Inspection Reports for Charter Senior Living of Shiloh
1201 Hartman Ln, Belleville, IL 62221, United States, IL, 62221
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Inspection Report
Annual Inspection
Census: 41
Deficiencies: 5
Sep 17, 2025
Visit Reason
The inspection was conducted as part of the annual licensure survey to assess compliance with state regulations and facility policies.
Findings
The facility was found deficient in multiple areas including disaster preparedness drills, quality improvement program implementation, personnel CPR certification, physician assessments prior to admission, and resident rights related to medication misappropriation.
Severity Breakdown
Type 2: 3
Type 3: 2
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure tornado drills were completed on all shifts in February, conduct bi-monthly fire drills, and orient resident R2 to emergency and evacuation plans within 10 days of admission. | Type 2 |
| Failure to establish and implement an effective quality improvement program including resident and family feedback and quarterly reviews. | Type 3 |
| Failure to ensure at least one staff member on duty at all times had current CPR certification. | Type 2 |
| Failure to ensure resident R4's physician assessment was completed by a physician prior to admission. | Type 3 |
| Failure to ensure residents were free from misappropriation of narcotic medications, evidenced by diversion of oxycodone by staff member E7. | Type 2 |
Report Facts
Residents present: 41
Narcotic medication diversion incidents: 3
Dates staff without CPR certification worked night shift: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E4 | Environmental Service Director | Stated no tornado drills were completed in February 2025 and no fire drills between 9/20/2024 and 4/14/2025 |
| E2 | Health and Wellness Director | Provided census information and confirmed late resident orientation and physician assessment timing |
| E8 | Operations Specialist | Confirmed lack of quality improvement activities since January 2023 |
| E6 | Business Office Manager | Confirmed E10 and E11 were new staff without CPR certification working night shifts |
| E9 | Advanced Practice Registered Nurse | Signed resident R4's Physician's Plan of Care |
| E12 | Corporate Nurse | Interviewed resident R4 and discovered narcotic diversion |
| E7 | Caregiver | Terminated for narcotic medication diversion |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 28, 2025
Visit Reason
The visit was conducted as a complaint investigation (#2540682/IL185196) 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
The facility, Charter Senior Living of Shiloh, was found to be in compliance with the relevant assisted living regulations and administrative codes during this complaint investigation.
Complaint Details
Complaint Investigation #2540682/IL185196; the facility was found to be in compliance with applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 27, 2025
Visit Reason
The survey was conducted following a facility reported incident on 2025-01-11 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
The facility was found to be in compliance with the applicable assisted living regulations and administrative codes at the time of the survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation (#2449323/IL180921) related to medication reminders, supervision of self-medication, medication administration, and storage.
Findings
The establishment failed to ensure residents received their medication as prescribed without error, resulting in a medication mix-up where one resident received another resident's medications due to similar names and storage issues. The incident was confirmed by staff and the resident involved.
Complaint Details
Complaint Investigation #2449323/IL180921. The complaint was substantiated as the facility failed to prevent a medication error where Resident R2 received Resident R3's medications due to similar names and medication storage issues.
Severity Breakdown
R2: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents received their medication as prescribed without error, including medication mix-up due to similar resident names and storage practices. | R2 |
Report Facts
Incident time: 727
Incident report time: 733
Nurse Practitioner call return time: 738
Medication doses: 3
Policy revision date: 1021
Resident service plan date: 52824
Incident confirmation date and time: 1119241000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | LPN | Stated details about medication storage and error on 11/19/2024 |
| E3 | Resident Assistant | Accidentally picked up wrong medication planner on 10/13/24 |
| NP | Nurse Practitioner | Returned call and assessed medication error impact on resident |
Inspection Report
Plan of Correction
Deficiencies: 1
Nov 19, 2024
Visit Reason
The document is a Plan of Correction submitted in response to a medication administration error involving resident Carolyn Dow at Charter Senior Living, following an internal incident report and subsequent investigation.
Findings
The report details a medication error where a resident received another resident's medications due to similar naming and locked medication storage issues. The facility implemented corrective actions including retraining staff, posting the six rights of medication administration, adding locked medication boxes, and conducting resident assessments with no adverse findings.
Deficiencies (1)
| Description |
|---|
| Medication error involving administration of another resident's medications due to similar naming and storage issues. |
Report Facts
Medication error incident report notation timeframe: 3
Resident age: 94
Medication reorder date: Oct 13, 2024
Medication administration retraining date: Oct 17, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Denita Wilkins | MSN, FNP-BC | Nurse Practitioner who assessed resident with no findings or new orders |
| Amanda Gillespie | NP, Regional Director of Clinical Operations | Nurse who communicated with care staff and resident's PCP regarding medication error |
| Margaret Hite | Health and Wellness Director (HWD) | Named in medication error investigation and retraining of caregiver |
| Crystin Wilborn | RA | Interviewed in internal investigation statement regarding medication error |
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