Inspection Reports for Silverado St. Charles Memory Care Community
IL, 60174
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 29, 2025, identified a deficiency related to the monitoring of residents’ narcotic analgesic patches, which were missing or improperly placed for some residents. Earlier inspections showed mixed results, including issues with staffing qualifications and failure to provide timely care that led to a resident developing a facility-acquired unstageable heel ulcer. Inspectors also cited failures in required reporting procedures during a complaint investigation in February 2025, although the underlying abuse allegation was found unsubstantiated. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The pattern suggests ongoing challenges with medication monitoring and staffing, with no clear indication of improvement or worsening over time.
Deficiencies (last 1 years)
Deficiencies (over 1 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 29, 2025
Visit Reason
The inspection was conducted following a facility-reported incident on 10/22/2025 regarding medication administration issues, specifically related to the supervision and monitoring of residents' narcotic analgesic patches.
Findings
The facility failed to monitor narcotic analgesic patches to ensure they were administered for the duration ordered by the physician for 2 of 3 residents reviewed. Patches were found missing or improperly placed, posing a substantial probability of harm. The facility implemented new procedures including shift checks and covering patches with Tegaderm but had not updated policy.
Deficiencies (1)
Failure to monitor residents' narcotic analgesic patches to ensure administration for the duration ordered by the physician.
Report Facts
Residents reviewed for medication administration: 3
Residents with medication administration failure: 2
Fentanyl patch dosage for R1: 12
Fentanyl patch dosage for R2: 50
Facility policy date: 61524
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Licensed Practical Nurse | Reported missing patches and described medication administration events |
| E4 | Licensed Practical Nurse | Reported missing patches and assisted with patch placement |
| E2 | Nurse | Described medication administration and patch monitoring procedures |
| E1 | Administrator | Confirmed inservice and new procedures for patch monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 19, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on an allegation that a resident was made uncomfortable by staff during a shower.
Complaint Details
The complaint investigation was triggered by an allegation on 2/12/25 that a resident was made uncomfortable by staff during a shower. The allegation was investigated and determined to be unsubstantiated. However, the facility failed to notify the Department or submit a written report of the investigation as required.
Findings
The establishment failed to notify the Department within 24 hours of the abuse allegation and did not develop or submit a written report of the investigation within the required timeframe. The allegation was investigated internally and found unsubstantiated, but the required reporting to the Department was not completed.
Deficiencies (1)
Failure to notify the Department within 24 hours of an abuse allegation and failure to develop and submit a written report of the investigation within 14 days and 24 hours respectively.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Administrator | Interviewed regarding the abuse allegation and confirmed failure to report to the Department or complete a written investigation report. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 19, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on an allegation that a resident was made uncomfortable by staff during a shower.
Complaint Details
The complaint investigation was triggered by an allegation on 2/12/25 that a resident was made uncomfortable by staff during a shower. The allegation was investigated and found unsubstantiated. The facility did not notify the Department or submit a written report of the investigation as required.
Findings
The facility failed to notify the Department within 24 hours of the abuse allegation and did not develop or submit a written report of the investigation within 14 days as required. The allegation was investigated internally and found unsubstantiated, but the required reporting to the Department was not completed.
Deficiencies (1)
Failure to notify the Department within 24 hours of an abuse allegation and failure to develop and submit a written report of the investigation within 14 days.
Report Facts
Residents reviewed: 3
Date of complaint allegation: Feb 12, 2025
Date of complaint investigation: Feb 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Administrator | Named in relation to failure to report abuse allegation and complete investigation report |
| Director of Nursing | Mentioned as backup reporter and responsible for investigation completion |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 5, 2025
Visit Reason
The inspection was conducted as a facility reported incident (FRI) investigation related to complaints IL 183658, IL 184048, and IL 178973.
Complaint Details
Investigation of facility reported incidents IL 183658, IL 184048, and IL 178973 concluded with the facility in compliance.
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
Annual Inspection
Deficiencies: 1
Date: Feb 5, 2025
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with personnel requirements, qualifications, and training regulations at Silverado St Charles memory care facility.
Findings
The facility failed to have sufficient staff with adequate skills, education, and experience to immediately address monitoring and healing interventions for a resident (R5) who developed a blister on the left heel, which progressed to a facility-acquired unstageable heel ulcer due to lack of timely intervention and monitoring.
Deficiencies (1)
Failure to have staff sufficient with adequate skills, education, and experience to immediately address monitoring and healing interventions for one resident who developed a blister to the left heel, resulting in a facility-acquired unstageable heel ulcer.
Report Facts
Resident age: 72
Blister size: 5
Pressure ulcer size: 4
Pressure ulcer size: 1.8
Pressure ulcer size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing | Stated resident R5's condition and confirmed lack of monitoring and interventions for pressure ulcer |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 5, 2025
Visit Reason
The Illinois Department of Public Health conducted an annual survey for Silverado St. Charles to assess compliance with the Assisted Living and Shared Housing Establishment Code Section 295.3000.
Findings
The facility failed to meet personnel requirements, qualifications, and training standards, resulting in a Type 2 violation. Specifically, inadequate staffing and failure to provide timely monitoring and healing interventions led to a resident developing a facility-acquired unstageable heel ulcer.
Deficiencies (1)
Failure to have sufficient staff with adequate skills, education, and experience to meet resident needs and provide ongoing training.
Report Facts
Resident age: 72
Wound measurements: 5
Wound measurements: 4
Wound measurements: 1.8
Dates of documentation: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jill Parrish | Administrator | Signed letter regarding annual license survey |
| Director of Nursing | Named in plan of correction to ensure timely and accurate documentation and wound care | |
| Assistant Director of Nursing | Named in plan of correction to ensure timely and accurate documentation and wound care | |
| E2 | Director of Nursing (DON) | Provided statements about resident mobility and wound care |
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