Inspection Reports for
Franciscan Village of Lemont
1260 Franciscan Dr, Lemont, IL, 60439
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
214% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 6, 2025
Visit Reason
Annual Licensure Survey 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 establishment was found to be in compliance with the applicable assisted living and shared housing regulations during this annual licensure survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
The inspection was conducted following a complaint investigation regarding the facility's failure to ensure safe transfer mobility and adequate supervision, which resulted in a resident (R118) falling from her wheelchair and sustaining a fracture injury.
Complaint Details
The complaint investigation was substantiated. The facility failed to properly transfer resident R118 who required two staff members for assistance, resulting in a fall and fracture. Family members and staff interviews confirmed inadequate transfer techniques and failure to use assistive devices as recommended.
Findings
The facility failed to follow recommended transfer assistance and appropriate use of assistive devices for residents identified as high-risk for falls, affecting 4 of 4 residents reviewed. The investigation revealed multiple incidents of improper transfers leading to falls and injuries, including a fracture for resident R118.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents. This failure resulted in resident R118 falling from her wheelchair and sustaining a fracture injury due to improper transfer assistance and lack of adherence to recommended safety protocols.
Report Facts
Residents reviewed for accidents and supervision: 19
Residents affected by transfer failures: 4
Date of survey completion: Aug 21, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V24 | Registered Nurse | Named in transfer failure and fall incident involving resident R118 |
| V3 | Assistant Director of Nursing | Notified of incident and involved in investigation and staff education |
| V2 | Director of Nursing | Provided statement on fall prevention interventions |
| V19 | Certified Nursing Assistant | Assisted resident R52 during toileting without gait belt |
| V20 | Certified Nursing Assistant | Assisted resident R43 transfer via mechanical lift |
| V21 | Certified Nursing Assistant | Assisted resident R43 transfer via mechanical lift |
Inspection Report
Routine
Census: 97
Deficiencies: 10
Date: Aug 21, 2025
Visit Reason
Routine inspection of Franciscan Village nursing home to assess compliance with regulatory requirements including resident care, medication management, nutrition, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to provide adequate assistance with activities of daily living, improper transfer techniques resulting in resident injury, inadequate pain management, medication storage and administration errors, failure to provide fortified foods as recommended, improper food preparation and sanitation, and lapses in infection control practices.
Deficiencies (10)
F0677: The facility failed to provide assistance to residents requiring help with activities of daily living, including feeding and incontinence care, affecting 2 of 3 residents reviewed.
F0689: The facility failed to ensure safe transfer mobility and proper use of assistive devices, resulting in a resident fall with fracture and actual harm to 4 residents reviewed.
F0697: The facility failed to assess and provide interventions for a resident exhibiting pain during care, including delayed administration of pain medication.
F0755: The facility failed to ensure controlled substance medications were completely sealed in their packaging for 7 residents reviewed.
F0759: The facility failed to follow physician orders for medication administration, including crushing extended-release tablets, resulting in a 7.14% medication error rate for 1 resident reviewed.
F0800: The facility failed to provide fortified foods as recommended for 6 residents reviewed, resulting in residents not receiving prescribed nutritional supplements.
F0803: The facility failed to follow menu portion sizes for mechanical soft diets, serving incorrect scoop sizes to 4 residents reviewed.
F0805: The facility failed to follow diet guidance for mechanical soft diets by serving inappropriate fruits and vegetables to 6 residents reviewed.
F0812: The facility failed to prepare food, clean dishes, and store pots and pans in sanitary conditions, including dirty food processor, rusted shelving, food debris on fryer, and improper dish machine temperature monitoring affecting all 97 residents.
F0880: The facility failed to follow standard infection control practices related to hand hygiene and glove use during activities of daily living care for 3 residents reviewed.
Report Facts
Medication error rate: 7.14
Facility census: 97
Medication packaging issues: 7
Residents affected by transfer failure: 4
Residents affected by ADL assistance failure: 2
Residents affected by infection control failure: 3
Residents reviewed for fortified foods: 6
Residents reviewed for mechanical soft diet portion errors: 4
Residents reviewed for mechanical soft diet food form errors: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V24 | Registered Nurse | Named in transfer failure incident resulting in resident fall and fracture |
| V30 | Certified Nursing Assistant | Named in pain management and ADL assistance deficiencies |
| V19 | Certified Nursing Assistant | Named in infection control lapses during incontinence care |
| V21 | Certified Nursing Assistant | Named in infection control lapses during incontinence care |
| V2 | Director of Nursing | Provided statements on medication and infection control policies |
| V17 | Registered Dietitian | Provided statements on diet and nutrition deficiencies |
| V6 | Assistant Dining Service Director | Provided statements on diet and food service deficiencies |
| V9 | Executive Chef | Provided statements on kitchen sanitation and dish machine issues |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 9, 2025
Visit Reason
The inspection was conducted following a substantiated incident involving a resident (R1) who eloped from the memory support unit, to evaluate compliance with service plan requirements and abuse, neglect, and financial exploitation prevention regulations.
Findings
The facility failed to address a resident's history of elopement and exit-seeking behavior in the service plan and failed to ensure newly hired staff were aware of residents with such behaviors. Additionally, the facility failed to ensure the safety of the resident who eloped from the memory support unit, which was not detected by a new care aide unfamiliar with the residents. The resident was later transferred to another facility as the establishment could no longer meet his needs.
Deficiencies (2)
Failure to address in the service plan a history of elopement and exit seeking behavior for one resident who eloped off the memory care unit and failure to ensure newly hired staff were made aware of residents with such behaviors.
