Inspection Reports for
Franciscan Village of Lemont
1260 Franciscan Dr, Lemont, IL, 60439
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Inspection Report — Nov 6, 2025
Annual Inspection
Date: Nov 6, 2025
Visit Reason
Annual Licensure Survey. For this survey, the establishment is in 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 in compliance with all applicable regulations during this annual licensure survey.
Inspection Report — Jan 9, 2025
Complaint Investigation
Date: Jan 9, 2025
Visit Reason
Facility Reported Incident: IL174662/FRI 5.24.24-Substantiated
Complaint Details
Facility Reported Incident IL174662/FRI 5.24.24-Substantiated
Findings
The establishment failed to address a resident's history of elopement and exit seeking in the service plan and failed to ensure newly hired staff were aware of this risk. The resident was found outside after eloping from the memory support unit, and was later transferred to another facility as the establishment could no longer meet his needs.
Deficiencies (2)
A4010 (295.4010 Service Plan) - The establishment failed to address in the service plan a history of elopement and exit seeking behavior for one resident who eloped from the memory support unit and failed to ensure newly hired staff were made aware of this risk.
A6010 (295.6010 Abuse, Neglect, and Financial Exploitation Prevention and Reporting) - The establishment failed to ensure the safety of one resident who eloped from the memory support unit unnoticed by a new care aide unfamiliar with the residents, resulting in the resident being outside for an unknown amount of time.
Report Facts
Residents affected: 1
Inspection Report — Jan 9, 2025
Plan of Correction
Date: Jan 9, 2025
Visit Reason
This plan of correction answers the survey dated 1-9-2025.
Findings
The facility committed to monitoring residents with elopement risk, training new hires on the memory care unit, auditing and updating service plans weekly, and presenting audit results to the Quality Assurance Committee to prevent recurrence of the deficiencies.
Inspection Report — Dec 5, 2024
Plan of Correction
Date: Dec 5, 2024
Visit Reason
This plan of correction answers the survey dated 12-05-2024 with deficiency cited in Section 295.4060 regarding Alzheimer's and Dementia Programs.
Findings
The facility committed to ensuring all employees complete four hours of dementia-specific orientation prior to assuming job responsibilities without direct supervision and will audit employee files weekly for four weeks, then monthly for three months to ensure compliance.
Report Facts
Employees affected: 5
4 CMS Surveys
Inspection Report — Aug 21, 2025
Annual Inspection
Date: Aug 21, 2025
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to provide adequate assistance with activities of daily living, failure to ensure safe transfer and fall prevention, inadequate pain management, improper medication storage and administration, failure to provide fortified foods and correct diet portions, unsanitary food preparation and dishwashing practices, and lapses in infection control practices related to hand hygiene and glove use.
Deficiencies (10)
F0677 - The facility failed to provide assistance with activities of daily living including feeding and incontinence care for two of three residents reviewed.
F0689 - The facility failed to ensure safe transfer and supervision to prevent accidents, resulting in a resident falling and sustaining a fracture, and failed to follow recommended transfer assistance for four residents reviewed.
F0697 - The facility failed to assess and provide appropriate pain management for a resident exhibiting pain during care.
F0755 - The facility failed to ensure controlled substance medications were completely sealed in their packaging for seven residents reviewed.
F0759 - The facility failed to follow physician orders for medication administration, including crushing extended-release medication for one resident.
F0800 - The facility failed to provide fortified foods as recommended for six residents reviewed.
F0803 - The facility failed to follow menu spreadsheets to serve correct portions for main entree for residents on mechanical soft diets.
F0805 - The facility failed to follow diet guidance for mechanical soft diets by serving inappropriate vegetables and fruits to residents.
F0812 - The facility failed to prepare food, clean dishes, and store pots and pans in sanitary conditions, including dirty food processor, rust on shelving, food debris on fryer and stove, and improper dishwashing monitoring.
F0880 - The facility failed to follow standard infection control practices related to hand hygiene and glove use during activities of daily living care for three residents reviewed.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 7
Medication errors: 2
Residents affected: 6
Residents affected: 4
Residents affected: 6
Residents affected: 97
Residents affected: 3
Inspection Report — Aug 21, 2025
Date: Aug 21, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, the inspection type is classified as 'other'.
