Inspection Report Summary
The most recent inspection on October 7, 2025, identified deficiencies related to failure to report a serious fall incident and submit final incident reports within required timeframes. Earlier inspections showed multiple deficiencies involving personnel training, service plans, response to resident calls, medical record documentation, dining staff adequacy, and resident care monitoring. Inspectors cited issues with timely reporting and documentation as well as care and staffing concerns. Complaint investigations included substantiated findings about inadequate dining staffing and resident monitoring, but no fines or enforcement actions were listed in the available reports. The facility submitted a plan of correction addressing these issues, indicating efforts toward improvement, though deficiencies have appeared consistently over recent inspections.
Deficiencies (last 1 years)
Deficiencies (over 1 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 7, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to failure to report incidents and accidents, specifically regarding fall incidents with significant injury at the facility.
Findings
The facility failed to report a fall incident with significant injury to the Illinois Department of Public Health (IDPH) within 24 hours for one resident and failed to submit final incident reports within required timeframes for two residents. The facility staff acknowledged gaps in internal policies and timely submission of incident reports and indicated plans to improve training and compliance.
Complaint Details
Complaint Investigation 2579117/IL197651 regarding failure to report incidents and submit final incident reports as required by Illinois regulations.
Severity Breakdown
Type 3 Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report a serious fall incident with significant injury to IDPH within 24 hours. | Type 3 Violation |
| Failure to submit a final incident report to IDPH within 14 days after the incident for two residents. | Type 3 Violation |
Report Facts
Residents reviewed for incidents and accidents: 3
Incident case number: 1005379
Incident report initial submission date: Aug 14, 2025
Incident report initial submission date: Aug 28, 2025
Final incident report submission date: Sep 2, 2025
Final incident report submission date: Oct 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Resident Care Director | Interviewed regarding incident reporting policies and acknowledged failures in timely reporting and final report submission. |
| E2 | Area Director of Nurses | Interviewed and acknowledged lack of clarity on ensuring timely incident report submissions and need for training. |
Inspection Report
Plan of Correction
Deficiencies: 4
Jul 11, 2025
Visit Reason
This document is a Plan of Correction submitted by Sunrise of Westmont in response to deficiencies cited during an inspection conducted on 7/11/25.
Findings
The Plan of Correction addresses multiple regulatory deficiencies related to personnel training, service plans, response to resident calls, and medical record documentation. The facility outlines immediate solutions, expanded scope, systemic changes, and monitoring plans to ensure compliance.
Deficiencies (4)
| Description |
|---|
| Personnel Requirements, Qualifications and Training |
| Service Plan |
| Response to resident pendant calls and check-ins |
| Medical record documentation including late entry |
Report Facts
Inspection date: Jul 11, 2025
Plan submission date: Jul 29, 2025
Correction target dates: 71525
Correction target dates: 72825
Correction target dates: 71625
Correction target dates: 72125
Correction target dates: 63025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anne Hoeksema | Executive Director | Signing the Plan of Correction and responsible for compliance reporting |
Inspection Report
Annual Inspection
Deficiencies: 4
Jul 1, 2025
Visit Reason
The inspection was conducted as an Annual Licensure Survey combined with a Complaint Investigation Survey that was substantiated.
Findings
The facility was found deficient in multiple areas including inadequate dining staff leading to delayed meal service, failure to update personalized fall prevention interventions for high-risk residents, failure to provide adequate care and monitoring for a resident left unattended in a recliner for hours, and failure to maintain resident records as required.
Complaint Details
The complaint investigation was substantiated and involved issues such as inadequate dining staff causing delays in meal service and failure to provide adequate care and monitoring for a resident left unattended in a recliner for hours.
Severity Breakdown
Type 2 Violation: 1
General Violation: 2
Type 3 Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to have adequate dining staff to ensure residents received meals in a timely manner. | Type 2 Violation |
| Failed to update residents' service plans to include personalized interventions to prevent falls for high-risk residents. | General Violation |
| Failed to provide adequate and appropriate care and monitoring for a resident who was left unattended in a recliner for about 20 hours. | General Violation |
| Failed to maintain resident records as required, including failure to provide requested resident records upon inspection. | Type 3 Violation |
Report Facts
Fall incidents: 15
Duration unattended: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Named in relation to failure to provide dining staff schedule and awareness of resident unattended incident. |
| E2 | Resident Care Director | Discussed service plan updates and awareness of resident unattended incident. |
| E4 | Dining Service Coordinator | Provided information about dining service delays and staff training. |
| E10 | Care Manager | Mentioned resident check policies and lack of recall of incidents. |
| E11 | Care Manager | Mentioned resident check policies and lack of recall of incidents. |
| E12 | Concierge | Did not recall family member requesting key to resident's apartment. |
| E13 | Resident Care Coordinator | Provided details about resident unattended incident and staff responses. |
| E16 | Care Manager | Discussed resident check policies. |
| E17 | Former Executive Director | Mentioned in relation to family reporting resident unattended incident. |
| Z1 | Family Member | Reported resident unattended incident and dining delays. |
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