Failure to ensure the safety of one resident with a history of exit seeking and elopement behavior who eloped from the memory support unit and was outside for an unknown amount of time.
Report Facts
Incident date: May 24, 2024
Transfer date: Jul 17, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Resident Care Aide | Newly hired staff involved in the incident where resident R1 eloped |
| E2 | Assisted Living Manager | Provided investigation details and documentation regarding resident R1's elopement and transfer |
| E3 | Certified Nursing Assistant (CNA) | Shadowed by E1 during the incident and instructed E1 to get a mask |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 9, 2025
Visit Reason
The plan of correction addresses deficiencies found related to abuse, neglect, and financial exploitation, specifically concerning a resident with a history of elopement and exit seeking behavior who eloped from the memory support unit.
Findings
The facility failed to ensure the safety of one resident with Alzheimer's disease who eloped from the memory support unit due to unfamiliarity of a new resident care aide with the residents. Corrective actions include monitoring residents with elopement history, training new hires on the memory care unit, and auditing service plans to include elopement history.
Deficiencies (2)
Failure to ensure the safety of a resident with a history of elopement and exit seeking behavior.
Service plans did not address history of elopement and exit seeking behavior for a resident.
Report Facts
Date of compliance: Mar 31, 2025
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Aug 9, 2024
Visit Reason
The inspection was conducted as a comprehensive annual survey of Franciscan Village nursing home to assess compliance with regulatory requirements across multiple areas including resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to keep call lights within residents' reach, failure to invite residents to care plan meetings, inadequate assistance with activities of daily living, failure to provide restorative nursing programs, failure to use fall mats properly for a high fall risk resident, failure to recognize and respond to significant weight loss, failure to discard expired food and properly store food, and failure to follow infection prevention protocols including hand hygiene and PPE use.
Deficiencies (9)
F 0558: The facility failed to ensure call lights were within reach for 3 residents, compromising their ability to summon help.
F 0657: The facility failed to invite 2 residents to their care plan meetings, denying them participation in care decisions.
F 0677: The facility failed to provide adequate personal hygiene and grooming assistance to 10 residents, resulting in poor nail and facial hair care.
F 0679: The facility failed to provide meaningful activities to 2 residents confined to their rooms, limiting their social engagement.
F 0688: The facility failed to provide restorative nursing programs for 3 residents with limited range of motion, risking functional decline.
F 0689: The facility failed to place fall mats properly and keep beds in the lowest position for a high fall risk resident.
F 0692: The facility failed to obtain monthly weights and recognize significant weight loss for a resident, resulting in a 12.47% weight loss over 90 days.
F 0812: The facility failed to discard expired food and properly store food in the freezer, risking food safety for all residents.
F 0880: The facility failed to implement infection prevention protocols including hand hygiene, glove changes, and PPE use during wound care and meal service for multiple residents.
Report Facts
Residents reviewed: 34
Residents affected by call light issue: 3
Residents affected by care plan meeting issue: 2
Residents affected by ADL care issue: 10
Residents affected by activity provision issue: 2
Residents affected by restorative nursing issue: 3
Residents affected by fall mat issue: 1
Residents affected by weight loss issue: 1
Weight loss percentage: 12.47
Residents affected by expired food issue: 98
Residents affected by infection control issue: 6
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Oct 19, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations and standards at Franciscan Village nursing home.
Findings
The facility was found deficient in multiple areas including failure to assist residents with personal hygiene, inadequate provision of supportive devices for range of motion, medication administration errors, failure to provide prescribed diets and supplements, failure to offer pneumococcal vaccines per policy, and lack of a working call light system in a resident's bathroom.
Deficiencies (9)
F 0677: The facility failed to assist residents needing help with personal hygiene, including trimming and cleaning fingernails for 6 of 7 residents reviewed.
F 0688: The facility failed to provide supportive devices to prevent further reduction in range of motion for 2 of 6 residents reviewed, resulting in residents having clenched fingers without proper positioning devices.
F 0697: The facility failed to ensure a resident received medication to treat hemorrhoidal pain as ordered.
F 0759: The facility failed to administer medications as ordered, resulting in a 17.85% medication error rate for 3 of 5 residents observed during medication pass.
F 0760: The facility failed to ensure 2 residents received medications as prescribed for Parkinson's disease and blood thinning.
F 0805: The facility failed to serve pureed consistency Chicken Cacciatore and vegetables without lumps or seeds to 5 residents on pureed diets.
F 0808: The facility failed to provide nutrition supplements and diet consistency as ordered by the physician for 4 residents.
F 0883: The facility failed to follow policy to offer pneumococcal vaccines PCV15 or PCV20 to 6 residents previously vaccinated with PPSV23.
F 0919: The facility failed to ensure a call light was accessible to a resident lying on the bathroom floor due to a non-functioning bathroom call light pull cord.
Report Facts
Medication error rate: 17.85
Residents affected: 6
Residents affected: 2
Residents affected: 5
Residents affected: 4
Residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Acknowledged residents' fingernails needed trimming and cleaning; involved in medication and care plan discussions. |
| V3 | Assistant Director of Nursing | Observed medication pass and involved in medication errors including missed medications. |
| V15 | Registered Nurse | Prepared and administered medications incorrectly; aware of call light issue but did not notify maintenance. |
| V16 | Occupational Therapist | Screened residents for supportive devices and provided palm protectors. |
| V7 | Dietitian | Notified about pureed diet issues and diet order discrepancies. |
| V22 | Director of Plant Operations | Unaware of bathroom call light issue prior to notification. |
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