4 Reports
Inspection Report — May 17, 2026
Complaint Investigation
Date: May 17, 2026
Visit Reason
Facility Reported Incident of 3/16/2026/IL201115 and Facility Reported Incident of 3/23/2026/IL200897 involving sections 295.2050a)b), 295.4010a)c), 295.9040a).
Complaint Details
Facility Reported Incident of 3/16/2026/IL201115 - Sections 295.2050a)b), 295.4010a)c), 295.9040a) cited. Facility Reported Incident of 3/23/2026/IL200897 - Sections 295.2050a)b), 295.4010a)c), 295.9040a) cited.
Findings
The facility failed to report an incident resulting in a resident's unknown injury within 24 hours and failed to follow service plans for three residents, including supervision and documentation. The facility also failed to provide a safe environment for one resident by not ensuring emergency pull cords were accessible.
Deficiencies (3)
A2050 (295.2050 Incident and Accident Reporting) - The facility failed to report an incident that resulted in resident R1's right humerus fracture to the Illinois Department of Public Health within 24 hours of the incident.
A4010 (295.4010 Service Plan) - The facility failed to follow service plans to keep three residents (R1, R4, R5) in a safe supervised environment and failed to ensure one resident's (R4) service plan was signed and dated by the POA.
A9040 (295.9040 Environmental Requirements) - The facility failed to provide a safe environment for resident R4 by having the emergency pull cord in the bathroom tied up and out of reach.
Report Facts
Residents affected: 3
Residents in memory care unit: 24
Residents in activity room unsupervised: 14
Residents reviewed for reporting: 4
Inspection Report — Sep 19, 2025
Complaint Investigation
Date: Sep 19, 2025
Visit Reason
Original investigation of FRI IL 197269.
Complaint Details
Facility Reported Incident (FRI) IL 197269: Section 295.6000 a)13) cited.
Findings
The establishment neglected to address one of three residents experiencing pain and vomiting. The caregiver responsible was terminated for failure to follow required overnight protocol.
Deficiencies (1)
A6000 (295.6000 Resident Rights) - The establishment neglected to address one of three residents experiencing pain and vomiting, resulting in a substantial probability of harm.
Report Facts
Residents affected: 1
Residents reviewed: 3
Inspection Report — Feb 18, 2025
Plan of Correction
Date: Feb 18, 2025
Visit Reason
This plan of correction answers a survey that cited violations of Section 295.5000 & 295.6000 during an investigation of a self-reported incident on February 5, 2025.
Findings
The facility implemented enhanced security and monitoring protocols for hospice comfort kit medications, including weekly audits by hospice nurses and a double-lock security system. Medication quantities were optimized and protocols will be continuously monitored for compliance and effectiveness.
Inspection Report — Feb 5, 2025
Complaint Investigation
Date: Feb 5, 2025
Visit Reason
Entity Reported Incident Investigation IL184971 was substantiated with no deficiency cited. IL183665 was substantiated with violations of 295.5000 and 295.6000 cited.
Complaint Details
Entity Reported Incident Investigation IL184971: Substantiated, no deficiency cited. IL183665: Substantiated, 295.5000, 295.6000 cited.
Findings
The establishment failed to follow their policy on controlled medication storage and shift-to-shift counts, resulting in missing controlled substances for residents R16 and R17. The facility reported the incident to police and could not identify who took the medications.
Deficiencies (2)
A5000 (295.5000 Medication Reminders, Supervision of Self Med) - The establishment failed to follow their policy and procedure on controlled medication storage and supervision, affecting four residents reviewed.
A6000 (295.6000 Resident Rights) - The establishment failed to prevent misappropriation of controlled medications paid for by residents, affecting two residents reviewed.
Report Facts
Residents affected: 4
Residents affected: 2
Medication missing: 28.75
Medication missing: 19.25
Medication missing: 30
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