Inspection Reports for The Lamoine Retirement Living
203 N Randolph Street, Macomb, IL, 61455
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 8, 2025, identified a technical infraction related to staffing levels and resident safety during evacuation. Earlier inspections showed a pattern of deficiencies involving service plan updates, fall prevention, medication administration, employee orientation, training, and background checks. Complaint investigations included a substantiated case in October 2024 where failures in fall prevention and medication administration contributed to a resident’s injury and death. Most other complaints were either found compliant or did not have substantiation status clearly stated, and enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to be addressing these issues with corrective actions, but deficiencies have persisted across multiple areas over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 1
Date: Oct 8, 2025
Visit Reason
The inspection was conducted as part of a complaint investigation #252950/IL197827, which included review of prior complaint #2561360/IL186607.
Complaint Details
Complaint Investigation #252950/IL197827 was conducted, part of which was previously investigated in complaint #2561360/IL186607. The report cites technical infractions but does not state substantiation status explicitly.
Findings
The facility was found to have technical infractions related to Sections 295.2000 a)c)5) and 295.4060 h)6). Staffing levels were insufficient to safely evacuate all 30 residents, especially those requiring mechanical lifts and two staff for transfers.
Deficiencies (1)
Technical infraction related to Section 295.2000 a)c)5) and Section 295.4060 h)6) concerning staffing and resident safety.
Report Facts
Residents requiring mechanical lift with two staff: 4
Minimum staffing at night: 4
Staffing for day and evening shifts: 6
Current residents: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Memory Care Director | Provided staffing and resident transfer information. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 31, 2025
Visit Reason
The inspection was conducted in response to an original complaint #2520492/IL184836.
Complaint Details
Original complaint #2520492/IL184836; the facility was found compliant.
Findings
The establishment was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Oct 30, 2024
Visit Reason
The inspection was conducted as an original complaint investigation (#2428416/IL179404) regarding failure to develop and update service plans with fall prevention interventions and failure to administer medications to hospice residents.
Complaint Details
The complaint investigation was triggered by concerns about failure to update service plans and prevent falls, and failure to administer medications to hospice residents. The complaint was substantiated with findings of neglect in fall prevention and medication administration, contributing to resident injury and death.
Findings
The facility failed to develop and update service plans with fall prevention interventions for three residents at high risk for falls, including two receiving hospice services. One resident (R2) sustained multiple brain bleeds from falls, was placed on hospice, and expired. The facility also failed to administer prescribed pain and anti-anxiety medications to R2 during hospice care. Incident reports lacked assessments or interventions following falls.
Deficiencies (3)
Failure to develop and update service plans with interventions to prevent falls for three residents at high risk for falls, including failure to include hospice services in plans.
Failure to provide supervision and interventions to prevent falls for one resident (R2) resulting in serious injury and death.
Failure to administer pain and anti-anxiety medications to a resident receiving hospice services (R2).
Report Facts
Fall incidents: 12
Medication doses missed: 7
Staples needed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Verified fall interventions were added late and service plans were not updated; described nursing and medication administration issues. |
| E8 | Licensed Practical Nurse (LPN) | Described incident reporting process and nursing staffing including on-call nurse responsibilities. |
| E9 | Registered Nurse (RN) | Documented missed hospice medication doses for resident R2. |
| Z1 | Hospice Care Coordinator | Confirmed hospice services for resident R2 and stated hospice nurses do not administer medications at the facility. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 30, 2024
Visit Reason
The Illinois Department of Public Health conducted a complaint survey for The Lamoine on October 30, 2024.
Complaint Details
The visit was complaint-related as stated. Specific substantiation status is not provided.
Findings
The facility failed to complete Section 295.4010/Service Plans and Section 295.600 Residents Rights in a timely manner according to rules and regulations. The Lamoine is taking corrective actions including reviewing and updating service plans, educating staff on residents' rights, and hiring a Medical Director to improve care plan management and medication administration.
Deficiencies (2)
Failure to complete Section 295.4010/Service Plans in a timely manner according to rules and regulations.
Failure to complete Section 295.600 Residents Rights according to rules and regulations.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Magic | Executive Director | Contact person for the facility and signatory of the statement of correction. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 13, 2024
Visit Reason
The inspection was conducted as an original complaint investigation (#2427028/IL177525) regarding employee orientation, ongoing training, and health care worker background checks.
Complaint Details
Original complaint investigation #2427028/IL177525. Substantiation status not explicitly stated.
Findings
The facility failed to complete timely orientation for four of five employees reviewed and failed to complete timely health care worker background checks for two of five employees. Interviews and record reviews confirmed delays in training and background checks.
Deficiencies (2)
Failed to complete orientation timely for four of five employees (E4, E5, E6, and E7).
Failed to complete Health Care Worker Background Check timely for two of five employees (E5 and E7).
Report Facts
Employees reviewed for orientation: 5
Employees with untimely orientation: 4
Employees reviewed for background checks: 5
Employees with untimely background checks: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E4 | Certified Nursing Assistant | Named in orientation timeliness deficiency. |
| E5 | Health Aide | Named in orientation and background check deficiencies. |
| E6 | Health Aide | Named in orientation timeliness deficiency. |
| E7 | Certified Nursing Assistant | Named in orientation and background check deficiencies. |
| E8 | Administrative Assistant | Interviewed regarding orientation process and audit. |
| E1 | Interviewed regarding background check process and billing issues. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 13, 2024
Visit Reason
The Illinois Department of Public Health staff conducted a complaint survey at The Lamoine Assisted Living and Memory Care on September 13, 2024.
Complaint Details
Complaint survey conducted on September 13, 2024. The violations were related to employee orientation, training, and background checks. Substantiation status is not explicitly stated.
Findings
The facility was found to have failed to complete employee orientation and ongoing training in a timely manner, and failed to complete health care worker background checks timely according to rules and regulations. The facility is auditing employee files and planning corrective actions to ensure compliance by the end of the month.
Deficiencies (2)
Failed to complete Section 295.3020 Employee Orientation and Ongoing Training in a timely manner according to rules and regulations.
Failed to complete Section 295.3040 Health Care Worker Background Checks in a timely manner according to rules and regulations.
Report Facts
New employees: 8
Current employees: 3
Next training class date: Oct 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rachel Magic | Executive Director | Named as new Executive Director and contact for the facility; involved in corrective action communication |
Viewing
Loading inspection reports...
