL, 62563
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 23, 2025, identified deficiencies related to failure to report serious incidents timely, incomplete service plan updates, and inadequate protection of residents’ dignity and privacy. Earlier inspections showed a mix of compliance and issues, including a substantiated complaint in August 2024 involving staff abuse of a resident, which led to staff termination and retraining. The main themes across deficiencies involved incident reporting, resident rights, and care plan documentation. Complaint investigations were mostly unsubstantiated except for the two substantiated cases noted in August 2024 and September 2025. The pattern suggests ongoing challenges with resident protection and reporting, with some corrective actions taken but recurring issues persisting.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 23, 2025
Visit Reason
The inspection was conducted due to an investigation of incidents involving resident-to-resident sexual intimacy and failure to report serious incidents timely to the Illinois Department of Public Health.
Complaint Details
The investigation was complaint-driven, focusing on incidents involving resident-to-resident sexual intimacy and failure to report these incidents timely. The complaint was substantiated with findings of multiple incidents involving residents R2, R3, and R4, and staff failure to report and update care plans accordingly.
Findings
The facility failed to report serious incidents within 24 hours, did not update service plans to reflect residents' special needs and behaviors, and failed to maintain residents' dignity and privacy. Multiple incidents of inappropriate resident-to-resident sexual contact were documented, and staff failed to report these incidents promptly. Service plans lacked documentation of sexual behaviors and interventions. Residents R3 and R4's bodily privacy and dignity were not adequately protected.
Deficiencies (3)
Failure to report serious incidents to the Department within 24 hours after occurrence.
Failure to develop and revise service plans to include residents' special diets, preferences, and sexual behaviors.
Failure to ensure residents' rights to dignity, individuality, privacy, and respect, especially during care and treatment.
Report Facts
Incident date: Sep 17, 2025
Incident date: Sep 6, 2025
Temperature: 170
Incident report delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing | Named in relation to late reporting of incidents and oversight of incident reporting |
| E3 | Resident Care Coordinator | Named in relation to failure to report incidents timely and knowledge of reporting requirements |
| E5 | Dietary Manager | Provided information about coffee temperature served to resident R1 |
| E6 | Resident Care Associate | Provided statement regarding coffee spill incident involving resident R1 |
| E1 | Executive Director | Mentioned regarding pain medication administration to resident R1 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 24, 2025
Visit Reason
Original investigation of Complaints 2542092 / IL 187855 and 2542199 / IL 188047.
Complaint Details
Investigation of complaints 2542092 / IL 187855 and 2542199 / IL 188047; establishment found in compliance.
Findings
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.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 17, 2024
Visit Reason
Annual Licensure Survey to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
No violations were cited. The establishment was found to be in compliance with applicable assisted living regulations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 6, 2024
Visit Reason
The inspection was conducted as an original complaint investigation (complaint number 177272).
Complaint Details
Original complaint 177272 was investigated and found to be unsubstantiated with no violations cited.
Findings
The allegations were not substantiated and no violations were cited. The facility was found to be in compliance with the applicable Illinois Assisted Living regulations.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 15, 2024
Visit Reason
The inspection was conducted as an incident report investigation following a complaint regarding alleged verbal and physical abuse of a resident (R1) by a staff member.
Complaint Details
The complaint was substantiated based on camera footage and incident reports showing the staff member's verbal and physical aggression toward resident R1. The staff member was terminated and the facility conducted retraining.
Findings
The facility failed to ensure that resident R1 was free from abuse by a staff member who was verbally and physically aggressive. The staff member was observed on camera roughly handling R1 and using inappropriate language, leading to immediate termination after investigation. The facility retrained staff on abuse and neglect policies and resident care techniques.
Deficiencies (1)
Failure to ensure resident R1 was free of abuse by a staff member who was verbally and physically aggressive.
Report Facts
Mini Mental Status Exam score: 2
Incident date: Aug 4, 2024
Discipline action date: Aug 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Resident Care Assistant | Staff member terminated for verbal and physical aggression toward resident R1 |
| E2 | Wellness Director | Conducted investigation and retraining related to the incident |
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