Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Deficiencies: 0
Date: Aug 7, 2025
Visit Reason
The document is a statement of deficiencies and plan of correction for Dobson Plaza, representing a regulatory inspection visit completed on 08/07/2025.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jun 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of abuse involving resident R70 at the facility.
Complaint Details
The complaint involved an allegation that staff member V12 wrenched resident R70's arm. The investigation revealed failure to report the abuse allegation timely, delayed investigation, and lack of abuse care plan. Resident R70 had bruising and reported pain. Staff interviews and records showed inconsistent reporting and investigation delays. V12 was suspended pending investigation.
Findings
The facility failed to timely report suspected abuse, initiate a timely investigation, and develop a comprehensive person-centered care plan for abuse for resident R70. Additionally, the facility failed to properly label and store food items in the kitchen, risking contamination for all 77 residents.
Deficiencies (4)
F 0609: Facility staff failed to report an allegation of abuse to the State Survey Agency within 24 hours of being made aware of a potential abuse allegation from resident R70.
F 0610: Facility failed to initiate an investigation in a timely manner for an allegation of abuse for resident R70.
F 0656: Facility failed to develop and implement a comprehensive person-centered care plan for abuse for resident R70.
F 0812: Facility failed to properly label and store food, including expired and unlabeled items, risking contamination for all 77 residents.
Report Facts
Residents in sample: 35
Residents affected by food storage deficiency: 77
Use by date: May 17, 2024
Use by date: May 15, 2024
Use by date: Feb 20, 2024
Use by date: Mar 12, 2024
Freezer temperature range: 4-17
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physical Therapy Manager | V11 documented resident's report of arm being wrenched and reported to nurse | |
| Certified Nursing Assistant | V7 reported observing bruise on resident R70's arm | |
| Regional Director | V3 involved in ongoing investigation and received reports | |
| Abuse Coordinator | V2 described abuse investigation procedures and reporting requirements | |
| Dietary Manager | V17 described food storage and labeling deficiencies | |
| Social Service Consultant | V4 discussed care plan and abuse risk assessment practices | |
| Clerical Supervisor and Schedule Coordinator | V13 confirmed absence of abuse care plans or risk assessments for resident R70 |
Inspection Report
Routine
Deficiencies: 6
Date: Aug 4, 2023
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident dignity, restraint use, pressure ulcer care, nurse staffing posting, pharmaceutical services, and infection control.
Findings
The facility was found deficient in multiple areas including failure to provide dignity during feeding, improper use of physical restraints, incorrect use of pressure-relieving mattresses, failure to post nurse staffing data, inadequate controlled substance storage and documentation, and failure to follow infection control hand hygiene policies.
Deficiencies (6)
F 0550: The facility failed to provide dignity during meal time by standing over a resident while feeding. This affected 1 resident in a sample of 21.
F 0604: The facility failed to ensure 2 residents were free from physical restraints, as they were seated in chairs restricting movement without medical orders.
F 0686: The facility failed to correctly use pressure relieving mattresses for 3 of 4 residents at risk for skin alteration by placing multiple layers of linen between the resident and mattress.
F 0732: The facility failed to post complete nurse staffing data in a prominent place accessible to residents and visitors, affecting all 81 residents.
F 0755: The facility failed to follow controlled substance policy by not storing controlled drugs in a locked refrigerator and failing to accurately document controlled drug counts and receipts, affecting 5 residents.
F 0880: The facility failed to follow standard precaution policy when a staff member did not perform hand hygiene after picking up a resident's fruit cup from the floor.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 81
Residents affected: 5
Residents observed: 12
Sample size: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 | Director of Nursing | Named in dignity during feeding, physical restraint, pressure ulcer care, and pharmaceutical services findings |
| V21 | Activity Aide | Named in dignity during feeding finding |
| V5 | Certified Nursing Assistant | Named in physical restraint finding |
| V22 | Regional Director | Named in physical restraint and nurse staffing posting findings |
| V6 | Registered Nurse | Named in physical restraint finding |
| V14 | Registered Nurse | Named in pharmaceutical services deficiency |
| V7 | Registered Nurse | Named in pharmaceutical services deficiency |
| V9 | Activity Aid | Named in infection control deficiency |
| V8 | Food Service Supervisor | Named in infection control deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 2, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to complete a thorough investigation of an injury of unknown origin for one resident (R2) and failure to follow professional standards of care after a resident (R6) experienced a fall resulting in injury.
Complaint Details
The complaint investigation focused on two residents: R2, who sustained bruises and a right femoral fracture after improper repositioning and incomplete injury investigation, and R6, who sustained a right femur fracture after a fall and inadequate immobilization and supervision. The investigation included interviews with nursing and CNA staff, review of medical records, incident reports, and facility policies.
Findings
The facility failed to complete a thorough investigation of an injury of unknown origin for resident R2 and failed to follow professional standards of care by not immobilizing the suspected injury area after resident R6's fall, resulting in a right femur fracture requiring surgery. Additionally, the facility failed to provide adequate fall prevention and supervision for R6 and failed to properly assist R2 during repositioning, causing bruises and injury.
Deficiencies (3)
F 0610: Facility failed to complete a thorough investigation of injury of unknown origin for resident R2, including incomplete staff interviews and inconsistent statements.
F 0658: Facility failed to follow professional standards by not immobilizing the suspected injury area after resident R6's fall and allowing weight bearing activity, resulting in a right femur fracture.
F 0689: Facility failed to implement effective fall prevention and supervision for resident R6, resulting in a fall with injury and subsequent surgery, and failed to properly assist resident R2 during repositioning, causing bruises and injury.
Report Facts
Date of survey completion: May 2, 2023
Fall risk assessment date: Mar 3, 2023
Fall incident date: Mar 27, 2023
Incident date: Mar 31, 2023
Date of hospital transfer: Apr 1, 2023
Date of policy: Jun 1, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Named in investigation and interviews related to injury investigation and repositioning procedures |
| V6 | Registered Nurse | Involved in care and assessment of resident R2 during injury incident |
| V7 | Certified Nurse Assistant | Assisted in repositioning resident R2 and involved in injury incident |
| V14 | Registered Nurse | Provided nursing care and documented fall incident for resident R6 |
| V17 | Registered Nurse | Provided nursing care and documented fall incident for resident R6 |
| V19 | Nurse Practitioner | Interviewed regarding fall and care of resident R6 |
| V4 | Certified Nursing Assistant | Provided care and observations related to resident R6 and R2 |
| V16 | Regional Director | Provided statements on expectations for injury investigations and repositioning procedures |
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