The most recent inspection on October 8, 2025, identified deficiencies related to failure to protect residents from sexual abuse by another resident and failure to timely report the abuse to the Illinois Department of Public Health. Earlier inspections showed a pattern of deficiencies involving staffing shortages, service plan accuracy, disaster preparedness, and communicable disease policies, including substantiated complaints about inadequate COVID-19 testing and reporting. Prior reports also noted issues with resident care, such as insufficient assistance with feeding, incomplete wound care interventions, and inadequate dementia program staffing and training. Complaint investigations included substantiated findings for short staffing and COVID-19 protocol failures, while most other complaints were either unsubstantiated or resolved with acceptable plans of correction. The facility’s inspection history reflects ongoing challenges with staffing and resident protection, with recent findings continuing some earlier themes.
Deficiencies (last 1 years)
Deficiencies (over 1 years)22 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
529% worse than Illinois average
Illinois average: 3.5 deficiencies/year
Deficiencies per year
86420
2025
Census
Latest occupancy rate37 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
The inspection was conducted to determine compliance with the Assisted Living and Shared Housing Establishment Code following a complaint investigation and a facility reported incident.
Findings
Findings and violations were identified during the inspection, requiring an acceptable Statement of Correction (SOC), which has since been received by the Department.
Complaint Details
The visit was complaint-related, and an acceptable Statement of Correction was required and received. No substantiation status is explicitly stated.
Employees Mentioned
Name
Title
Context
Sheila A. Driver
Deputy Director
Signed the letter documenting receipt of the acceptable Statement of Correction.
The inspection was conducted as a complaint investigation related to allegations of sexual abuse by one resident against others and failure to report the abuse timely to the Illinois Department of Public Health.
Findings
The facility failed to protect residents' rights to be free from sexual abuse by another resident, resulting in two residents being sexually abused. Additionally, the facility failed to notify the Illinois Department of Public Health within 24 hours of the abuse allegation, reporting it three days late.
Complaint Details
Complaint Investigation 2599365/ IL197759 was unsubstantiated. Facility Reported Incident 9/28/25 IL197851 involved failure to protect residents from sexual abuse and failure to timely report the abuse to the Department.
Severity Breakdown
Type 1 Violation: 1Type 3 Violation: 1
Deficiencies (2)
Description
Severity
Failure to protect residents' rights to be free from sexual abuse by another resident.
Type 1 Violation
Failure to notify the Department within 24 hours of an allegation of abuse.
Type 3 Violation
Report Facts
Residents reviewed for abuse: 3Days late reporting incident: 3
Employees Mentioned
Name
Title
Context
Licensed Practical Nurse
E9 observed and reported the sexual abuse incidents
Director of Nursing
E2 confirmed the incidents and acknowledged late reporting to IDPH
The inspection was conducted as a complaint investigation related to a facility-reported incident concerning communicable disease policies and COVID-19 outbreak management.
Findings
The facility failed to follow COVID-19 guidelines for testing residents and reporting positive cases to the local health department, involving all 16 residents reviewed who tested positive. The facility did not conduct required testing after the last positive cases on 8/5/25 and failed to report all positive cases to the health department.
Complaint Details
Complaint Investigation 2597147/IL196764 related to failure to follow COVID-19 testing and reporting guidelines. The complaint was substantiated by findings of inadequate testing and incomplete reporting of COVID-19 positive residents.
Severity Breakdown
Type 2 Violation: 1
Deficiencies (1)
Description
Severity
Failure to meet Section 295.4040 Communicable Disease Policies, including inadequate COVID-19 testing and reporting to local health department.
Type 2 Violation
Report Facts
Residents tested positive for COVID-19: 16Facility census: 37Residents tested positive on 8/2/25: 11Residents tested positive on 8/4/25: 2Residents tested positive on 8/5/25: 3
Employees Mentioned
Name
Title
Context
Staff Developmental Director
Mentioned as managing the COVID outbreak.
Former Clinical Staff Director
Mentioned as managing the COVID outbreak.
Licensed Practical Nurse
Provided information about COVID outbreak and testing.
Clinical Service Director
Provided information about COVID testing protocols and outbreak management.
The inspection was conducted as a complaint investigation for the facility Emerald Place.
Findings
The Emerald Place was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Complaint Details
Complaint Investigation 2595052/IL193793 concluded with the facility in compliance.
Annual Licensure Survey conducted to assess compliance with state regulations for Emerald Place, a regulated care facility.
Findings
The inspection identified multiple deficiencies including failure to meet residency requirements for a resident needing two-person assistance, inadequate disaster preparedness drills, lack of CPR certification for staff, incomplete healthcare worker background checks, insufficient service plan updates after resident falls and wounds, and inadequate Alzheimer's and dementia program staffing and training. Staffing shortages were frequently reported, impacting resident supervision and care.
