Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 29, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to report a fall incident involving a resident to the state agency.
Findings
The facility failed to report a fall incident involving resident R1 to the state agency within 24 hours as required. R1 was found lying on the floor with injuries consistent with a fall, but the incident was not documented or reported in a timely manner, resulting in a Type 3 violation.
Complaint Details
Complaint Investigation: 25910138/IL198097- 295.2050a)b). The complaint involved failure to report a fall incident of resident R1 who was receiving hospice care and expired on 4/25/25. The fall was observed on video, and the facility staff did not document or report the incident timely.
Severity Breakdown
Type 3 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report a fall incident involving resident R1 to the state agency within 24 hours as required by Section 295.2050 Incident and Accident Reporting. | Type 3 Violation |
Report Facts
Residents reviewed: 3
Date of fall incident: Apr 25, 2025
Date of resident admission: Apr 23, 2023
Date of resident expiration: Apr 25, 2025
Date of staff termination: May 5, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Notified of the fall incident and interviewed regarding the video footage |
| E2 | Director of Resident Care | Notified of the fall incident |
| E3 | Resident Care Coordinator | Notified of the fall incident |
| E6 | Lead Care Manager | Did not document the fall incident in a timely manner and was terminated |
| Z1 | Daughter of resident R1 | Reported observing the fall on video footage |
Inspection Report
Annual Inspection
Deficiencies: 4
Sep 2, 2025
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with state regulations for assisted living and dementia care programs at Sunrise of Flossmoor.
Findings
The facility failed to revise service plans for residents regarding urinary catheter care, fall incident interventions, and sling application/removal for a fractured clavicle. Additionally, the facility did not provide required dementia-specific training for newly hired direct care staff and lacked documentation of management qualifications for the Reminiscence Care Coordinator.
Deficiencies (4)
| Description |
|---|
| Failure to revise service plans addressing care and responsibility for maintenance of an indwelling urinary catheter for one resident. |
| Failure to revise service plans for application and removal of a sling and compression stockings for a resident with a fractured clavicle and fall incidents. |
| Failure to provide required 16 hours of on-the-job dementia-specific training for newly hired direct care staff. |
| Lack of documentation of college degree or two years management experience in dementia care for the Reminiscence Care Coordinator. |
Report Facts
Personnel files reviewed: 9
Personnel files with training deficiencies: 4
Resident falls documented: 3
Resident age: 90
Resident age: 91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E11 | Executive Director | Provided information during exit conference regarding urinary catheter care and staff training. |
| E10 | Business Office Coordinator | Assisted surveyor in reviewing personnel files and provided information on dementia care qualifications. |
| E9 | Reminiscence Care Coordinator | Lacked documented college degree or required management experience in dementia care. |
| E1 | Licensed Practical Nurse | Personnel file reviewed; did not complete required dementia training. |
| E5 | Licensed Practical Nurse | Personnel file reviewed; did not complete required dementia training. |
| E6 | Care Manager | Personnel file reviewed; did not complete required dementia training. |
Inspection Report
Plan of Correction
Deficiencies: 1
May 31, 2025
Visit Reason
The document is a Plan of Correction submitted in response to a facility reported incident dated 3/29/25, related to a Statement of Finding from the Illinois Department of Public Health.
Findings
The Plan of Correction addresses a resident's skin tear incident, detailing immediate treatment, removal of a resident from the community, updates to the service plan, and staff retraining on abuse prevention and resident rights. Monitoring and ongoing compliance measures are outlined.
Deficiencies (1)
| Description |
|---|
| Resident R1 had a skin tear requiring treatment and monitoring; resident E9 was removed from the community following a statement. |
Report Facts
Date of Survey: May 31, 2025
Date of Incident: Mar 29, 2025
Plan of Correction Target Dates: Mar 29, 2025
Plan of Correction Target Date: Apr 2, 2025
Plan of Correction Target Date: Apr 30, 2025
Plan of Correction Target Date: Jun 30, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Edwina Winton | Executive Director | Signed letter and responsible for compliance and corrective actions |
| Suzanne Reynolds | Resident daughter notified about the incident | |
| DR Joshi | MD | Made aware of the incident and provided new orders for evaluation and treatment |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 31, 2025
Visit Reason
Investigation of a facility reported incident of abuse involving resident R1 on 3/29/2025, substantiated by the Illinois Department of Public Health.
Findings
The facility failed to ensure a resident was free from abuse, as evidenced by a substantiated incident where resident R1 sustained a skin tear after being hit by a staff member. Multiple staff interviews and observations confirmed the incident and the resident's inability to recall the event.
Complaint Details
The complaint investigation was substantiated based on observation, interviews, and record review. Resident R1 was found to have a skin tear consistent with abuse, and staff statements corroborated the incident.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a resident was free from abuse, resulting in a skin tear injury to resident R1. |
Report Facts
Date of incident: Mar 29, 2025
Size of skin tear: 7.5
Number of residents reviewed for abuse: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E4 Life Enrichment Manager | Life Enrichment Manager | Observed resident R1 upset and reported unusual behavior on 3/29/25 |
| E6 Director of Sales | Director of Sales | Overheard incident on 3/29/25, removed alleged staff from unit, reported observations |
| E7 LPN | Licensed Practical Nurse | Assessed resident R1 and documented skin tear injury on 3/29/25 |
| E9 Care Manager | Care Manager | Alleged staff involved in incident, provided written statement about event |
| E1 Executive Director | Executive Director | Notified of incident, confirmed injury based on interviews and observations |
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