Deficiencies (last 2 years)
Deficiencies (over 2 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
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of physical abuse by a Certified Nursing Assistant (CNA) against a resident (R1).
Complaint Details
The complaint investigation substantiated that a CNA (V4) physically abused resident R1 by hitting her arm and hand multiple times during care, causing pain and emotional distress. The facility failed to immediately remove the CNA and conducted an inadequate investigation, ultimately concluding the allegation as unsubstantiated. The CNA was terminated. The executive director did not cooperate with surveyor requests.
Findings
The facility failed to protect a resident from physical abuse by a CNA who struck the resident multiple times causing pain and emotional distress. The facility also failed to conduct a thorough and accurate investigation into the abuse allegation, improperly handled the removal of the alleged perpetrator, and concluded the allegation as unsubstantiated despite evidence.
Deficiencies (2)
F 0600: The facility failed to protect a resident from physical, mental, sexual abuse, physical punishment, and neglect by staff, resulting in actual harm to a few residents.
F 0610: The facility failed to respond appropriately to all alleged violations, including inadequate investigation and failure to immediately remove the alleged abuser from resident contact, causing minimal harm or potential for actual harm to many residents.
Report Facts
Residents reviewed for abuse: 3
Residents affected: Few residents affected by actual harm; many residents affected by minimal harm or potential harm
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 | Registered Nurse (RN) | Responded to resident's screams, observed abuse, reported incident |
| V4 | Certified Nursing Assistant (CNA) | Alleged perpetrator who physically abused resident |
| V2 | Director of Nursing (DON) | Instructed removal of CNA from building after abuse allegation |
| V7 | Executive Director | Did not respond to surveyor requests during investigation |
| V8 | Interim Administrator | Created internal investigation, no longer with facility |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 5, 2025
Visit Reason
The visit was conducted as a complaint investigation identified by case number 25910715/IL198338.
Complaint Details
Complaint Investigation 25910715/IL198338 - No citation issued.
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 Illinois. No citations were issued.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 21, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's property, specifically the theft of a resident's wallet and credit card within the facility.
Complaint Details
The complaint investigation was substantiated. The resident's wallet was stolen while in the facility, with the credit card used fraudulently at multiple locations. The facility reported the incident, prohibited the suspected staff member from working, and involved police who conducted an investigation.
Findings
The facility failed to protect a resident's right to be free from misappropriation of property as evidenced by the theft of R1's credit card from her wallet while in the facility. The incident was reported, investigated by police, and the facility implemented new policies to prevent future occurrences.
Deficiencies (1)
F 0602: Protect each resident from the wrongful use of the resident's belongings or money. The facility failed to prevent the theft of a resident's credit card from her wallet while in the facility.
Report Facts
Residents reviewed for misappropriation: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V14 | Certified Nursing Assistant | Named as the staff member assigned to care for the resident on the day of the incident and prohibited from working pending investigation |
| V1 | Administrator/Abuse Coordinator | Provided statements regarding the incident, facility policies, and actions taken |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 24, 2025
Visit Reason
The inspection was conducted as an Annual Certification and Licensure Survey focusing on Infection Prevention and Control compliance at the facility.
Findings
The facility failed to follow contact isolation protocols by not placing correct signage on resident room doors, not placing a resident on contact isolation in an appropriate room, and not properly containing a resident's breathing mask. These deficiencies affected two residents reviewed for infection control.
Deficiencies (3)
Failed to place correct signage on resident room door regarding isolation precautions.
Failed to ensure that a resident on contact isolation was placed in an appropriate room.
Failed to ensure that a resident's breathing mask was properly contained in accordance with infection control protocols.
Report Facts
Residents reviewed for infection control: 6
Resident age: 86
Resident age: 79
Date of resident admission: Apr 1, 2025
Date isolation started: Feb 24, 2025
Date of wound swab: May 13, 2025
Plan of correction completion date: May 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing (DON) | Provided statements regarding lack of documentation for discontinuation of contact isolation and infection control policies. |
| V3 | Infection Prevention Nurse | Provided information about resident isolation status and hospital communication. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to investigate infection prevention and control practices related to contact isolation protocols for residents on isolation precautions.
Complaint Details
The investigation was complaint-related focusing on infection control failures. The complaint was substantiated as the facility did not have documentation discontinuing contact isolation for a resident and failed to follow required isolation precautions.
Findings
The facility failed to follow contact isolation protocols by not placing correct signage on resident room doors, not ensuring residents on contact isolation were placed in appropriate rooms, and not properly containing a resident's breathing mask. These issues applied to two residents reviewed for infection control.
Deficiencies (1)
F 0880: The facility failed to provide and implement an infection prevention and control program by not following contact isolation protocols, including improper signage, inappropriate room placement, and failure to contain a resident's breathing mask.
Report Facts
Residents reviewed for infection control: 6
Isolation start date: Feb 24, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Infection Prevention Nurse (V3) | Provided information about resident isolation status and hospital communication. | |
| Director of Nursing (V2) | Reported lack of documentation for discontinuation of contact isolation and noted protocol failures. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 3, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following a resident fall incident involving unsafe transfer practices by staff.
Complaint Details
The complaint investigation substantiated that the resident fell due to improper transfer by an agency CNA who lost grip during the transfer. The resident sustained lacerations requiring hospital sutures. The CNA was placed on do not return status.
Findings
The facility failed to transfer a resident safely, resulting in the resident falling and sustaining lacerations to her right foot toes requiring sutures. The investigation confirmed the fall occurred during a transfer by a Certified Nursing Assistant who lost grip, and the resident was sent to the hospital for treatment.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents. This failure caused a resident to fall during transfer, resulting in lacerations requiring sutures.
Report Facts
Laceration measurements: 1.5
Laceration measurements: 0.8
Laceration measurements: 1
Laceration measurements: 2
Laceration measurements: 0.6
Suture removal timeframe: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V7 | Certified Nursing Assistant | Named in the finding for unsafe transfer causing resident fall |
| V2 | Director of Nursing | Provided statements regarding transfer procedures and staff status |
| V5 | Licensed Practical Nurse | Nurse on duty who assessed resident after fall |
| V1 | Administrator | Provided statements regarding staff status |
Inspection Report
Deficiencies: 0
Date: Mar 23, 2024
Visit Reason
The inspection was conducted as a regulatory survey of the nursing home facility Three Crowns Park.
Findings
No health deficiencies were found during the inspection.
Viewing
Loading inspection reports...