Findings
The facility failed to ensure safe transfer mobility for residents at high risk for falls, resulting in a resident (R118) falling from her wheelchair and sustaining a fracture. Multiple residents were affected due to inadequate supervision and failure to follow recommended transfer assistance and use of assistive devices.
Deficiencies (1)
F0689 - The facility failed to ensure safe transfer mobility and adequate supervision to prevent accidents, resulting in a resident (R118) falling from her wheelchair and sustaining a fracture, and failed to follow recommended transfer assistance and use of assistive devices for four high-risk residents.
Report Facts
Residents affected: 4
Inspection Report — Aug 9, 2024
Annual Inspection
Date: Aug 9, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to accommodate resident needs, incomplete care plans, inadequate assistance with activities of daily living, lack of restorative nursing programs, failure to prevent accidents, failure to maintain adequate nutrition, improper food storage, and lapses in infection prevention and control practices.
Deficiencies (9)
F0558 (Reasonably accommodate the needs and preferences of each resident) - The facility failed to put call lights within reach for 3 of 3 residents reviewed.
F0657 (Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals) - The facility failed to invite 2 residents to their care plan meetings and document invitations or attendance.
F0677 (Provide care and assistance to perform activities of daily living for any resident who is unable) - The facility failed to provide adequate personal hygiene and grooming care to 10 residents reviewed.
F0679 (Provide activities to meet all resident's needs) - The facility failed to provide ongoing activities based on assessments and preferences for 2 residents.
F0688 (Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason) - The facility failed to provide restorative nursing programs to 3 residents with limited range of motion.
F0689 (Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents) - The facility failed to place fall mats on both sides of the bed for a resident at high fall risk.
F0692 (Provide enough food/fluids to maintain a resident's health) - 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.
F0812 (Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards) - The facility failed to discard expired food items and properly store food in the freezer, resulting in ice buildup on food packages and the floor.
F0880 (Provide and implement an infection prevention and control program) - The facility failed to perform hand hygiene and glove changes during incontinence care, wound care, and meal service, and failed to use proper PPE during wound care for residents on enhanced barrier precautions.
Report Facts
Residents affected: 3
Residents affected: 2
Residents affected: 10
Residents affected: 2
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 98
Residents affected: 6
Inspection Report — Oct 19, 2023
Annual Inspection
Date: Oct 19, 2023
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to provide adequate personal hygiene assistance, improper medication administration, failure to serve pureed diets correctly, failure to provide therapeutic diets as ordered, failure to offer pneumococcal vaccines per policy, and failure to maintain a working call light in a resident's bathroom.
Deficiencies (9)
F0677 - The facility failed to assist residents identified as needing assistance with personal hygiene, including trimming and cleaning fingernails for six of seven residents reviewed.
F0688 - The facility failed to assess and provide supportive devices to prevent further reduction in range of motion for two of six residents reviewed.
F0697 - The facility failed to ensure a resident received medication to treat hemorrhoidal pain.
F0759 - The facility failed to administer medications as ordered by the physician, resulting in a 17.85% medication error rate.
F0760 - The facility failed to ensure that two residents were given medications as prescribed for Parkinson's disease and to prevent blood clotting.
F0805 - The facility failed to serve pureed consistency Chicken Cacciatore and vegetables to residents on pureed diets, with seed-like hard pieces present.
F0808 - The facility failed to serve nutrition supplements and diet consistency as ordered by the physician for four of five residents reviewed for dining.
F0883 - The facility failed to follow their policy to offer residents the pneumococcal vaccine, including PCV15 or PCV20, to six of six residents reviewed for immunizations.
F0919 - The facility failed to ensure a call light was accessible to a resident if lying on the bathroom floor, as the bathroom call light pull cord did not activate the call light.
Report Facts
Residents affected: 6
Residents affected: 2
Residents affected: 1
Medication opportunities: 28
Medication errors: 5
Residents affected: 2
Residents affected: 5
Residents affected: 4
Residents affected: 6
Residents affected: 1
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