Inspection Reports for
PLYMOUTH PLACE, INC. (Assisted Living)
315 N LaGrange Rd, LaGrange Park, IL, 60526
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
120% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
99% occupied
Based on a January 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jul 21, 2025
Visit Reason
Annual Licensure Survey conducted to assess compliance with state regulations for Plymouth Place, Inc., a memory care facility.
Findings
The facility failed to adequately revise and implement service plans addressing residents' physical and behavioral needs, including aggressive behaviors, elopement risks, fall injuries, and cast care. Additionally, the facility did not ensure required dementia-specific orientation training for newly hired direct care and non-direct care staff.
Deficiencies (2)
Failure to revise service plans to address physical and verbally aggressive behaviors, elopement and exit seeking behaviors, fall injury interventions, cast care, and staff responsibilities for residents in the memory care unit.
Failure to ensure all staff members received required dementia-specific orientation training prior to assuming job responsibilities, including 4 hours of orientation and 16 hours of on-the-job training for direct care staff.
Report Facts
Residents reviewed for behaviors: 5
Residents with unwitnessed fall incidents: 3
Newly hired employees reviewed: 8
Dementia orientation hours incomplete: 3.75
Dementia orientation hours incomplete: 3
Dementia orientation hours incomplete: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Resident Care Aide | Did not complete required dementia-specific orientation hours |
| E2 | Licensed Practical Nurse | Did not complete required dementia-specific orientation hours |
| E3 | Resident Aide | Did not complete required dementia-specific orientation hours |
| E4 | Resident Aide | Did not complete required dementia-specific orientation hours |
| E5 | Resident Aide | Did not complete required dementia-specific orientation hours |
| E6 | Life Enrichment Staff | Did not complete required dementia-specific orientation hours |
| E7 | Server | Did not complete required dementia-specific orientation hours |
| E8 | Maintenance | Did not complete required dementia-specific orientation hours |
| E9 | Executive Director | Acknowledged lack of dementia training records for employees |
| E10 | Clinical Nurse Lead | Unable to explain why service plan concerns were not addressed |
Inspection Report
Annual Inspection
Census: 77
Deficiencies: 6
Date: Jan 24, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey of Plymouth Place nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, room comfort and heating, fall prevention and safe resident transfers, food safety and kitchen sanitation, bed safety, and sharps disposal container management.
Deficiencies (6)
F 0554: The facility failed to ensure residents were assessed to self-administer medications and keep them at their bedsides. Several residents had unlabeled or unauthorized medications at bedside without physician orders.
F 0584: The facility failed to provide a warm, comfortable room as a heating unit in a resident's room was broken for more than a week and repair was delayed.
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent falls. Multiple residents experienced falls or unsafe conditions related to bed and transfer safety.
F 0812: The facility failed to maintain the kitchen in a manner to prevent foodborne illness. Issues included dented cans, unlabeled and undated food items, improper food storage order, and inadequate sanitizer monitoring.
F 0909: The facility failed to ensure resident beds were safely maintained. Beds had exposed frames, unsecured mattresses, and missing safety latches increasing risk of injury.
F 0921: The facility failed to ensure residents' rooms with sharps disposal containers were safely maintained. Several sharps containers were overfilled beyond the safe fill line.
Report Facts
Residents served by dietary services: 77
Residents reviewed for medication storage: 23
Residents reviewed for homelike environment: 23
Residents reviewed for safety and accidents: 23
Residents reviewed for resident equipment: 23
Residents reviewed for facility environment: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided statements regarding medication self-administration, fall prevention, bed safety, and sharps disposal |
| V3 | Culinary Director | Provided statements regarding kitchen conditions, food storage, and sanitizer procedures |
| V1 | Administrator | Provided statements regarding room heating issues and maintenance procedures |
| V10 | Licensed Practical Nurse | Reported on resident fall incident and transfer safety |
| V7 | Certified Nurse Assistant | Reported on resident fall incident and bed safety |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 2, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding inadequate wound care and failure to properly assess and treat residents' wounds, including a resident who required leg amputation after discharge.
Complaint Details
The investigation was complaint-driven, focusing on wound care deficiencies that led to a resident's hospitalization and amputation. The complaint was substantiated with findings of inadequate wound assessment, treatment, and documentation.
Findings
The facility failed to ensure proper wound assessments and treatments were performed and documented, including failure to notify physicians and incomplete wound care documentation. One resident was discharged with untreated wounds that led to gangrene and an above-the-knee amputation. Additionally, wound care treatments were documented as completed on days when the wound care nurse was absent.
Deficiencies (1)
F 0684: The facility failed to provide appropriate wound care and assessments, resulting in a resident developing gangrene and requiring leg amputation. Documentation was incomplete and wound care treatments were falsely recorded as completed on days the nurse was absent.
