Inspection Report Summary
The most recent inspection on October 15, 2025, found no deficiencies and the complaint investigated was unsubstantiated. Earlier inspections showed a pattern of deficiencies primarily related to resident rights, documentation, and staff training, including failures to provide proper involuntary discharge notices, maintain resident records, and ensure timely emergency response. Several substantiated complaints involved issues such as staff misconduct violating resident privacy, financial exploitation, neglect resulting in injury, and failure to report incidents promptly. Enforcement actions included termination of staff involved in privacy violations, but fines or license suspensions were not listed in the available reports. The facility appears to be addressing prior issues through plans of correction and staff education, with the most recent inspection indicating improvement.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
143% worse than Illinois average
Illinois average: 3.5 deficiencies/year
Deficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation for complaint number 2549729/IL197899.
Findings
The complaint could not be substantiated and no violations were cited. 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.
Complaint Details
Complaint 2549729/IL197899 was investigated and found to be unsubstantiated with no violations cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 28, 2025
Visit Reason
The document is a Plan of Correction submitted in response to the June 2025 Annual Survey for Trustwell Living at Springfield Assisted Living.
Findings
The Plan of Correction addresses the termination of residency requirements deficiency, detailing corrective actions such as removal of affected residents, review of 30-day notice requirements, education of staff, and ongoing monitoring to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Termination of Residency Requirements |
Report Facts
Completion date for corrective actions: Aug 15, 2025
Date of survey: Jul 28, 2025
Findings received date: Aug 4, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Penny Dowell | Executive Director | Named as attendee in staff meeting related to education on 30-day notice process |
| Tatia Dugger | Interim HRD | Presented staff meeting on education regarding 30-day notice process |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jul 24, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to issue proper 30-day involuntary termination notices to residents who no longer met residency requirements.
Findings
The facility failed to provide the required 30-day written notice of involuntary discharge to two residents who required two-person assistance, which exceeded the facility's licensed care capabilities. The Executive Director acknowledged not issuing the notices due to lost forms and busy conditions.
Complaint Details
Complaint investigation 2546491/IL196421 regarding failure to provide 30-day involuntary discharge notices to residents R1 and R2. The complaint was substantiated based on interviews and record review.
Deficiencies (1)
| Description |
|---|
| Failure to issue a 30-day involuntary notice of discharge for two residents who no longer met residency requirements due to needing two-person assistance. |
Report Facts
Residents reviewed for discharge: 2
Date of survey completion: Jul 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Named in findings related to failure to issue discharge notices and assessment of residents |
Inspection Report
Complaint Investigation
Deficiencies: 2
May 20, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to ensure residents had physician assessments completed annually and upon significant changes in condition, and to maintain proper resident records including notation of accidents, incidents, and documentation of significant changes in residents' conditions.
Findings
The facility failed to ensure physician assessments were completed annually and upon significant changes for residents, specifically for residents R1 and R2. Additionally, the facility did not maintain adequate resident records, lacking documentation of known accidents, incidents, and significant changes in residents' physical, cognitive, or functional conditions, as evidenced by missing progress notes and hospital documentation for resident R1.
Complaint Details
Complaint investigation 2544092/IL192028. The facility was found to be behind on obtaining resident physician certifications and lacked documentation of incidents and hospital visits for resident R1. The Executive Director acknowledged deficiencies in documentation and stated plans to conduct chart audits to address the issues.
Deficiencies (2)
| Description |
|---|
| Failure to ensure residents had physician assessments completed annually and with identification of significant changes in condition. |
| Failure to maintain resident records with notation of known accidents, incidents, or injuries and documentation of significant changes in resident condition triggering assessments or evaluations. |
Report Facts
Date of resident admission: Oct 20, 2023
Date of resident admission: Jun 17, 2023
Physician certification date: Oct 18, 2023
Physician certification date: Aug 10, 2023
Oxygen flow rate: 4
Oxygen flow rate: 2
Physical therapy duration: 30
Dialysis frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | E1 (Executive Director) acknowledged facility was behind on resident physician certifications and documentation issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 19, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint# 2541847/IL 187508, following a previous citation for R1 with original investigation IL#186257.
Findings
The report references prior citations under multiple regulatory codes but does not provide detailed findings or new deficiencies in this document.
Complaint Details
Complaint# 2541847/IL 187508 was investigated, with prior citations noted for R1 in the original investigation IL#186257.
Inspection Report
Complaint Investigation
Census: 8
Deficiencies: 3
Feb 25, 2025
Visit Reason
The inspection was conducted following a complaint investigation regarding staff misconduct involving resident privacy violations and failure to complete required employee orientation and dementia-specific training.
Findings
The facility failed to ensure proper employee orientation and ongoing training for four employees, including dementia-specific training and on-the-job supervision. Additionally, two employees violated resident rights by taking and distributing inappropriate photos of residents, resulting in their termination.
Complaint Details
The complaint involved two residents (R1 and R2) whose privacy was violated by staff members E5 and E6. Photos of R1 were posted on social media showing staff making inappropriate hand gestures, and a nude photo of R2 was threatened to be posted. Both staff were terminated following the investigation.
