Inspection Reports for Evergreen Senior Living – Chillicothe

404 S Stillwater Drive, Chillicothe, IL, 61523

Back to Facility Profile

Inspection Report Summary

The most recent inspection on October 8, 2025, identified a deficiency related to the facility’s failure to prevent a resident from eloping the locked Memory Care unit. Earlier inspections, including the May 29, 2025 annual survey, noted multiple deficiencies involving medication administration, documentation inaccuracies in service plans, and employee health screenings. Inspectors cited issues primarily with medication supervision and staff qualifications, as well as incomplete health documentation. The October complaint investigation substantiated the elopement incident but did not list enforcement actions or fines in the available reports. The pattern suggests ongoing challenges with medication management and resident safety, with recent findings indicating some persistent concerns.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 6 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

71% worse than Illinois average
Illinois average: 3.5 deficiencies/year

Deficiencies per year

8 6 4 2 0
2025

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Oct 8, 2025

Visit Reason
The inspection was conducted as an original investigation following a complaint regarding the facility's failure to prevent a resident from eloping from the Memory Care unit.

Complaint Details
The complaint investigation found that resident R1 eloped from the locked Memory Care unit on 10/1/25 without staff knowledge. The resident was found by staff a couple blocks away and was escorted back to the facility. The resident's Power of Attorney expressed upset over the incident due to the resident's confusion and lack of safety awareness.
Findings
The facility neglected to prevent one of three sampled residents (R1) from eloping from the locked Memory Care unit, which posed a substantial probability of causing severe harm. The resident was found a couple of blocks away in a local physician's office parking lot and was not injured.

Deficiencies (1)
Failure to prevent one of three sampled residents from eloping from the establishment.

Employees mentioned
NameTitleContext
Executive DirectorStated details about the elopement incident and staff response.
Activity DirectorFound the resident a couple blocks away in a local physician's office parking lot.

Inspection Report

Annual Inspection
Census: 70 Deficiencies: 5 Date: May 29, 2025

Visit Reason
Annual licensure survey conducted to assess compliance with regulations related to Alzheimer's special care, employee health evaluations, service plans, medication administration, and resident rights.

Findings
The facility failed to specify licensed health care provider to resident ratios in Alzheimer's disclosures, had caregivers supervising medication administration contrary to service plans, lacked TB skin test documentation for some employees, and had service plans that did not accurately reflect residents' medication supervision needs.

Deficiencies (5)
Failure to specify licensed health care provider to resident ratio and non-licensed staff facilitating medication pass on the Memory Care Unit.
Failure to perform TB skin tests for two of four employees reviewed.
Failure to accurately document medication reminders, supervision, or administration in service plans for four of six residents.
Caregivers on Memory Care Unit opening medication containers and supervising self-administration contrary to policy stating licensed nurses will administer all medications.
Failure to ensure residents' service plans matched current care needs regarding medication supervision.
Report Facts
Residents affected: 8 Residents in facility: 70 Employees without TB test: 2 Residents with inaccurate service plans: 4 Sample size for service plans: 6

Employees mentioned
NameTitleContext
E2Alzheimer's DirectorEmployee lacking documented TB skin test.
E3CaregiverEmployee lacking documented TB skin test.
E4Licensed Practical Nurse (LPN)Confirmed medication supervision practices and TB test documentation.
E8CaregiverObserved supervising medication self-administration and opening medication containers on Memory Care Unit.

Viewing

Loading inspection reports...