Inspection Report Summary
The most recent inspection on October 28, 2025, identified deficiencies related to failure to maintain updated service plans for residents with multiple falls. Earlier inspections showed mixed results, including a substantiated complaint in September 2025 for failure to report a resident fall with injury, but no deficiencies were found during the January 15, 2025 annual licensure survey. The main issues across inspections involved fall prevention planning and incident reporting. Complaint investigations included substantiated findings about reporting failures and service plan updates, while others related to COVID-19 were mostly unsubstantiated. The record shows some recurring concerns with fall-related care and reporting, with no clear improvement trend.
Deficiencies (last 1 years)
Deficiencies (over 1 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 28, 2025
Visit Reason
The inspection was conducted following a facility-reported incident on 10/18/2025 involving falls and injuries among residents, focusing on compliance with service plan requirements to prevent further falls.
Complaint Details
The investigation was triggered by a facility-reported incident involving multiple falls and injuries among residents R1, R2, and R3. The complaint was substantiated by findings that service plans were not updated timely after falls, increasing risk of harm.
Findings
The facility failed to maintain updated service plans for three residents with documented histories of multiple falls, resulting in a substantial probability of harm. Service plans were not revised promptly after fall incidents despite multiple falls and injuries documented for residents R1, R2, and R3.
Deficiencies (1)
Failure to maintain an updated service plan to prevent further falls and injuries for residents with documented history of multiple falls.
Report Facts
Fall incidents for R1: 5
Fall incidents for R2: 33
Fall incidents for R3: 8
Fall risk assessment scores: 21
Fall risk assessment scores: 18
Fall risk assessment scores: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | E2 (Director of Nursing) provided statements regarding fall incidents, service plan updates, and facility policies. | |
| Licensed Practical Nurse | E3 (LPN) observed resident R2 and provided information about resident's confusion and fall history. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to report a serious incident involving a resident fall with injury.
Complaint Details
Complaint Investigation 2572539/IL188729. Facility reported incidents on 7/1/25 were substantiated with no deficiencies; on 7/11/25 were unsubstantiated. The current investigation found failure to report a serious incident.
Findings
The facility failed to report a resident fall resulting in a right femur fracture to the Illinois Department of Public Health as required by regulation. The investigation confirmed the fall occurred on 3/8/25 and was not reported despite policy requirements.
Deficiencies (1)
Failure to report a resident fall with injury to the Department for 1 of 5 residents reviewed for falls.
Report Facts
Residents reviewed for falls: 6
Residents with fall injury not reported: 1
Date of resident fall: Mar 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E5 | Registered Nurse | Interviewed regarding resident fall and injury |
| E1 | Executive Director | Interviewed regarding failure to report fall incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to COVID-19 outbreak and facility reported incidents.
Complaint Details
Complaint Investigation #2479601/#IL181429 was partially substantiated related to a COVID outbreak. Facility Reported Incidents #IL182228 and #IL183620 were not substantiated.
Findings
The complaint investigation was partially substantiated for one complaint regarding a COVID outbreak, but no establishment failure or deficiencies were found. Two other facility reported incidents were not substantiated and no deficiencies were written. The facility was found in compliance with applicable Illinois Assisted Living regulations.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 15, 2025
Visit Reason
Annual Licensure Survey conducted to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The facility was found to be in compliance with all applicable regulations, and no deficiencies were written during this annual licensure survey.
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