The most recent inspection on December 8, 2025, identified deficiencies related to incident reporting, physician assessments, service plans, dementia training, and resident rights concerning electronic monitoring. Earlier inspections showed a pattern of issues with following service plans, resident safety, employee background checks, and documentation, including substantiated complaints about wound care and a resident’s stolen wallet. Inspectors cited failures in completing physician assessments, ensuring staff received required dementia training, and protecting residents’ privacy and consent rights. Complaint investigations were mostly unsubstantiated except for the wound care and background check concerns, and no fines or enforcement actions were listed in the available reports. The facility’s deficiencies suggest ongoing challenges with documentation and resident care protocols without a clear trend of improvement or worsening.
Deficiencies (last 1 years)
Deficiencies (over 1 years)10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Annual Licensure Survey conducted to assess compliance with Illinois Department of Public Health regulations including incident reporting, physician assessments, service plans, Alzheimer's and dementia program training, and resident rights related to electronic monitoring.
Findings
The facility was found deficient in multiple areas including failure to report serious incidents within 24 hours, incomplete physician assessments for residents, inadequate service plans not addressing all resident needs and safety concerns, insufficient dementia-specific training for some staff, and failure to comply with resident rights regarding electronic monitoring including lack of consent forms and required signage.
Complaint Details
Investigation of complaint 25111370 / IL198673 was unsubstantiated with no violations written.
Severity Breakdown
Type 3 Violation: 3Type 2 Violation: 1General Violation: 1
Deficiencies (5)
Description
Severity
Failure to report serious incidents and accidents to the Department within 24 hours.
Type 3 Violation
Failure to ensure residents had a completed comprehensive physician assessment signed by a physician.
Type 3 Violation
Service plans did not address all needs and safety concerns of residents, including use of pressure relieving devices, medications increasing fall risk, and electronic monitoring devices.
Type 2 Violation
Failure to ensure all new employees received four hours of dementia-specific orientation prior to assuming job responsibilities without direct supervision.
Type 3 Violation
Failure to ensure residents' rights to dignity, privacy, and choice regarding electronic monitoring were protected, including lack of consent forms and required signage.
General Violation
Report Facts
Residents reviewed for physician assessment: 9Residents reviewed for service plan deficiencies: 9Employees reviewed for dementia training: 9Residents with electronic monitoring: 6
Employees Mentioned
Name
Title
Context
E1
Director of Health and Wellness
Interviewed regarding incident reporting and electronic monitoring consent and signage.
Z1
Advanced Practice Nurse (APN)
Signed progress notes used in resident physician assessments.
Z2
Advanced Practice Nurse (APN)
Signed progress notes used in resident physician assessments.
Z3
Advanced Practice Nurse (APN)
Signed progress notes used in resident physician assessments.
Inspection Report Deficiencies: 0Nov 3, 2025
Visit Reason
Investigation of a facility reported incident dated October 28, 2025.
Findings
The survey found the establishment in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act, with no findings.
The inspection was conducted following a facility-reported incident on 10/23/2025 concerning failure to follow service plan interventions related to wound care for a resident.
Findings
The facility failed to ensure that service plan interventions for wound dressing changes were followed for 1 of 3 residents reviewed. Dressings were found saturated with blood and not changed as ordered, posing a risk of infection, slow healing, and pain. Documentation of dressing changes was incomplete and the facility did not provide evidence of resident refusal or unavailability for care.
Complaint Details
The visit was complaint-related based on a facility-reported incident dated 10/23/2025. The complaint involved failure to follow wound care service plans, with substantiation implied by the deficiency findings.
Severity Breakdown
Type 2 Violation: 1
Deficiencies (1)
Description
Severity
Failure to ensure service plan interventions were followed for wound care and dressing changes for resident R1.
Type 2 Violation
Report Facts
Residents reviewed for service plans: 3Dressing change frequency: 2Date of incident: Oct 23, 2025
Employees Mentioned
Name
Title
Context
E1
Director of Health and Wellness
Provided statements regarding nursing responsibilities and dressing change protocols
E2
Registered Nurse
Reported communication with home health nurse about dressing changes
The inspection was conducted based on complaint investigations regarding healthcare worker background checks, resident safety related to service plans, and resident rights violations including alleged theft.
Findings
The facility failed to ensure mandated healthcare worker background checks were fully documented prior to employment for 9 of 10 employees reviewed. The facility also failed to follow the service plan related to safety for one resident who experienced an unwitnessed fall. Additionally, the facility failed to maintain a resident's right to be free from abuse and theft, as a resident's wallet was stolen and fraudulent charges were made on her credit card.
Complaint Details
The complaint investigation included allegations of theft of a resident's wallet and fraudulent credit card charges. The resident, who requires assistance to get out of bed, reported the theft and suspects a caregiver. The facility conducted an investigation including interviews and review of surveillance and key fob access logs but was unable to determine the exact circumstances of the theft. The caregiver suspected was terminated for unrelated performance issues. The police were notified and an investigation is pending.
Severity Breakdown
Type 2 Violation: 2
Deficiencies (3)
Description
Severity
Failed to ensure all mandated healthcare worker background website checks were completed and documented prior to employment for 9 of 10 employees reviewed.
Type 2 Violation
Failed to follow the service plan related to safety for 1 of 3 residents reviewed, resulting in an unwitnessed fall in a common area bathroom.
Type 2 Violation
Failed to maintain resident rights to be free from abuse and theft; resident's wallet was stolen and fraudulent charges were made on her credit card.
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Report Facts
Employees with incomplete background check documentation: 9Charges on resident's credit card: 14Resident sample size for safety review: 3Resident sample size for theft review: 5
Employees Mentioned
Name
Title
Context
E5
Caregiver
Suspected in resident wallet theft; terminated for unsatisfactory performance.
E1
Executive Director
Interviewed regarding background checks and theft investigation.
E4
Caregiver
Placed resident's wallet in purse during training of E5; interviewed during theft investigation.
E2
Wellness Director
Provided information on caregiver termination and fall incident.
E6
Memory Care Director
Reported fall incident and bathroom door locking procedures.
E7
Licensed Practical Nurse (LPN)
Reported on fall incident and bathroom door security.
E20
Licensed Practical Nurse (LPN)
Reported on resident fall and condition post-fall.
Z1
Resident's Husband
Provided statements denying involvement in wallet theft.
Z2
Resident's Daughter
Reported wallet missing and expressed concerns about theft.
Inspection Report Plan of CorrectionDeficiencies: 1May 19, 2025
Visit Reason
The document is a plan of correction submitted following a survey conducted on May 19, 2025, related to compliance with the Health Care Worker Background Check Act and other regulatory requirements.
Findings
The facility was found to be in compliance with the Health Care Worker Background Check Act but failed to retain documentation of six registry checks in employee files. An audit confirmed no employees had disqualifying crimes. The facility implemented training and auditing processes to ensure ongoing compliance.
Deficiencies (1)
Description
Failure to retain documentation of the six registry checks in employee files to support compliance with the Health Care Worker Background Check Act.