19 CMS Surveys
Inspection Report — Oct 10, 2025
Complaint Investigation
Date: Oct 10, 2025
Visit Reason
Complaint investigation of alleged physical abuse of a resident by a certified nursing assistant.
Complaint Details
Complaint investigation of alleged physical abuse substantiated. No other complaints listed.
Findings
The facility substantiated the abuse allegation against the certified nursing assistant who was terminated. The facility implemented abuse prevention training, created quality control tools, and conducted staff education to prevent future incidents.
Deficiencies (1)
F0600 - Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. The facility failed to protect a resident from physical abuse when a certified nursing assistant pulled the resident's ear and forcibly dragged him out of his chair, causing bruising and fear.
Report Facts
Residents affected: 1
Inspection Report — Jun 12, 2025
Annual Inspection
Date: Jun 12, 2025
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to ensure call lights were accessible, improper use and documentation of psychotropic medications, inadequate assistance with activities of daily living, failure to maintain pressure ulcer prevention equipment, incomplete range of motion exercises, unsafe respiratory care practices, improper pharmaceutical services including controlled substance management, medication storage and labeling issues, food safety concerns, inadequate infection control practices for COVID-19 isolation, and unsafe laundry practices.
Deficiencies (13)
F0558 (295.0558 Reasonably accommodate the needs and preferences of each resident) - The facility failed to ensure call lights were accessible as stated in the care plans for two residents reviewed.
F0605 (295.0605 Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function) - The facility failed to provide clinical rationale or physician documentation justifying the increase in dosage of a psychotropic medication for one resident reviewed.
F0677 (295.0677 Provide care and assistance to perform activities of daily living for any resident who is unable) - The facility failed to ensure residents dependent on staff assistance received oral care and timely incontinence care for four residents reviewed.
F0686 (295.0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing) - The facility failed to ensure a low air loss mattress ordered for a resident at risk for pressure ulcer was functioning.
F0688 (295.0688 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 range of motion exercises and apply restorative devices, potentially contributing to contractures for three residents reviewed.
F0695 (295.0695 Provide safe and appropriate respiratory care for a resident when needed) - The facility failed to contain and label oxygen equipment properly, failed to display oxygen in use signage, and failed to follow physician orders for oxygen use for six residents reviewed.
F0755 (295.0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist) - The facility failed to ensure controlled medications were stored in a double locked setting, failed to ensure completed controlled medications were returned to the pharmacy, and failed to ensure outgoing nurse signed the narcotic shift-to-shift count sheet.
F0761 (295.0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs) - The facility failed to refrigerate unopened insulin pens, label multi-dose medications, discard expired medications, and monitor refrigerator temperatures affecting seven residents and potentially all residents on the 3rd floor.
F0812 (295.0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards) - The facility failed to ensure a wet kitchen sanitation cloth was kept in the sanitizing bucket and failed to discard expired milk cartons from the walk-in cooler of the kitchen.
F0813 (295.0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors) - The facility failed to provide thermometers and maintain refrigerator logs for four residents' personal refrigerators.
F0814 (295.0814 Dispose of garbage and refuse properly) - The facility failed to ensure that outside garbage dumpsters were closed with lids to prevent pest infestation and foul odor.
F0880 (295.0880 Provide and implement an infection prevention and control program) - The facility failed to provide trash receptacles in transmission-based precaution rooms and failed to maintain contact/droplet isolation for COVID-19 positive residents, placing all residents at risk for infection spread.
F0921 (295.0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public) - The facility failed to empty the lint compartment and filter of the residents' personal dryer, creating a fire hazard.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 3
Residents affected: 6
Residents affected: 3
Residents affected: 7
Residents affected: 150
Residents affected: 4
Residents affected: 150
Residents affected: 2
Residents affected: 150
Inspection Report — May 29, 2025
Complaint Investigation
Date: May 29, 2025
Visit Reason
Complaint Investigation regarding alleged resident abuse involving residents R2 and R3, including a verbal altercation and water throwing incident.
Complaint Details
Complaint Investigation: Alleged resident abuse involving residents R2 and R3; investigation found no harm and no further action by police.
Findings
The facility failed to ensure residents R2 and R3 were free from abuse during a verbal altercation where R3 threw water at R2. The facility investigated, found no harm, and took corrective actions including room reassignment and psychiatric services.
