Deficiencies (last 5 years)
Deficiencies (over 5 years)
3.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% better than Illinois average
Illinois average: 3.5 deficiencies/year
Deficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
74% occupied
Based on a July 2024 inspection.
Occupancy rate over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 30, 2026
Visit Reason
The inspection was conducted following a complaint regarding improper use of mechanical lift transfers at the nursing home, specifically concerning a fall incident involving Resident R1.
Complaint Details
The complaint investigation found that Resident R1 fell during a mechanical lift transfer on 11/27/25 due to improper sling placement and insufficient trained staff assistance. The fall was substantiated with minor injury and corrective actions were taken.
Findings
The facility failed to follow its policy requiring two trained staff members to perform mechanical lift transfers, resulting in Resident R1 slipping out of the sling and falling during transfer. The resident sustained a minor abrasion but no fractures, and corrective actions including staff counseling and policy reinforcement were implemented.
Deficiencies (1)
F 0689: The facility failed to ensure mechanical lift transfers were performed by two trained staff members, causing Resident R1 to slip out of the sling and fall. The sling was improperly placed between the resident's legs, leading to a fall with minor injury.
Report Facts
Date of fall incident: Nov 27, 2025
Date of survey completion: Jan 30, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V5 | Certified Nursing Assistant | Named in mechanical lift transfer fall incident and subsequent counseling |
| V7 | Private Caregiver | Assisted with mechanical lift transfer without training, involved in fall incident |
| V2 | Director of Nursing | Provided statement on proper mechanical lift use and staff counseling |
Inspection Report
Deficiencies: 1
Date: Sep 12, 2025
Visit Reason
The inspection was conducted to investigate a fall incident involving resident R1 during a transfer using a lift machine, focusing on accident hazards and supervision adequacy in the nursing home.
Findings
The facility failed to ensure safe transfer of resident R1, resulting in a fall and a displaced fracture of the right femur. Staff did not use a gait belt during the transfer, and the lift machine was improperly positioned, contributing to the fall.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in resident R1 falling and fracturing her right femur during transfer.
Report Facts
Residents Affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V9 | Certified Nursing Assistant | Named in transfer incident and failure to use gait belt |
| V10 | Certified Nursing Assistant | Assisted during transfer and commented on proper use of gait belt |
| V8 | Licensed Practical Nurse | Responded to fall incident and assisted resident |
| V3 | Director of Rehab/Physical Therapist | Provided explanation of proper lift machine use |
| V2 | Director of Nursing | Provided information on resident condition and transfer policy |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 9, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to a resident fall incident at the facility.
Complaint Details
The complaint investigation was substantiated based on observation, interview, and record review. The resident fell from bed due to inadequate supervision and environmental hazards such as the absence of bed side rails and raised bed height.
Findings
The facility failed to ensure a resident was safely positioned in bed, resulting in a fall from bed and a laceration requiring staples. The investigation found that the resident was left unattended on the side of a bed without side rails, which contributed to the fall.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents. This failure led to a resident falling from bed and sustaining a laceration requiring staples.
Report Facts
Length of laceration: 1
Staples placed: 4
Fall incident time: 450
Bed height: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V13 | Certified Nursing Assistant | Named in fall incident providing care to resident at time of fall |
| V2 | Director of Nursing | Reported details of the fall incident and supervision concerns |
| V12 | Licensed Practical Nurse | Responded to fall incident and called 911 |
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
| 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
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
| 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 |
Inspection Report
Complaint Investigation
Census: 73
Deficiencies: 2
Date: Jul 24, 2024
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to follow its fall prevention program and provide adequate supervision, resulting in multiple resident falls and injuries.
Complaint Details
The complaint investigation substantiated that the facility failed to provide adequate supervision and follow fall prevention protocols for residents R15, R18, and R60, resulting in serious injuries. The facility also failed to implement required infection control precautions for residents with wounds and indwelling devices.
Findings
The facility failed to implement its fall prevention program and provide adequate supervision for residents at high risk of falls, resulting in hospitalizations for three residents due to fractures and injuries. Additionally, the facility failed to implement Enhanced Barrier Precautions to prevent the spread of multi-drug resistant organisms, potentially affecting all residents.
Deficiencies (2)
F 0689: The facility failed to follow its fall prevention program and provide supervision for three residents at high risk of falls, resulting in hospitalizations for nasal, tibial, and hip fractures.
F 0880: The facility failed to implement Enhanced Barrier Precautions to protect residents and prevent the spread of multi-drug resistant organisms, affecting 73 residents.
Report Facts
Residents currently residing: 73
Fall risk scores: 10
Number of falls for R15: 3
Number of falls for R60: 7
Fall risk scores for R60: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 | Chief Nursing Director | Named in fall prevention program findings and interviews regarding resident falls |
| V2 | Director of Nursing (DON) | Named in fall prevention program findings and interviews regarding resident falls |
| V4 | Licensed Practical Nurse/Infection Control Preventionist | Named in infection control findings and interviews regarding failure to implement Enhanced Barrier Precautions |
| V8 | Certified Nursing Assistant (CNA) | Observed assisting resident R15 during fall incident |
| V12 | Certified Nursing Assistant (CNA) | Interviewed regarding fall risk star program and resident supervision |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 3
Date: Jul 19, 2023
Visit Reason
The inspection was conducted based on complaints regarding catheter care, psychotropic medication use, and food storage safety at the facility.
