Deficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 4, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with care and treatment standards, focusing on residents' adherence to physician orders, facility protocols, and professional standards of practice.
Findings
The facility failed to provide appropriate treatment and care according to residents' plans of care, physician orders, and facility protocols, affecting two residents (R2 and R4) with skin impairments and wound care issues. Deficiencies included delayed treatment orders, lack of documentation, failure to update care plans, and inadequate communication with family members.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, specifically related to fungal rash and wound care for residents R2 and R4.
Report Facts
Residents affected: 2
Deficiency severity level: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 DON | Director of Nursing | Mentioned in relation to grievance report and wound care oversight |
| V4 Wound Care Nurse | Wound Care Nurse | Reviewed medical records and provided information on wound care and care plan updates |
| V8 LPN | Licensed Practical Nurse | Observed providing wound care and treatment to residents R2 and R4 |
| V9 CNA | Certified Nurse Assistant | Applied Vitamin D ointment to resident R2 |
| V3 ADON | Assistant Director of Nursing | Informed of observations and concerns regarding wound care |
| V15 Nurse Consultant | Nurse Consultant | Informed of concerns identified during inspection |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 8, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including PASARR screening for mental disorders and intellectual disabilities, and pressure ulcer care and prevention.
Findings
The facility failed to conduct PASARR screenings for residents with mental disorders prior to admission for 4 of 6 residents reviewed, and failed to assess and provide appropriate pressure ulcer care for 1 of 4 residents reviewed for pressure ulcers, resulting in a facility-acquired stage 4 pressure ulcer.
Deficiencies (2)
Failed to conduct PASARR (pre-admission screening and resident review) for residents with mental disorders prior to admission for 4 of 6 residents reviewed.
Failed to assess pressure ulcer for 1 of 4 residents reviewed, resulting in a facility-acquired stage 4 pressure ulcer with inadequate documentation and treatment.
Report Facts
Residents reviewed for PASARR screening: 6
Residents affected by PASARR deficiency: 4
Residents reviewed for pressure ulcers: 50
Residents reviewed for pressure ulcers in detailed sample: 4
Residents affected by pressure ulcer deficiency: 1
BIMS cognitive scores: 11
Wound assessment dates: Apr 8, 2025
Pain medication order end date: May 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V10 | Admissions Director | Inquired about PASARR screenings and submitted screenings upon surveyor request |
| V1 | Administrator | Inquired about PASARR screening for R25 and provided facility policy |
| V7 | Registered Nurse | Reported on wound care and resident transfer to hospital for R105 |
| V2 | Director of Nursing | Provided information on skin assessment policies and wound care |
| V6 | Wound Care Nurse | Responded to skin assessment requests and described wound status |
| V12 | Licensed Practical Nurse | Assisted with wound care for R105 |
| V13 | Family Member | Reported on resident's condition and hospital communication |
| V18 | Nursing Practitioner | Provided wound debridement and described wound condition |
| V14 | Certified Nursing Assistant Supervisor | Assisted with wound care and communicated with nursing staff |
Inspection Report
Deficiencies: 1
Date: Oct 12, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on handling of soiled linens and incontinence care practices.
Findings
The facility failed to ensure soiled linens were handled to prevent cross contamination and did not complete incontinence care properly for one resident, resulting in potential infection control issues.
Deficiencies (1)
Failure to handle soiled linens in a manner to prevent cross contamination and failure to ensure proper incontinence care to prevent contamination for one resident.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided statements regarding proper incontinence care and infection control procedures. | |
| Certified Nursing Assistant | Observed performing inadequate incontinence care and improper handling of soiled linens. |
Inspection Report
Routine
Census: 144
Deficiencies: 3
Date: Jun 7, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights and food safety standards, including privacy during care and proper food labeling and sanitation procedures.
Findings
The facility failed to ensure resident privacy when a resident was left exposed during care, affecting one resident. Additionally, the facility did not label and date certain food items and did not follow sanitizer immersion time requirements, potentially affecting residents on oral and puree diets.
Deficiencies (3)
Failed to follow the Statement of Resident Rights when a resident was left exposed showing bare chest and legs visible from the hallway.