Deficiencies (1)
F0600 (295.6000 Resident Rights) - The facility failed to protect residents from abuse as evidenced by a verbal altercation and water throwing incident involving two residents.
Report Facts
Residents affected: 2
Inspection Report — May 8, 2025
Complaint Investigation
Date: May 8, 2025
Visit Reason
Complaint investigation regarding resident-to-resident physical and verbal abuse incidents involving residents R1, R2, and R4, documented through facility reported incidents dated 04/06/2025 and 04/29/2025.
Complaint Details
Complaint #145654: Section 295.6000 cited.
Findings
The facility failed to prevent and protect residents from resident-to-resident physical and verbal abuse. The incidents involved R1 pushing R2 and punching and verbally abusing R4, resulting in minimal harm and requiring staff intervention and monitoring.
Deficiencies (1)
F0600 (295.6000 Resident Rights) - The facility failed to prevent and protect residents from resident-to-resident physical and verbal abuse, affecting two residents out of five reviewed, including incidents where R1 pushed R2 and punched and verbally abused R4.
Report Facts
Residents affected: 2
Residents reviewed: 5
Inspection Report — Mar 25, 2025
Annual Inspection
Date: Mar 25, 2025
Visit Reason
Annual Licensure Survey. For this survey, the establishment was found not in compliance with Part 295 due to cited violations.
Findings
The facility failed to respond timely to nurse call activations for several residents and failed to ensure residents' right to be free from abuse, resulting in minor injuries to two residents. The facility's policies and procedures regarding call lights and abuse prevention were reviewed.
Deficiencies (2)
F0558 (295.5580 Reasonably accommodate the needs and preferences of each resident) - The facility failed to respond to nurse call activations in a timely manner for 3 of 10 residents included in the sample, with observations of call lights being unanswered for up to two hours.
F0600 (295.6000 Protect each resident from all types of abuse) - The facility failed to ensure the right to be free of abuse in 2 residents, resulting in minor injuries and requiring psych evaluations and increased monitoring.
Report Facts
Residents affected: 3
Residents affected: 2
Inspection Report — Dec 20, 2024
Complaint Investigation
Date: Dec 20, 2024
Visit Reason
Complaint investigation of an alleged physical abuse incident where resident R1 punched resident R2 in the back on 11/30/2024.
Complaint Details
Complaint investigation of alleged physical abuse incident on 11/30/2024 involving residents R1 and R2.
Findings
The facility failed to follow their policy to ensure a resident is free from abuse. The investigation found that resident R1 deliberately hit resident R2 in the back, constituting physical abuse, with no injuries noted but confirmed by multiple witnesses and staff.
Deficiencies (1)
F0600 (Protect each resident from all types of abuse) - The facility failed to prevent physical abuse when resident R1 punched resident R2 in the back on 11/30/2024, affecting one of three residents reviewed.
Report Facts
Residents affected: 1
Residents reviewed for abuse: 3
Inspection Report — Oct 11, 2024
Complaint Investigation
Date: Oct 11, 2024
Visit Reason
Complaint Investigation regarding verbal abuse allegations by a former receptionist towards a resident.
Complaint Details
Complaint # not explicitly stated in the document; investigation found the allegation unsubstantiated but confirmed inappropriate communication.
Findings
The investigation concluded that the allegation of verbal abuse could not be substantiated, but the former receptionist's communication was inappropriate and made the resident feel uncomfortable. The resident reported feeling safe and did not experience physical or emotional distress from the incident.
Deficiencies (1)
F0600 (Protect each resident from all types of abuse) - The facility failed to prevent staff (former receptionist) from verbally abusing one of three residents reviewed, using profanity and inappropriate communication.
Report Facts
Residents affected: 1
Residents reviewed: 3
Inspection Report — Aug 22, 2024
Date: Aug 22, 2024
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to provide scheduled pain medication (Tramadol) per doctor's order for one resident, resulting in minimal harm or potential for actual harm.
Deficiencies (1)
F0697 (not explicitly referenced to a section in the prompt) - The facility failed to provide scheduled pain medication (Tramadol) per doctor's order for one resident, causing pain and discomfort.