Severity Breakdown
Type 3 Violation (REPEAT): 1Type 2 Violation: 2General Violation: 1
Deficiencies (6)
Description
Severity
Failed to meet residency requirements for a resident requiring two-person assistance with activities of daily living and emergency evacuation.
Type 3 Violation (REPEAT)
Failed to conduct tornado drills on all shifts and document resident participation and staff involvement in drills.
Type 2 Violation
Failed to ensure CPR certification documentation for all direct care staff and have at least one CPR certified staff on duty during night shift.
—
Failed to conduct and document healthcare worker background checks and employment verification for multiple staff.
Type 2 Violation
Failed to revise service plans to include individualized fall interventions after falls with major injury and wound care interventions for residents.
—
Failed to ensure staff complete required dementia-specific training and maintain documentation; failed to provide sufficient staffing to meet needs of residents with cognitive impairments.
General Violation
Report Facts
Residents requiring mechanical lifts: 11Memory care residents: 31Residents on Hospice care: 10Falls for resident R2: 2Fall risk assessment score for R2: 19Fall risk assessment score for R3: 22Length of wound on R4: 3Staff training hours required: 12Staff training hours required: 16
The inspection was an annual survey conducted to assess compliance with residency requirements, disaster preparedness, personnel qualifications, background checks, service plans, and dementia program requirements.
Findings
The facility identified deficiencies related to residency requirements, disaster preparedness drills, personnel CPR certification tracking, healthcare worker background checks, service plan reviews, and dementia education programs. Plans of correction with completion dates were provided for each deficiency.
Deficiencies (6)
Description
Residency requirements, qualifications, and training
Disaster preparedness including tornado and fire drills
Personnel requirements, qualifications, and training including CPR card collection
Health care worker background check verification
Service plans review for accuracy and proper interventions
Alzheimer’s and dementia program education and staffing levels
Report Facts
Completion Date: Jun 30, 2025Completion Date: Jul 30, 2025Completion Date: Jun 30, 2025Completion Date: Jun 5, 2025Completion Date: Jul 30, 2025Completion Date: Aug 31, 2025
The inspection was conducted as a complaint investigation related to substantiated short staffing violations involving residents R1 and R5.
Findings
The investigation substantiated a violation at regulation 295.3000 a) for short staffing based on review of residents R1 and R5.
Complaint Details
The complaint investigation was substantiated for short staffing involving residents R1 and R5, with an exit date of 2025-02-03 and correction date of 2025-02-28.
The inspection was conducted as a complaint survey based on deficiencies cited under IL180059/2498878 and IL183314/24910549, focusing on staffing adequacy and service plan compliance.
Findings
The facility failed to provide adequate staffing to meet residents' needs, particularly for nursing services and feeding assistance, affecting multiple residents. Additionally, the service plan for one resident at risk for wounds was incomplete, lacking individualized interventions to promote wound healing and prevent skin breakdown. Residents requiring physical assistance with meals were not fed in a timely or dignified manner.
Complaint Details
The visit was complaint-related with deficiencies cited under IL180059/2498878 and IL183314/24910549. Staffing shortages and inadequate feeding assistance were key issues. The facility staff and management provided conflicting statements about staffing adequacy.
Severity Breakdown
Type 2 Violation: 3
Deficiencies (3)
Description
Severity
Failed to provide adequate number of staff to meet the needs of residents, affecting five residents reviewed for Nursing Services.
Type 2 Violation
Failed to ensure service plan interventions to promote wound healing and prevent skin breakdown for one resident at risk for developing wounds.
Type 2 Violation
Failed to provide adequate number of staff to feed residents in a dignified and timely manner for six residents needing physical assistance with meals.
The inspection was conducted as a complaint investigation under survey numbers #183314 and #180059.
Findings
The facility identified deficiencies related to staffing adequacy, accuracy and intervention in service plans, and resident rights concerning dining assistance. Plans of correction include hiring additional staff, reviewing and educating on service plans, and offering extended dining hours to accommodate residents needing physical assistance.
Complaint Details
Complaint investigation conducted under survey numbers #183314 and #180059.
Deficiencies (3)
Description
Personal Requirements, Qualifications and Training - staffing adequacy and recruitment
Service Plans - ensuring accuracy and proper interventions to promote wound healing and prevent skin breakdown
Resident Rights - offering extended dining hours to accommodate residents needing physical assistance
Report Facts
Completion Date: Feb 28, 2025Completion Date: Mar 31, 2025
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