Inspection Reports for Ciel at Plainfield
12446 S Van Dyke Rd, Plainfield, IL 60585, United States, IL, 60585
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Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 19, 2025
Visit Reason
The inspection was conducted following facility-reported incidents involving medication administration and resident rights violations, specifically concerning medication supervision and resident safety.
Findings
The facility failed to have a policy for reordering medications supplied by residents' families, resulting in one resident missing a critical prostate cancer medication for over three months. Additionally, the facility neglected to provide adequate supervision for a high fall-risk resident, leading to a fall and injury. The caregiver involved was terminated for neglect and falsifying documentation.
Complaint Details
The investigation was triggered by facility-reported incidents involving medication administration errors and resident neglect. The medication error was substantiated with evidence of 101 missed doses over three months. The neglect incident was substantiated by video evidence and witness statements, leading to termination of the caregiver.
Severity Breakdown
Type 1 Violation: 1
Type 2 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to have a policy and procedure for reordering medications supplied by residents' families, resulting in a resident missing prescribed medication for over three months. | Type 1 Violation |
| Neglect to provide adequate supervision for a high fall-risk resident, resulting in a fall causing a laceration. | Type 2 Violation |
Report Facts
Missed medication doses: 101
Medication supply duration: 90
Incident date: Sep 26, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Provided statements regarding lack of medication reorder procedure and caregiver neglect investigation. |
| E4 | Caregiver who left resident unsupervised leading to fall and was terminated for neglect and falsifying documentation. | |
| Z3 | Power of Attorney and Daughter of Resident R3 | Provided statements about medication reorder misunderstanding. |
| Z2 | Power of Attorney and Daughter of Resident R2 | Provided statements and reviewed video of fall incident. |
| Z1 | Medical Doctor Hematology / Oncology | Provided expert statement on medication importance and risks of discontinuation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 18, 2025
Visit Reason
The inspection was conducted following a facility-reported incident involving alleged abuse of a resident (R1) by a caregiver (E3), including physical restraint, hitting, and pushing that caused injury to the resident.
Findings
The investigation confirmed that on 7/12/2025, caregiver E3 physically abused resident R1 by restraining, hitting, and pushing him, causing R1 to fall and hit his head. The facility video monitoring system captured the incident. E3 was terminated and arrested. The resident was hospitalized with a closed head injury and bruising. The facility followed policy after the incident was reported.
Complaint Details
The complaint investigation substantiated abuse of resident R1 by caregiver E3. The facility reported the incident, reviewed video evidence, terminated E3, and notified police who arrested E3. Resident R1 sustained injuries including a closed head injury and bruising. The facility was notified on 7/13/25 and followed abuse policies thereafter.
Severity Breakdown
Type 2 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents remain free of abuse, resulting in physical abuse of resident R1 by caregiver E3. | Type 2 Violation |
Report Facts
Incident date: Jul 12, 2025
Video incident time: 10.51
Video incident duration (minutes): 10
Employee shift hours: 8
Date of observation note: Jul 12, 2025
Date of resident hospital transfer: Jul 13, 2025
Date of resident return: Jul 13, 2025
Date of employee file review: Jul 29, 2025
Date of attempted resident interview: Jul 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Caregiver | Named in abuse incident involving resident R1; terminated and arrested |
| E1 | Executive Director | Reviewed video evidence, terminated E3, and provided information on abuse policies |
| E4 | Nurse | Responded to fall alert, assessed resident R1, observed video evidence, and completed incident reporting |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 9, 2024
Visit Reason
The inspection was conducted as an original investigation of Complaint 2476271 / IL 176503 and FRI IL 177424, specifically related to resident rights and care decisions.
Findings
The facility was found to have failed to allow one resident (R1) to direct her own care by preventing her from going to the hospital after a fall, despite her expressed wish to do so. The resident was on hospice care, and staff instructed EMTs to return her to the facility instead of allowing hospital transport.
Complaint Details
Complaint IL 176503 was substantiated with citation for violation of resident rights. FRI IL 177424 had no violations.
Severity Breakdown
TYPE 3 VIOLATION: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to allow a resident to direct her own care and negotiate terms of care, specifically preventing hospital transport despite resident's request. | TYPE 3 VIOLATION |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Stated unawareness of resident's denied hospital transport and affirmed resident's right to direct own care. |
| Z1 | EMT Manager | Reported that resident requested hospital transport and that nurse made EMTs unload resident from ambulance. |
| E3 | LPN | Assessed resident after fall and communicated hospice instructions to EMTs. |
| E4 | Nurse | Made EMTs unload resident from ambulance and return her to the facility. |
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