Report Facts
Residents affected: 1
Inspection Report — Jul 12, 2024
Annual Inspection
Date: Jul 12, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to protect residents from abuse, failure to provide appropriate treatment and care, failure to supervise a resident with self-harmful behaviors, and failure to provide pharmaceutical services in compliance with professional standards. These failures resulted in actual harm to several residents including fractures and injuries.
Deficiencies (4)
F0600 (295.6000 Resident Rights) - The facility failed to protect two residents from physical and verbal abuse, resulting in one resident sustaining a subacute fracture of the distal right fourth metatarsal.
F0684 (295.6800 Resident Care and Services) - The facility failed to provide appropriate treatment and care by not following professional standards and facility policy, resulting in delayed notification and treatment of fractures and pain for two residents.
F0689 (295.6800 Resident Care and Services) - The facility failed to ensure adequate supervision and monitoring of a resident with a history of unsafe and self-harmful behaviors, resulting in a nasal fracture.
F0755 (295.7500 Pharmaceutical Services) - The facility failed to provide medication in compliance with professional standards and facility policy, including improper documentation and administration of lidocaine patches for one resident.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Inspection Report — May 23, 2024
Annual Inspection
Date: May 23, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to protect resident dignity, improper medication self-administration procedures, inadequate home-like environment, incomplete criminal background checks for residents and employees, failure to provide communication devices, improper pressure ulcer prevention, failure to maintain midline catheter dressings, respiratory care issues, inaccurate nurse staffing postings, inadequate food storage monitoring, and lapses in infection prevention and control practices.
Deficiencies (12)
F0550 (295.6000 Resident Rights) - The facility failed to ensure resident information was not in plain view of other residents and visitors, affecting one resident.
F0554 (295.6000 Resident Rights) - The facility failed to ensure medication and/or treatment was not left inside the room of a resident whose ability to safely self-administer medications was not assessed, affecting one resident and potentially all 54 residents on the 3rd floor.
F0584 (295.6000 Resident Rights) - The facility failed to provide a home-like environment due to holes, cracks, chipped paint, and damaged furniture in multiple resident rooms, affecting five residents.
F0600 (295.6000 Resident Rights) - The facility failed to perform timely criminal background checks and fingerprinting for new residents, affecting many residents and potentially all 137 residents.
F0607 (295.6000 Resident Rights) - The facility failed to ensure timely and complete health care worker background checks, including fingerprinting, for employees, potentially affecting all 137 residents.
F0676 (295.6000 Resident Rights) - The facility failed to provide communication devices identified on a resident's care plan, affecting one resident.
F0686 (295.6000 Resident Rights) - The facility failed to ensure low air loss mattresses were set to appropriate weight settings for four residents, risking pressure ulcer prevention.
F0694 (295.6000 Resident Rights) - The facility failed to follow policy for changing midline catheter dressings, resulting in a dressing not changed for one resident and signs of possible infection.
F0695 (295.6000 Resident Rights) - The facility failed to ensure safe respiratory care by not securing a nebulizer mask when not in use and not changing oxygen tubing weekly for two residents.
F0732 (295.6000 Resident Rights) - The facility failed to post daily nursing staffing information timely and accurately, affecting all residents.
F0812 (295.6000 Resident Rights) - The facility failed to maintain adequate monitoring of food storage temperatures, with missing temperature recordings for milk cooler.
F0880 (295.6000 Resident Rights) - The facility failed to ensure staff disposed of used personal protective equipment after sorting dirty linens and failed to post appropriate precaution signage for a resident on enhanced barrier precautions, risking infection spread.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 137
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 137
Residents affected: 137
Residents affected: 1
Inspection Report — Apr 8, 2024
Annual Inspection
Date: Apr 8, 2024
Visit Reason
Annual Licensure Survey. For this survey, the establishment is not in compliance with Part 295 due to failure to follow policy and procedure for resident assessment and documentation after a fall/incident.
Findings
The facility failed to complete an immediate assessment, incident report, and follow-up documentation after a resident fall, as required by their policy and procedure.
Deficiencies (1)
F0689 (Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents) - The facility failed to follow their policy and procedure for resident assessment and documentation after a fall/incident for 1 resident of 3 reviewed, including lack of immediate comprehensive assessment, incident report, and documentation of physical and mental status post-fall.
Report Facts
Residents affected: 1
Residents reviewed: 3
Inspection Report — Mar 29, 2024
Annual Inspection
Date: Mar 29, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility failed to provide timely incontinence care for one resident and failed to provide restorative services and adequate staffing to ensure restorative services for two residents. The facility's staffing shortages resulted in restorative aides being pulled to cover other duties, impacting resident care.
