Inspection Reports for Mill Creek Alzheimer‘s Special Care Center
3319 Ginger Creek Dr, Springfield, IL 62711, United States, IL, 62711
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 29, 2025, found that two substantiated complaints did not result in any cited violations. Earlier inspections identified deficiencies related to fall prevention, medication administration, physician assessments, tuberculosis screenings, and staffing for elopement prevention. Inspectors cited failures to implement fall prevention interventions after resident injuries, missed medication administrations affecting multiple residents, incomplete physician assessments, and insufficient staffing and training to prevent elopement. Complaint investigations included substantiated findings for falls and elopement incidents, while most other complaints were unsubstantiated. The facility has taken corrective actions such as staff training, adding alarms, and policy updates, but the pattern of deficiencies suggests ongoing challenges with resident safety and care processes.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 29, 2025
Visit Reason
The document is a plan of correction following an incident report investigation related to allegations IL 197942 and IL 198034.
Complaint Details
Allegations IL 197942 and IL 198034 were substantiated but no violations were cited.
Findings
Both allegations were substantiated, but no violations were cited. 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
Date: Sep 30, 2025
Visit Reason
The inspection was conducted following a facility-reported incident investigation related to falls involving one resident (R1) on 09/23/2025.
Complaint Details
The visit was complaint-related based on a facility-reported incident involving resident R1's falls on 09/23/2025. The complaint was substantiated as the facility neglected to implement required fall prevention interventions.
Findings
The facility failed to implement fall prevention interventions for resident R1, who fell twice on 09/23/2025 resulting in injuries including skin tears and fractures. The resident was found unattended in an area where supervision was required, violating resident rights and fall prevention policies.
Deficiencies (1)
Failure to ensure fall prevention interventions were implemented to prevent further falls for one resident, resulting in harm.
Report Facts
Fall Risk Evaluation Score: 12
SLUMS Assessment Score: 7
Blood Pressure: 14782
Temperature: 96.8
Pulse: 71
Respirations: 16
Pulse Oximetry: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activities Staff (E6) | Witnessed R1's first fall at 12:00 PM on 09/23/2025. | |
| Health Services Director (E2) | Primary Care Physician and involved in notification and fall prevention oversight. | |
| Caregiver (E3) | Observed R1 on 09/29/2025 and described resident's condition and fall risk. | |
| Registered Nurse (E4) | Nurse on duty during R1's second fall at 07:20 PM on 09/23/2025, provided care and notified physician. | |
| Wellness Director (E2) | Stated R1 was self-propelling wheelchair unattended at time of fall and confirmed supervision interventions were not implemented. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Aug 7, 2025
Visit Reason
The annual survey was conducted to assess compliance with state regulations including physician assessments and tuberculosis screening procedures at Mill Creek Alzheimer's SCC.
Findings
The facility failed to ensure that annual physician assessments were completed and signed by a physician for three of five residents reviewed. Additionally, the facility did not conduct annual tuberculosis screenings for four of five residents reviewed.
Deficiencies (2)
Failure to ensure a Physician's Assessment was completed and signed by the Physician annually for three of five residents reviewed.
Failure to conduct an annual Tuberculosis screening for four of five residents reviewed.
Report Facts
Residents reviewed for Physician's Assessments: 5
Residents with missing annual Physician's Assessment: 3
Residents reviewed for Tuberculosis screening: 5
Residents with missing annual Tuberculosis screening: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Confirmed missing physician signatures on assessments for residents R3, R4, and R5 |
| E2 | Health Services Director | Confirmed missing annual Tuberculosis screenings for residents R2, R3, R4, and R5 |
| E4 | Nurse Practitioner | Signed physician assessments that were not signed by a physician for residents R3 and R4 |
Inspection Report
Original Licensing
Deficiencies: 0
Date: Jul 18, 2025
Visit Reason
Original investigation for licensing of the assisted living facility Mill Creek Alzheimer's SCC.