Failed to label and date a package of pita bread and a bulk bag of Indian flour as per Kitchen Policy.
Failed to follow Sanitizer Manufacturer Instructions by not immersing blender items for the required one minute in the 3 compartment sink.
Report Facts
Residents on oral diet: 131
Residents on puree diet: 13
Residents reviewed for privacy: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V12 | Certified Nurse Aide | Observed changing linen and involved in privacy deficiency |
| V2 | Director of Nursing | Provided statement on privacy procedures |
| V14 | Social Service Director | Provided information on resident preferences and behavior care plan |
| V11 | Dietary Manager | Provided statements on food labeling and sanitation procedures |
| V13 | Cook | Observed sanitizing blender items and provided statements on sanitation time |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 1, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to keep a resident free from physical abuse by another resident.
Complaint Details
The complaint investigation found that on 05/11/23, resident R3 became aggressive with resident R4, causing physical injury to R4's right upper arm. R4 was hospitalized and readmitted with shoulder pain post altercation. Multiple staff interviews indicated no witnesses to the incident. R3 has a history of delusional and aggressive behavior, and the facility acknowledged limitations in supervision.
Findings
The facility failed to protect residents R3 and R4 from physical abuse by another resident. R3 was physically aggressive towards R4, resulting in R4 sustaining a right upper arm contusion and shoulder pain requiring hospital admission and medication. Staff interviews revealed no witnesses to the incident, and the facility acknowledged challenges in providing consistent one-to-one supervision for residents with delusional and aggressive behaviors.
Deficiencies (1)
Failure to protect residents from physical abuse by another resident, resulting in injury.
Report Facts
Date of incident: May 11, 2023
Date of survey completion: Jun 1, 2023
Medication dosage: 50
Pain level: 10
Number of staff interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V10 | Licensed Practical Nurse | Reported and described the incident between R3 and R4 |
| V2 | Director of Nursing | Received report of incident from V10 |
| V13 | Social Services Worker | Reported on R3's mood and behavior |
| V5 | Social Services Director | Provided information on R3's admission paperwork and behavior |
| V1 | Administrator | Discussed supervision challenges and staff interviews |
Inspection Report
Routine
Deficiencies: 4
Date: May 18, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pressure ulcer care, pain management, pharmaceutical services, and medication storage and labeling at the nursing home.
Findings
The facility failed to prevent and properly treat pressure ulcers in one resident, failed to perform comprehensive pain assessments and administer pain medications consistently for two residents, failed to maintain accurate counts of controlled medications for one resident, and failed to properly label and store medications for several residents.
Deficiencies (4)
Failed to prevent or identify formation of pressure injury and failed to follow physician's orders for pressure ulcer treatment for 1 of 4 residents reviewed.
Failed to perform comprehensive pain assessments as scheduled and failed to administer pain medication as requested/needed for 2 of 4 residents reviewed.
Failed to maintain an accurate count of schedule II controlled pain medication for 1 of 85 residents during medication storage and labeling task.
Failed to follow pharmacy medication storage and labeling policy and medication pass policy by not noting and implementing open date labels and failing to refrigerate new medication requiring refrigeration before opening for 6 of 85 residents.
Report Facts
Wound size: 6
Wound size post debridement: 1.5
Pain level ratings: 18
Medication discrepancy: 149.5
Resident count: 133
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V13 | Wound Care Coordinator | Performed wound care and provided information about resident R49's pressure ulcer |
| V22 | Registered Nurse | Named in pain medication administration inconsistency for resident R115 |
| V16 | Regional Nurse Consultant | Provided information on pain assessment requirements and last comprehensive pain assessment for resident R115 |
| V21 | Physician | Provided medical opinion on resident R115's pain management and resident R129's ability to articulate pain |
| V17 | Registered Nurse/ Clinical Care Coordinator | Interviewed regarding resident R129's pain and controlled medication administration process |
| V18 | Licensed Practical Nurse | Involved in medication administration and discrepancy related to resident R129's controlled medication |
| V19 | Licensed Practical Nurse | Interviewed about controlled medication discrepancy procedures |
| V2 | Director of Nursing | Provided information on investigation of medication discrepancy and medication storage policies |
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