Deficiencies (3)
F0677 (295.2040) - The facility failed to provide timely incontinence care for one resident (R8) out of seven reviewed.
F0688 (295.2040) - The facility failed to follow their policy to conduct quarterly restorative assessments, follow therapy recommendations, and provide restorative services for two residents (R8 and R9) of nine reviewed.
F0725 (295.2040) - The facility failed to provide enough nursing staff daily to meet the needs of every resident and have a licensed nurse in charge on each shift, affecting restorative services for two residents (R8 and R9).
Report Facts
Residents affected: 1
Residents affected: 2
Inspection Report — Nov 17, 2023
Annual Inspection
Date: Nov 17, 2023
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to maintain confidentiality of resident information on social media, failure to timely report and investigate an injury of unknown source and alleged misappropriation of resident property, failure to conduct ongoing assessment and timely care for a resident with a femur fracture, and failure to administer medications according to physician orders.
Deficiencies (4)
F0583 (77 Ill. Adm. Code Part 295) - The facility failed to maintain confidentiality of medical records by using an unsecured social media platform to share residents' personal health information for 8 residents.
F0609 (77 Ill. Adm. Code Part 295) - The facility failed to timely report and investigate an injury of unknown source and an alleged misappropriation of resident property affecting 2 residents.
F0610 (77 Ill. Adm. Code Part 295) - The facility failed to conduct ongoing assessment and provide timely care for one resident who sustained a left femur fracture, resulting in pain and delayed hospital transfer.
F0755 (77 Ill. Adm. Code Part 295) - The facility failed to administer medications as ordered by the attending physician for 4 residents, omitting multiple prescribed medications during observed medication administration.
Report Facts
Residents affected: 8
Residents affected: 2
Residents affected: 1
Residents affected: 4
Inspection Report — Aug 25, 2023
Date: Aug 25, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type. The findings relate to food temperature issues observed during the survey.
Findings
The facility failed to maintain hot food temperatures at a minimum of 135F, potentially affecting 139 residents. Observations and interviews confirmed food served below required temperatures and late meal service.
Deficiencies (1)
F0812 (not explicitly stated section, but related to food temperature standards) - The facility failed to maintain hot food temperatures at or above 135F during tray assembly, risking food borne illness for many residents.
Report Facts
Residents affected: 139
Inspection Report — Jul 28, 2023
Annual Inspection
Date: Jul 28, 2023
Visit Reason
Annual Licensure Survey. For this survey, the establishment was found to have multiple deficiencies related to medication administration, fall prevention, and enteral tube feeding management.
Findings
The facility failed to ensure proper medication administration for residents, failed to provide adequate supervision and assistance to prevent falls resulting in fractures for two residents, and failed to follow physician orders for enteral tube feeding and flushing for one resident.
Deficiencies (3)
F0684 - The facility failed to ensure residents received medications according to physician orders, affecting 2 of 7 residents reviewed.
F0689 - The facility failed to provide adequate supervision and assistance to prevent falls, resulting in fractures for two residents with multiple fall histories and care plan needs for two-person mechanical lift transfers.
F0693 - The facility failed to follow physician orders for enteral tube feeding and flushing for one resident, including administering the correct amount and maintaining proper tube care.
Report Facts
Residents affected: 2
Residents affected: 2
Residents affected: 1
Inspection Report — May 19, 2023
Date: May 19, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type. The content describes a deficiency related to fall prevention and care plan interventions for resident R1.
Findings
The facility failed to ensure fall prevention interventions were updated and followed for one resident, resulting in two falls with subdural hematomas. The care plan lacked documentation of one-on-one supervision despite known risks.
Deficiencies (1)
F0689 (not explicitly stated Illinois section, but corresponds to fall prevention) - The facility failed to follow their policy to ensure fall prevention interventions in the care plan were updated and followed for 1 of 3 residents reviewed, leading to two falls with head hematomas.
Report Facts
Residents affected: 1
Inspection Report — Apr 14, 2023
Annual Inspection
Date: Apr 14, 2023
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to follow call light policies, medication administration errors, infection control lapses, incomplete care plans, and inadequate quality assurance activities. Several residents were affected by these issues, and the facility lacked certain policies and procedures required for safe and effective care.
