Inspection Reports for Mill Creek Alzheimer‘s Special Care Center

The document is a plan of correction following an incident report investigation related to allegations IL 197942 and IL 198034.

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.

Allegations IL 197942 and IL 198034 were substantiated but no violations were cited.

The inspection was conducted following a facility-reported incident investigation related to falls involving one resident (R1) on 09/23/2025.

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.

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.

The annual survey was conducted to assess compliance with state regulations including physician assessments and tuberculosis screening procedures at Mill Creek Alzheimer's SCC.

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.

Original investigation for licensing of the assisted living facility Mill Creek Alzheimer's SCC.

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.

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.

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.

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.

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.

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.

The inspection was conducted as a complaint investigation for Complaint 2543924/IL191521 and an incident report investigation IL 190944.

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.

Complaint 2543924/IL191521 and Incident Report IL 190944 allegations were not substantiated; no violations cited.

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.

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.

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.

This document is a plan of correction following an original investigation and previous investigation of the assisted living facility.

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.