Inspection Report
Plan of Correction
Deficiencies: 0
May 8, 2025
Visit Reason
The document is a Plan of Correction submitted in response to the Annual Licensure Survey and Facility Reported Incident Survey conducted on 5/8/2025.
Findings
The Plan of Correction addresses concerns related to resident care plans, specifically regarding elopement risk, vascular wounds, and nephrostomy tube care. It outlines specific resident situations, facility identification of concerns, systemic measures, and monitoring plans to ensure compliance and improved care.
Report Facts
Inspection date: May 8, 2025
Plan of Correction submission date: Jun 2, 2025
Target correction dates: Multiple target dates ranging from 2025-04-03 to ongoing for correction completion
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelina Crescimone | Executive Director | Legal Entity Representative signing the Plan of Correction and responsible for retraining and compliance reporting |
Inspection Report
Plan of Correction
Deficiencies: 5
May 8, 2025
Visit Reason
The inspection was conducted as a licensure survey and plan of correction following a Facility Reported Incident (FRI) IL189202 dated 3/28/25.
Findings
The facility failed to follow its elopement policy, did not document elopement assessments for two residents, failed to document staff assessments of a nephrostomy site and tubing for one resident, failed to document care/assessment of a leg wound for another resident, and inadequately monitored a resident at risk of elopement who subsequently eloped and was injured. Additionally, the facility failed to develop and implement individualized service plans addressing elopement risks, wound care, and nephrostomy care for affected residents.
Deficiencies (5)
| Description |
|---|
| Failed to follow elopement policy and document elopement assessments for residents R5 and R6. |
| Failed to document staff assessments of the condition and appearance of resident R3's nephrostomy site and tubing. |
| Failed to document care/assessment of resident R2's leg wound. |
| Failed to adequately monitor resident R1, an elopement risk, who eloped and was injured outside the facility. |
| Failed to develop and implement individualized goals and interventions in service plans for residents R1, R5, R6 (elopement risks), R2 (vascular wound), and R3 (nephrostomy care). |
Report Facts
Date of resident elopement: Mar 28, 2025
Resident admission dates: Jan 25, 2024
Resident admission dates: Mar 22, 2023
Resident admission dates: Sep 2, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | E1 interviewed regarding resident R1's elopement risk and monitoring. | |
| Resident Care Director | E9 interviewed regarding resident R1's elopement risk and assessments. | |
| Maintenance Director | E10 involved in locating resident R1 after elopement. | |
| Lead Care Manager | E11 involved in locating resident R1 after elopement. | |
| Hospice Nurse | Z2 provided care for resident R3's nephrostomy. |
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