Inspection Report Summary
The most recent inspection on August 1, 2024, identified deficiencies related to the facility’s resident satisfaction survey, quality improvement program, employee orientation, and memory care training. Earlier inspections were not provided for comparison, so it is unclear whether these issues are recurring or new. The main themes of deficiencies involved documentation and staff training requirements, particularly in memory care and employee orientation. No complaint investigations or enforcement actions were listed in the available reports. Without additional data, no clear trend in compliance can be determined.
Deficiencies (last 1 years)
Deficiencies (over 1 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 3
Aug 1, 2024
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with state regulations including quality improvement, employee orientation and training, and Alzheimer's and dementia program requirements.
Findings
The facility failed to provide evidence of a resident satisfaction survey and Quality Improvement Program, did not ensure completion of required employee orientation for 2 of 5 employees reviewed, and failed to document 16 hours of on-the-job training in memory care for 5 caregivers.
Severity Breakdown
Type 3: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to present evidence of resident satisfaction survey and Quality Improvement Program affecting all 31 residents. | Type 3 |
| Failure to ensure completion of employee orientation as required for 2 employees (E8, E9) out of 5 reviewed. | Type 3 |
| Failure to ensure completion of 16 hours of on-the-job training in memory care for 5 caregivers (E6, E7, E8, E9, E10). | Type 3 |
Report Facts
Resident census: 31
Employees missing orientation training: 2
Caregivers missing memory care training: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Involved in receiving requests and acknowledging missing documentation |
| E2 | Director of Nursing | Presented with written request for documentation |
| E3 | Assistant Director of Nursing | Presented with written request for documentation |
| E8 | Certified Nursing Assistant | Missing documentation of orientation and disaster preparedness training |
| E9 | Certified Nursing Assistant | Missing documentation of orientation, resident rights, HIPAA, disaster preparedness, and abuse training |
| E11 | Human Resources | Responsible for employee files and training documentation; acknowledged missing training |
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