Inspection Reports for Luther Oaks
601 Lutz Rd, Bloomington, IL 61704, IL, 61704
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Inspection Report
Plan of Correction
Deficiencies: 0
Jan 2, 2026
Visit Reason
The survey was conducted following a facility reported incident (IL#199348) on 01/02/2026.
Findings
The establishment was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 23, 2025
Visit Reason
The inspection was conducted as an original investigation following a complaint regarding the theft of a resident's wallet at the facility.
Findings
The facility failed to prevent theft of a resident's wallet containing an ID and $30. The investigation revealed suspicion towards an agency nurse, who was subsequently terminated, although there was no definitive proof of theft.
Complaint Details
The complaint was substantiated as the facility failed to prevent theft of resident R1's wallet and money. The facility investigated and suspected an agency nurse but could not prove the theft.
Deficiencies (1)
| Description |
|---|
| Failure to prevent theft for one sampled resident. |
Report Facts
Amount stolen: 30
Date wallet found: Jun 8, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Confirmed theft and investigation details |
| E3 | Agency Nurse | Suspected of taking resident's wallet and terminated |
| Z1 | Resident's Son and POA | Provided information about resident's wallet and theft |
Inspection Report
Plan of Correction
Deficiencies: 1
Jun 23, 2025
Visit Reason
The visit was conducted as a complaint investigation related to resident rights, specifically regarding a theft incident involving a sampled resident.
Findings
The facility failed to prevent theft for one sampled resident. Corrective actions include assessment of the affected resident, inspection of other residents' belongings, policy review and updates, staff education, and ongoing monitoring to prevent recurrence.
Complaint Details
Complaint investigation related to theft affecting one resident; corrective actions and monitoring plans were implemented.
Deficiencies (1)
| Description |
|---|
| Failed to prevent theft for one sampled resident. |
Report Facts
Audit frequency: 5
Audit duration: 4
Audit duration: 2
Completion date: Jul 31, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health & Wellness Director | Responsible for auditing and monitoring compliance | |
| Director of Nursing | Responsible for auditing and monitoring compliance |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 13, 2025
Visit Reason
The inspection was conducted as an original investigation complaint (#2565185/IL194038) regarding failure to follow notification policies and medication reminder procedures.
Findings
The facility failed to notify a resident's family promptly about a hospital transfer and failed to properly observe and remind residents to take their medications, affecting two of four residents reviewed for medication management.
Complaint Details
Complaint #2565185/IL194038 regarding failure to notify family of resident's hospital transfer and failure in medication reminders and supervision.
Deficiencies (2)
| Description |
|---|
| Failure to follow notification policy by not notifying a resident's family for a change of condition/hospital transfer for one of four residents reviewed. |
| Failure to observe a resident take their medication during medication reminders and failure to provide medication reminders for another resident, two of four residents reviewed for medications. |
Report Facts
Residents reviewed for notification: 4
Residents reviewed for medication: 6
Residents with medication issues: 2
Date of hospital transfer: Jun 6, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Acting Director of Nursing | Provided statements regarding notification and medication reminder policies and staff education |
| E7 | Temporary Memory Care Administrator | Provided statements regarding notification policy |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 13, 2025
Visit Reason
The inspection was conducted in response to a complaint regarding medication reminders and supervision of self-medication, as well as failure to notify a resident's family about a change of condition or hospital transfer.
Findings
The facility failed to observe a resident taking medication during reminders and failed to provide medication reminders for another resident. Additionally, the facility did not notify a resident's family about a change of condition or hospital transfer as required.
Complaint Details
The complaint investigation found deficiencies related to medication reminders and failure to notify a resident's family about a change of condition or hospital transfer.
Deficiencies (2)
| Description |
|---|
| Failed to observe a resident take their medication during medication reminders and failed to provide medication reminders for another resident. |
| Failed to follow notification policy by not notifying a resident's family for a change of condition/hospital transfer. |
Report Facts
Residents reviewed for medications: 6
Residents reviewed for notification: 4
Residents affected: 2
Residents affected: 1
Monitoring period: 4
Monitoring period: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Health & Wellness Director | Responsible for auditing medication reminders and notification compliance | |
| Director of Nursing | Responsible for auditing medication reminders and notification compliance |
Inspection Report
Original Licensing
Deficiencies: 0
May 25, 2025
Visit Reason
Original investigation of FRI IL 192407 to determine 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 assisted living and shared housing regulations.
Inspection Report
Deficiencies: 0
Apr 8, 2025
Visit Reason
The survey was conducted 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 facility was found to be in compliance with the applicable assisted living and shared housing regulations during this survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 6, 2025
Visit Reason
Original investigation of complaint 2561467 / IL 186891.
Findings
The establishment is in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Complaint Details
Investigation of complaint 2561467 / IL 186891 resulted in compliance with applicable assisted living regulations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 20, 2025
Visit Reason
Original investigation of Complaint 2561165 / IL 186258.
Findings
The establishment is in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Complaint Details
Investigation of Complaint 2561165 / IL 186258 found the establishment in compliance with applicable assisted living regulations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 6, 2025
Visit Reason
Original investigation of Complaint 24610448 / IL 183151.
Findings
The establishment was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Complaint Details
Investigation of Complaint 24610448 / IL 183151 resulted in compliance with applicable assisted living regulations.
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 22, 2024
Visit Reason
The inspection was conducted as an original complaint investigation related to allegations that the facility failed to provide meals and showers as specified in residents' service plans.
Findings
The facility was found to have failed to provide meals and showers per the service plans for three residents (R1, R2, and R4) in a sample of six. Documentation and interviews revealed missed meals for R1 and inconsistent shower assistance and documentation for R1, R2, and R4.
Complaint Details
Original complaint investigation #2469359/IL180976 cited a violation of Section 295.6000 a)5) related to resident rights. Another complaint investigation #2469481/IL181211 found no violation.
Severity Breakdown
Type 3 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide meals and showers per resident's service plans for three residents (R1, R2, and R4). | Type 3 Violation |
Report Facts
Residents reviewed for service plans: 6
Residents with service plan deficiencies: 3
Showers documented for R1: 4
Showers refused by R1: 2
Showers documented for R2: 7
Showers documented for R4: 6
Showers refused by R4: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing | Provided statements regarding meal mix-up and shower documentation issues |
| E3 | Assistant Director of Nursing | Discussed problems with shower documentation and procedures |
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