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.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 26, 2025
Visit Reason
The document is a Plan of Correction related to a Medication Administration Self Report Survey conducted on June 26, 2025, addressing medication management and medication error policies following an incident.
Findings
The report indicates that all licensed nursing staff were in-serviced post-incident regarding medication management and error policies. The Health Service Director will continue education and monitoring to ensure compliance with facility policies and regulatory guidelines, including adherence to resident service plans.
Report Facts
Date of Survey: Jun 26, 2025
Corrective action effective date: Jun 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jen Hubbert | Executive Director | Signed the Plan of Correction letter |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jun 26, 2025
Visit Reason
The inspection was conducted following a facility-reported incident investigation regarding a failure to administer physician-ordered medications to residents on the evening of 06-14-2025.
Complaint Details
The complaint investigation was triggered by a facility-reported incident where a nurse failed to administer medications to 17 residents on 06-14-2025. The nurse was suspended and terminated after investigation. The Health Services Director and Executive Director were notified, and resident representatives and physicians were informed.
Findings
The investigation found that a registered nurse (E3) failed to administer evening medications to 17 residents (R1 through R17) on 06-14-2025, did not communicate this failure to other staff or supervisors timely, and was subsequently suspended and terminated. No adverse reactions were noted in residents. The facility notified all resident power of attorneys and physicians about the incident.
Deficiencies (3)
Failure to ensure residents R1 through R17 received physician ordered medications on the evening of 06-14-2025.
Failure to follow medication policy and procedure regarding medication administration and communication.
Failure to ensure residents received services specified in their service plans, including medication administration.
Report Facts
Residents affected: 17
Incident date: Jun 14, 2025
Suspension date: Jun 15, 2025
Termination date: Jun 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Registered Nurse | Failed to administer medications to 17 residents, did not communicate failure, was suspended and terminated. |
| E1 | Executive Director | Notified about medication incident, confirmed no residents were affected, and documented nurse termination. |
| E2 | Health Services Director | Notified about medication incident, placed nurse E3 on suspension, notified resident representatives and physicians. |
| E5 | Nurse | Took over medication carts after E3 left, was not informed by E3 about missed medications. |
| E4 | Licensed Practical Nurse | Notified E2 about incomplete medication pass on 06-14-2025. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 6, 2025
Visit Reason
The inspection was conducted as a complaint investigation for Complaint 2543924/IL191521 and an incident report investigation IL 190944.
Complaint Details
Complaint 2543924/IL191521 and Incident Report IL 190944 allegations were not substantiated; no violations cited.
Findings
The complaint and incident report allegations could not be substantiated, and no violations were cited. The facility 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
Date: Apr 3, 2025
Visit Reason
The inspection was conducted following an incident where resident R1 eloped from the facility on 04-03-2025, traveling 0.4 miles to a neighboring community. The investigation focused on the facility's compliance with staffing and safety regulations related to Alzheimer's and dementia care.
Complaint Details
The visit was complaint-related due to an elopement incident involving resident R1 on 04-03-2025. The complaint was substantiated by the investigation, which confirmed the facility's failure to prevent the elopement.
Findings
The facility failed to ensure resident safety to prevent elopement, as evidenced by R1 leaving the establishment unnoticed. The service plan did not document R1 as an elopement risk. Staff interviews and checks revealed no alarms sounded during the elopement, and the facility was unable to confirm how R1 exited. The facility has since added alarms, door closers, and conducted staff training and drills.
Deficiencies (1)
Failure to provide an appropriate number of staff with adequate skills and training to meet residents' needs and prevent elopement.
Report Facts
Distance traveled during elopement: 0.4
Date of elopement: Apr 3, 2025
Time elopement discovered: 1333
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | E1 checked windows and doors for alarms and ordered additional alarms and door closers after the incident | |
| Health Services Director | E2 stated she was unaware of R1's previous elopement and would have taken preventive measures if informed |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 20, 2024
Visit Reason
This document is a plan of correction following an original investigation and previous investigation of the assisted living facility.
Findings
The facility 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 during this survey.
Viewing
Loading inspection reports...