Complaint Details
The visit was complaint-related due to concerns about catheter care leading to urinary tract infections, inappropriate psychotropic medication use, and food safety violations. The complaint was substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to perform catheter care in a clean manner leading to repeated urinary tract infections for one resident. The facility also failed to identify appropriate indications and target behaviors for psychotropic medication use for one resident. Additionally, the facility failed to discard outdated food items in the refrigerator, potentially affecting all residents.
Deficiencies (3)
F 0690: The facility failed to perform catheter care in a clean manner for one resident, resulting in repeated urinary tract infections.
F 0758: The facility failed to identify appropriate indications and target behaviors for psychotropic medication use for one resident and administered medication without timely consent documentation.
F 0812: The facility failed to store food items in accordance with professional standards by not discarding outdated food items in the refrigerator, potentially affecting all 79 residents.
Report Facts
Residents in facility: 79
Urinary Tract Infections for resident R62: 11
Psychotropic medication behaviors documented: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 | Assistant Director of Nurses (ADON)/Registered Nurse | Confirmed improper catheter care and chronic urinary tract infections for resident R62 |
| V6 | Certified Nurse Assistant (CNA) | Performed catheter care improperly for resident R62 |
| V9 | Social Service Director (SSD) | Acknowledged outdated psychotropic medication policy |
| V2 | Chief Nursing Director | Acknowledged verbal consent issues for psychotropic medication for resident R178 |
| V7 | Dietary Aide | Provided information about food labeling and storage practices |
| V10 | Doctor | Stated contamination during catheter care can lead to repeated urinary tract infections |
| V11 | Urologist | Ordered antibiotic Augmentin for resident R62 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 16, 2023
Visit Reason
The inspection was conducted following a complaint alleging mental and emotional abuse of a resident by a certified nursing assistant.
Complaint Details
The complaint was substantiated. The resident reported the CNA placed a gait belt around her neck and treated her in a joking but degrading manner. The CNA admitted the incident occurred and was terminated.
Findings
The facility failed to protect a resident from mental and emotional abuse when a CNA placed a gait belt around the resident's neck in a degrading manner. The CNA was terminated following the incident.
Deficiencies (1)
F 0600: The facility failed to protect a resident from mental and emotional abuse when a CNA placed a gait belt around the resident's neck and treated the resident in a demeaning manner. This caused the resident to feel demeaned, degraded, and angry.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 | Certified Nursing Assistant | Named in mental and emotional abuse finding involving placing a gait belt around resident's neck. |
| V5 | Licensed Practical Nurse | Nurse on duty the night of the incident who responded to the resident's report. |
| V1 | Administrator | Administrator who terminated the CNA after the incident. |
Inspection Report
Complaint Investigation
Census: 71
Deficiencies: 6
Date: May 9, 2022
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, failure to revise care plans after incidents, pressure ulcer care deficiencies, fall prevention issues, and COVID-19 related compliance concerns.
Complaint Details
The investigation was complaint-driven, focusing on abuse allegations, care plan deficiencies, pressure ulcer care, fall prevention, and COVID-19 compliance. The abuse allegations were substantiated with failure to report. Other issues were identified through record review and interviews.
Findings
The facility failed to immediately report allegations of abuse, revise care plans after resident altercations, properly stage and care for pressure ulcers, use gait belts during resident transfers, and ensure COVID-19 testing and vaccination compliance among staff. These deficiencies affected multiple residents and posed potential harm.
Deficiencies (6)
F0609: The facility failed to timely report three allegations of abuse involving residents R12, R17, and R39 to the Administrator as required.
F0657: The facility failed to revise care plans following a physical altercation between residents R21 and R65.
F0686: The facility failed to stage and assess a pressure ulcer when discovered, perform incontinent care prior to wound care, and perform hand hygiene during pressure ulcer care for resident R59.
F0689: The facility failed to use a gait belt and provide supervision while transferring resident R46, contributing to a fall.
F0886: The facility failed to COVID-19 test unvaccinated staff two times a week as required, potentially affecting all 71 residents.
F0888: The facility failed to ensure all staff were fully vaccinated for COVID-19, track exemptions, and document vaccination status of contracted staff, potentially affecting all 71 residents.
Report Facts
Residents: 71
Staff: 88
Fully vaccinated staff: 51
Staff with exemptions: 36
Contracted staff: 25
Deficiency count: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V1 | Administrator | Named in failure to report abuse allegations |
| V10 | Social Service Director | Named in failure to revise care plans after resident altercation |
| V14 | Wound Nurse | Named in pressure ulcer care deficiencies |
| V16 | Registered Nurse | Named in pressure ulcer care deficiencies |
| V2 | Director of Nursing | Named in multiple findings including pressure ulcer care and fall prevention |
| V6 | Certified Nursing Assistant | Named in fall incident involving resident R46 |
| V4 | Assistant Administrator | Named in COVID-19 testing and vaccination compliance findings |
| V20 | Medical Assistant | Named in COVID-19 testing and vaccination compliance findings |
| V17 | Director of Human Resources | Named in COVID-19 vaccination status reporting |
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