Deficiencies per Year
4
3
2
1
0
High
Inspection Report
Annual Inspection
Census: 44
Deficiencies: 3
Sep 23, 2025
Visit Reason
Annual licensure survey conducted to assess compliance with personnel requirements, food service sanitation, and physical plant regulations.
Findings
The facility was found to have insufficient staffing on the 3rd shift with only one caregiver for 44 residents, food service sanitation violations including debris in steam table pans and freezer shelves, and failure to maintain acceptable evacuation capability documentation per NFPA Life Safety Code.
Severity Breakdown
Type 2 Violation: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to have sufficient staff on 3rd shift to meet 24 hour scheduled and unscheduled needs of residents and ability to intervene in a crisis. | Type 2 Violation |
| Failed to meet Food Service Sanitation Code due to buildup of debris on freezer shelf and debris in steam table pans. | Type 2 Violation |
| Failed to comply with NFPA Life Safety Code by not maintaining documentation demonstrating acceptable evacuation capability with evacuation time of 13 minutes or less. | Type 2 Violation |
Report Facts
Resident census: 44
Resident falls on 3rd shift: 16
Residents requiring evacuation assistance: 4
Evacuation time: 0.5
Evacuation time: 13
Previous residents during drills: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Manager | Interviewed regarding staffing on 3rd shift |
| E3 | Personal Assistant | Interviewed regarding staffing sufficiency and ability to call for help |
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 7, 2024
Visit Reason
Annual Survey conducted on 10/07/2024 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 the annual survey.
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