Inspection Report
Annual Inspection
Deficiencies: 5
May 22, 2025
Visit Reason
The inspection was conducted as an Annual Licensure Survey including a Facility Reported Incident and a Complaint Investigation Survey, both found unsubstantiated.
Findings
The facility failed to meet multiple regulatory requirements including employee orientation and ongoing training, initial health evaluations, health care worker background checks, tuberculin skin test procedures, and Alzheimer's and dementia program training for management staff. Documentation was missing or incomplete for several employees, potentially affecting all residents and staff.
Complaint Details
Complaint Investigation Survey IL00192367/2594268 was unsubstantiated.
Severity Breakdown
Type 2 Violation: 4
Type 3 Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to present documentation that new staff started orientation within 10 days of hire, completed orientation within 30 days, and documented required 8-12 hours of continuing education training. | Type 2 Violation |
| Failed to obtain initial medical health evaluations on staff within required timeframe. | Type 3 Violation |
| Failed to initiate health care worker background checks, employment verification, and retain criminal record requests for six employees. | Type 2 Violation |
| Failed to provide documentation that staff received tuberculin skin tests within required timeframes. | Type 2 Violation |
| Failed to ensure the Director of Memory Care completed required continuing education and training regarding Alzheimer's and dementia care. | Type 2 Violation |
Report Facts
Staff files reviewed: 9
Employees missing background checks: 6
Employees missing tuberculosis vaccination records: 4
Hours of ongoing training required: 8
Hours of annual continuing education regarding dementia care required: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Health and Wellness | Missing initial health evaluation and background check. |
| E4 | Director of Memory Care | Missing required continuing education and training for Alzheimer's/Dementia care. |
| E5 | Care Associate Assisted Living | Missing orientation documentation, background check, and tuberculosis vaccination records. |
| E6 | Certified Nursing Assistant Assisted Living | Missing orientation documentation, background check, and tuberculosis vaccination records. |
| E7 | Care Associate Memory Care | Missing orientation documentation, initial health evaluation, background check, and tuberculosis vaccination records. |
| E8 | Certified Nursing Assistant Memory Care | Missing orientation documentation, background check, and tuberculosis vaccination records. |
| E9 | Certified Nursing Assistant Assisted Living | Missing orientation documentation and background check. |
| E11 | Business Office Manager | Unable to produce documentation for staff orientation, training, background checks, and tuberculosis vaccination records. |
Inspection Report
Plan of Correction
Deficiencies: 5
May 20, 2025
Visit Reason
The document is a Plan of Correction submitted by The Sheridan at Park Ridge in response to deficiencies identified during an Annual Licensure Survey and Complaint Investigation Survey conducted by the Illinois Department of Public Health.
Findings
The facility was found to have multiple regulatory violations including failure to complete employee orientation and ongoing training within required timeframes, missing initial health evaluations, failure to conduct background checks, incomplete tuberculosis skin test documentation, and inadequate Alzheimer’s and dementia training for staff. Several staff files lacked required documentation and training records.
Complaint Details
Complaint Investigation Survey IL00192367/2594268 was unsubstantiated.
Severity Breakdown
Type 2 Violation: 4
Type 3 Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to present documentation that new staff started orientation within 10 days of hire and completed required continuing education training. | Type 2 Violation |
| Failure to obtain initial health evaluations for direct care and food service employees within required timeframes. | Type 3 Violation |
| Failure to initiate health care worker background checks on six employees and failure to retain required criminal record requests. | Type 2 Violation |
| Failure to provide documentation of tuberculosis skin tests for employees within required timeframes. | Type 2 Violation |
| Failure to ensure proper Alzheimer’s and dementia training and continuing education for Memory Care Unit staff. | Type 2 Violation |
Report Facts
Staff files reviewed: 9
Employees missing background checks: 6
Employees missing tuberculosis vaccination records: 4
Hours of ongoing training required: 8
Days for new employee orientation completion: 10
Date of inspection: May 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tammy DeCounter | Executive Director | Signed the Plan of Correction letter. |
| E2 | Director of Health and Wellness | Named in findings related to missing initial health evaluation and background checks. |
| E11 | Business Office Manager | Interviewed by surveyor and responsible for staff requirement log sheet and background check process. |
| E4 | Director of Memory Care | Named in findings related to incomplete dementia training documentation. |
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