Deficiencies (21)
F0558 - The facility failed to follow their call light policy to always place the call light in an accessible location for 6 residents in a sample of 27.
F0577 - The facility failed to have the most recent survey results available in a prominent and accessible area for residents and visitors to review.
F0583 - The facility failed to provide privacy and confidentiality for one resident's personal medication administration record.
F0656 - The facility failed to ensure that the comprehensive care plan was updated for one resident reviewed for accidents and hazards.
F0658 - The facility failed to meet professional standards of care in pharmaceutical services for 2 residents, including crushing extended-release medication and improper blood pressure monitoring.
F0689 - The facility failed to ensure safety measures for a high fall risk resident were followed for supervision and recommended safety equipment was in use.
F0695 - The facility failed to properly store respiratory supplies for one resident and ensure reusable equipment was cleaned after each resident use for seven residents.
F0755 - The facility failed to follow Medication Administration Guidelines for 2 residents observed during medication administration, including crushing extended-release medications and improper medication holding.
F0759 - The facility failed to maintain a medication error rate below 5%, with 2 medication errors out of 25 opportunities for 2 residents observed during medication administration.
F0760 - The facility failed to ensure that residents are free from significant medication errors, including administration of morphine without an order to one resident.
F0761 - The facility failed to ensure that medications on one of six medication carts were locked while not in use or in view.
F0803 - The facility failed to follow menu spreadsheets and recipe for pureed bread for 12 residents receiving a pureed diet consistency.
F0812 - The facility failed to ensure food items were properly labeled with dates, follow manufacturer guidelines for sanitizing and air-drying cooking equipment, and clean walk-in refrigerator and freezer door gaskets.
F0814 - The facility failed to ensure dumpster lids were fully closed to prevent the harborage of pests.
F0842 - The facility failed to maintain accurate resident record for a newly admitted resident with suspected Covid-19 to rule out infection.
F0865 - The facility failed to follow Quality Assurance / Performance Improvement Program (QAPI) policy and procedure by not establishing any QAPI programs to address care and services for the year 2022.
F0867 - The facility failed to follow Quality Assurance / Performance Improvement Program (QAPI) policy and procedure by not obtaining any data or feedback due to lack of QAPI program established for the year 2022.
F0880 - The facility failed to properly store respiratory supplies for one resident and ensure reusable equipment was cleaned after each resident use for seven residents.
F0883 - The facility failed to ensure residents' vaccination status is tracked and to provide education regarding influenza and pneumococcal immunization for five residents reviewed for immunization.
F0887 - The facility failed to develop policies and procedures to ensure each resident and staff member is educated and offered the COVID-19 vaccine and failed to provide education regarding the benefits and potential risks associated with COVID-19 vaccine to a resident who refused vaccination.
F0888 - The facility failed to develop policies and procedures to ensure that all staff are fully vaccinated for COVID-19.
Report Facts
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 7
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 12
Residents affected: 5
Residents affected: 133
Inspection Report — Mar 9, 2023
Date: Mar 9, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility was found to have multiple deficiencies related to medication self-administration assessments, call light accessibility, privacy of resident information, and medication cart security.
Deficiencies (4)
F0554 (295.2040) - The facility failed to assess two residents for knowledge and ability to self-administer medication safely before permitting unsupervised self-administration, resulting in unprescribed medications being kept at bedside without physician orders.
F0558 (295.2050) - The facility failed to ensure call lights were within reach for four residents, hindering their ability to summon assistance.
F0583 (295.2060) - The facility failed to maintain privacy of residents' personal and medical information, including leaving a medication cart unlocked with visible resident information and a urine collection bag visible from the hallway.
F0761 (295.2070) - The facility failed to ensure the medication cart was locked when not in visual proximity of the nurse, leaving medications unattended and accessible.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 1
Residents affected: 1
Inspection Report — Feb 2, 2023
Date: Feb 2, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to provide adequate supervision and assistive devices to prevent accidents for one resident, resulting in a fall with minimal harm.
Deficiencies (1)
F0689 (not explicitly stated section) - The facility failed to provide adequate supervision and assistive devices to prevent accidents in one of three residents reviewed, resulting in a fall and hospital evaluation.
Report Facts
Residents affected: 1
Loading inspection reports...
