Inspection Report Summary
The most recent inspection on October 20, 2025, identified a deficiency related to the facility’s failure to follow and update a resident’s service plan after significant events, resulting in the resident being found outside unsupervised. Earlier inspections showed mixed results, including deficiencies in emergency preparedness and tuberculosis testing from the April 2, 2025 annual survey, while a September 20, 2025 complaint investigation found the facility in compliance. The main themes of deficiencies involved resident care plan adherence and staff compliance with health and safety protocols. The substantiated complaint in October involved a resident safety issue linked to service plan oversight, while other complaint investigations were unsubstantiated or found compliance. The inspection history suggests some ongoing challenges with procedural adherence, though recent findings focus on specific incidents rather than broad systemic issues.
Deficiencies (last 1 years)
Deficiencies (over 1 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
Deficiencies: 1
Oct 20, 2025
Visit Reason
The inspection was conducted following a substantiated incident reported on 2025-09-27 involving a resident (R1) who was found wandering outside the facility unsupervised, triggering a complaint investigation.
Findings
The facility failed to ensure that a resident's service plan was followed and updated after significant events on 2025-07-20 and 2025-09-27. The resident was found outside unsupervised contrary to the service plan, which required staff escort, posing a substantial risk of harm.
Complaint Details
Facility reported incident on 2025-09-27 (IL197877) was substantiated as per regulation 295.4010d)e).
Severity Breakdown
Type 2 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident's service plan was followed and updated after significant events, resulting in the resident being found outside unsupervised. | Type 2 Violation |
Report Facts
Incident date: Sep 27, 2025
Service Plan date: May 9, 2025
Previous incident date: Jul 20, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing | Provided statements regarding the incident and service plan requirements |
| E3 | Licensed Practical Nurse | Nurse on duty during the incident, unaware resident was outside |
| E4 | Caregiver | Assigned to resident on incident date, unaware resident was outside |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 20, 2025
Visit Reason
The inspection was conducted as a complaint investigation identified by case number 2597689/IL00197016.
Findings
The facility 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.
Complaint Details
Complaint investigation 2597689/IL00197016 resulted in a finding of compliance with applicable Illinois assisted living regulations.
Inspection Report
Annual Inspection
Deficiencies: 2
Apr 2, 2025
Visit Reason
Annual licensure survey conducted to assess compliance with state regulations including disaster preparedness and tuberculosis skin test procedures.
Findings
The facility failed to ensure all new residents received orientation to emergency and evacuation plans within 10 days of admission, and documentation was missing. Additionally, the facility did not ensure all new staff completed the required two-step tuberculosis skin test within seven days of employment, affecting 9 employees.
Severity Breakdown
Type 2 Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure all new residents received orientation and signed documentation for emergency and evacuation plans within 10 days of admission. | Type 2 Violation |
| Failed to ensure all new staff members completed the two-step tuberculosis skin test as required, with only the first step completed for 9 employees. | Type 2 Violation |
Report Facts
Employees missing 2nd step TB test: 9
Resident files reviewed for orientation: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 Director of Memory Care | Director of Memory Care | Named as employee missing 2nd step TB test |
| E8 Life enrichment Coordinator | Life Enrichment Coordinator | Named as employee missing 2nd step TB test |
| E9 Cook | Cook | Named as employee missing 2nd step TB test |
| E10 Nurse | Nurse | Named as employee missing 2nd step TB test |
| E11 Caregiver | Caregiver | Named as employee missing 2nd step TB test |
| E12 Caregiver | Caregiver | Named as employee missing 2nd step TB test |
| E13 Housekeeping | Housekeeping | Named as employee missing 2nd step TB test |
| E14 Dishwasher | Dishwasher | Named as employee missing 2nd step TB test |
| E15 Dining Staff | Dining Staff | Named as employee missing 2nd step TB test |
Inspection Report
Plan of Correction
Deficiencies: 2
Apr 2, 2025
Visit Reason
The document is a Plan of Correction submitted following an Annual Licensure Survey conducted on 4/2/2025.
Findings
The facility was cited for two Type 2 violations related to disaster preparedness and tuberculin skin test procedures. The Plan of Correction outlines steps to address these deficiencies, including implementation of emergency procedure acknowledgements and tuberculosis screening protocols.
Severity Breakdown
Type 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure all new residents receive orientation and emergency evacuation plans within 10 days of arrival as required by A2040 Section 295.2040 Disaster Preparedness. | Type 2 |
| Failure to conduct tuberculin skin tests for employees and residents in accordance with Control of Tuberculosis Code as required by DA4050 Section 295.4050 Tuberculin Skin Test Procedures. | Type 2 |
Report Facts
Fine amount: 1000
Number of violations: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michael Amici | Executive Director | Signed letter regarding Plan of Correction and fine |
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