Report Facts
Residents reviewed for wound care: 8
Hours worked by wound care nurse on December 18, 2024: 0.5
Length of R4's left hip incision: 6
Wound measurement: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 | Wound Care Nurse / Licensed Practical Nurse | Named in findings for failing to properly assess wounds, document wound care, and falsely documenting wound care treatments. |
| V1 | Administrator | Provided statements regarding wound care documentation failures and nurse's absence. |
| V8 | Attending Physician | Commented on wound progression and lack of notification about wound status. |
| V7 | Licensed Practical Nurse | Discharged resident R1 and stated no head-to-toe skin assessment was done on discharge day. |
| V5 | Certified Nursing Assistant | Reported observations of resident R1's toe discoloration prior to discharge. |
| V9 | Registered Nurse | Signed treatment administration record and acknowledged seeing toe discoloration but did not notify physician. |
| V10 | Vascular Surgery Nurse Practitioner | Documented hospital admission and diagnosis of ischemic toes and gangrene. |
| V11 | Hospital Podiatrist | Documented surgical recommendations and amputation outcome. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 22, 2024
Visit Reason
Annual Licensure Survey 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 establishment was found to be in compliance with the applicable assisted living and shared housing regulations during this annual licensure survey.
Inspection Report
Routine
Census: 68
Deficiencies: 2
Date: Feb 16, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety standards, specifically focusing on proper labeling, dating, sealing, and storage of food items in the kitchen.
Findings
The facility failed to properly label, date, seal, and store food items in the kitchen, including expired and dented canned goods, unlabeled and unsealed food containers, and improper hair restraint use by staff. These deficiencies pose a risk of foodborne illness to residents.
Deficiencies (2)
F 0812: The facility failed to properly label, date, seal, and store food items in the kitchen, including opened meats, dented cans, expired products, and unlabeled produce and prepared foods.
Staff failed to wear hair restraints properly; the Director of Food and Nutrition's hair net did not restrain her bangs, risking contamination.
Report Facts
Resident census: 68
Expired food items: 2
Dented cans: 4
Unlabeled food items: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietician (V4) | Provided statements on food labeling, expiration, and contamination risks | |
| Director of Food and Nutrition (V5) | Present during kitchen tour; hair net not worn properly | |
| Executive Chef (V6) | Present during kitchen tour; commented on freezer burn causes |
Inspection Report
Routine
Census: 62
Deficiencies: 12
Date: Mar 30, 2023
Visit Reason
Routine inspection of Plymouth Place nursing home to assess compliance with resident rights, care quality, infection control, safety, and dietary standards.
Findings
The facility failed to ensure resident dignity and privacy during care, proper grievance resolution, assistance with personal hygiene, pressure ulcer care, range of motion exercises, safe resident transfers, urinary catheter care, infection control practices, and proper food preparation and serving sizes. Several residents were affected by these deficiencies.
Deficiencies (12)
F 0550: Facility failed to treat residents with dignity during care by not introducing staff, not explaining procedures, and leaving residents uncovered or addressed improperly.
F 0577: Facility failed to post survey results in a conspicuous area accessible to residents and visitors.
F 0583: Facility failed to ensure privacy during nursing care by leaving residents uncovered during care procedures.
F 0585: Facility failed to address resident grievances regarding staffing and call light response times documented over a year without resolution.
F 0677: Facility failed to assist residents with personal hygiene including nail and facial hair care for multiple residents.
F 0686: Facility failed to reposition a resident with a stage 4 pressure ulcer per plan of care, resulting in prolonged sitting beyond recommended time.
F 0688: Facility failed to provide passive range of motion exercises as required for a resident with limited mobility, with inconsistent documentation and performance.
F 0689: Facility failed to ensure safe transfers and wheelchair transport, resulting in a resident fall with head injury requiring sutures and emergency care.
F 0690: Facility failed to provide proper incontinence and urinary catheter care, including incomplete cleaning of peri-area and catheter tubing, and improper placement of drainage bags.
F 0803: Facility failed to follow recipe guidance and serving size standards for pureed diets, resulting in incorrect portion sizes and recipe preparation.
F 0812: Facility failed to maintain sanitary conditions in kitchen including improper glove use during dishwashing and dirty ingredient containers and equipment.
F 0880: Facility failed to follow infection control practices including hand hygiene and isolation precautions, allowing potential spread of infection among residents.
Report Facts
Resident census: 62
Residents affected: 2
Residents affected: 62
Residents affected: 7
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 4
Residents affected: 2
Residents affected: 62
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Named in findings related to dignity, personal hygiene, pressure ulcer care, range of motion, falls, catheter care, and infection control |
| V20 | Certified Nursing Assistant | Named in dignity, privacy, incontinence care, and infection control findings |
| V22 | Certified Nursing Assistant | Named in privacy, catheter care, infection control, and transfer safety findings |
| V23 | Certified Nursing Assistant | Named in catheter care and infection control findings |
| V25 | Nurse | Named in catheter care and infection control findings |
| V6 | Registered Dietitian | Named in pureed diet recipe and serving size findings |
| V8 | Utility Employee | Named in kitchen sanitation findings |
| V7 | Executive Chef | Named in kitchen sanitation findings |
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