Inspection Reports for Friendship Manor

IL, 61201

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Inspection Report Summary

The most recent inspection on February 6, 2025, found the facility in compliance with Illinois Assisted Living and Shared Housing regulations and noted no deficiencies. Earlier inspections in October 2024 identified a deficiency related to the failure to revise a resident’s service plan after multiple unwitnessed falls, which was addressed through a plan of correction that included updated service plans, fall risk assessments, and staff education. Inspectors cited issues primarily with service plan management and fall prevention. No complaint investigations or enforcement actions were listed in the available reports. The facility appears to have taken corrective steps, showing improvement from the earlier cited deficiency.

Deficiencies (last 2 years)

Deficiencies (over 2 years) 1 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

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

Deficiencies per year

4 3 2 1 0
2024
2025

Inspection Report

Annual Inspection
Deficiencies: 0 Date: 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 Date: 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.

Deficiencies (1)
Failed to review and revise resident R1's service plan after four unwitnessed falls within five days, missing interventions to reduce fall risk.
Report Facts
Falls: 4 Sampled residents: 3

Employees mentioned
NameTitleContext
E1Administrator of Clinical ServicesConfirmed R1's four unwitnessed falls
E2Memory Care ManagerResponsible 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 Date: 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.

Deficiencies (1)
Type 3 Violation cited related to Section 295.4010 Service Plan.
Report Facts
Records audit frequency: 4 Records audit frequency: 2 Plan of correction completion date: Completion date 11/12/2024

Employees mentioned
NameTitleContext
Chief Nursing DirectorCompleted and monitored the plan of correction
Nursing SupervisorCompleted and monitored the plan of correction
MC Nurse ManagerCompleted and monitored the plan of correction
AdministratorMonitored the plan of correction

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