Inspection Report
Annual Inspection
Deficiencies: 0
Feb 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 Illinois Assisted Living and Shared Housing regulations during this annual licensure survey.
Inspection Report
Original Licensing
Deficiencies: 1
Oct 25, 2024
Visit Reason
Original investigation of Friendship Manor of Illinois to assess compliance with regulatory requirements, specifically focusing on service plan adherence.
Findings
The facility failed to revise one of three sampled residents' service plans after multiple unwitnessed falls, resulting in a Type 3 violation for not addressing significant changes in the resident's condition.
Severity Breakdown
Type 3 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to review and revise resident R1's service plan after four unwitnessed falls within five days, missing interventions to reduce fall risk. | Type 3 Violation |
Report Facts
Falls: 4
Sampled residents: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Administrator of Clinical Services | Confirmed R1's four unwitnessed falls |
| E2 | Memory Care Manager | Responsible for Memory Care resident's service plans and confirmed falls were not addressed on R1's service plan |
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 25, 2024
Visit Reason
The document is a plan of correction submitted in response to a Type 3 Violation cited on 10/25/2024 related to Section 295.4010 Service Plan.
Findings
The facility updated service plans to reflect fall histories and interventions, conducted fall risk assessments for all assisted living and memory care residents, and educated staff on fall risk assessments and service plan reviews. Quality assurance measures and ongoing audits were established to ensure compliance.
Severity Breakdown
Type 3: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Type 3 Violation cited related to Section 295.4010 Service Plan. | Type 3 |
Report Facts
Records audit frequency: 4
Records audit frequency: 2
Plan of correction completion date: Completion date 11/12/2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Chief Nursing Director | Completed and monitored the plan of correction | |
| Nursing Supervisor | Completed and monitored the plan of correction | |
| MC Nurse Manager | Completed and monitored the plan of correction | |
| Administrator | Monitored the plan of correction |
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