Deficiencies (3)
| Description |
|---|
| Failure to have staff complete orientation and training as outlined in the regulation for four employees reviewed. |
| Failure to provide dementia-specific training and 16 hours of on-the-job supervision for four employees reviewed. |
| Failure to ensure resident rights to bodily privacy and freedom from emotional abuse when staff took and posted inappropriate photos of residents. |
Report Facts
Residents on memory care unit: 8
Employees reviewed for orientation and training: 4
Employees terminated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E5 | Certified Nursing Assistant | Named in findings for failure to complete orientation and training and resident rights violations involving inappropriate photos |
| E6 | Nursing Assistant | Named in findings for failure to complete orientation and training and resident rights violations involving inappropriate photos |
| E1 | Interim Executive Director | Provided statements regarding employee handbook and staff work assignments |
| E9 | Business Office Manager | Provided statements regarding employee handbook distribution and training |
| E4 | Regional Nurse Consultant | Conducted interviews and terminated employment of E5 and E6 |
| E3 | Regional Director of Operations | Received anonymous texts with inappropriate photos and initiated investigation |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 3, 2025
Visit Reason
The inspection was conducted as a complaint investigation for complaint number 2540590/IL185062.
Findings
The complaint could not be substantiated and no violations were cited. 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.
Complaint Details
Complaint 2540590/IL185062 was investigated and found to be unsubstantiated with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to allegations that the facility failed to respond timely to a resident's emergency communication call.
Findings
The complaint was substantiated with a violation found for failure to ensure the emergency communication response system was responded to in a timely manner for resident R2. The investigation included interviews and record reviews, revealing a delayed response of several days to a call pendant activation. Other complaints and incident investigations were not substantiated.
Complaint Details
Complaint 2540339/IL 184494 was substantiated with a violation related to the emergency communication response system. Other complaints (2540055/IL183534 and IL 184543) were not substantiated and no violations were cited.
Deficiencies (1)
| Description |
|---|
| Failure to ensure R2's emergency communication response system was responded to in a timely manner. |
Report Facts
Call pendant response time: 3
Staff working hours: 14.33
Staff working hours: 11.08
Staff working hours: 6.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Z1 | Power of Attorney for R2 | Interviewed regarding the emergency call response and resident condition. |
| E2 | Interviewed about the call light system and response times. | |
| E1 | Corporate Staff | Interviewed regarding complaints and investigation status related to call lights. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Dec 12, 2024
Visit Reason
The inspection was conducted as a complaint investigation for complaints 2449816/IL181812 and 2449440/IL181143. One complaint was substantiated regarding failure to maintain an establishment contract and service plan for resident R1.
Findings
The facility failed to ensure that an establishment contract and service plan were developed and maintained for resident R1. Documentation and interviews confirmed the absence of these required documents, as well as missing assessments and orientation to the evacuation plan. The complaint was substantiated with no other violations cited.
Complaint Details
Complaint 2449816/IL181812 was not substantiated with no violations cited. Complaint 2449440/IL181143 was substantiated based on failure to maintain required contracts and service plans for resident R1.
Deficiencies (4)
| Description |
|---|
| Failure to maintain an establishment contract for resident R1 throughout residency. |
| Failure to develop and mutually agree upon a written service plan for resident R1. |
| Failure to ensure resident rights including participation in service plan development and receipt of services specified in the plan. |
| Failure to maintain resident records including establishment contract, service plan, orientation to evacuation plan, and documented assessments for resident R1. |
Report Facts
Complaint numbers: 2
Dates of resident progress notes: Nov 10, 2023
Dates of resident progress notes: Jan 5, 2024
Dates of resident progress notes: Jan 6, 2024
Dates of resident progress notes: Jan 7, 2024
Date of doctor's progress note: Nov 16, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Interviewed staff member who stated no establishment contract, service plan, or documented assessments were available for resident R1. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 8, 2024
Visit Reason
The inspection was conducted in response to original complaints 179826 and 179906 to investigate allegations related to resident rights violations, specifically financial exploitation.
Findings
The facility was found to have failed to keep resident R1 free from financial exploitation, as evidenced by a stolen check from R1's room that was given by employee E2 to another person in an attempt to cash it, confirmed by interviews and a police report.
Complaint Details
Original Complaint 179826 and 179906; substantiation status not explicitly stated but violations were cited.
Severity Breakdown
Type 2 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to keep resident R1 free from financial exploitation, including theft and attempted cashing of a stolen check. | Type 2 Violation |
Report Facts
Complaint numbers: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Employee E2 involved in theft of resident's check; employee E1 interviewed |
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 18, 2024
Visit Reason
The inspection was conducted as an original complaint investigation involving multiple complaint numbers (177567, 177487, 177419, 177273).
Findings
The facility failed to report an incident to the Department of Public Health within 24 hours as required, and a resident (R1) sustained an injury to the hand resulting in broken bones while being redirected by staff. This failure to report and the injury indicate neglect and create a substantial probability of harm to residents.
Complaint Details
Original complaint investigation involving complaint numbers 177567, 177487, 177419, and 177273. The complaint was substantiated with findings of failure to report incidents timely and neglect resulting in resident injury.
Severity Breakdown
Type 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to contact the Department of Public Health within 24 hours after the occurrence of an incident or accident. | Type 2 |
| Failed to keep the resident free from neglect; resident sustained injury resulting in broken bones while being redirected by staff. | Type 2 |
Report Facts
Complaint numbers: 4
Incident date: Aug 14, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Interviewed staff member who stated unawareness of report being sent within 24 hours and described resident injury incident |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 18, 2024
Visit Reason
The inspection was conducted in response to an original complaint #177895.
Findings
The allegations in the complaint were not substantiated and no violations were cited. 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.
Complaint Details
Original complaint #177895 was investigated and found to be unsubstantiated with no violations cited.
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation to address allegations related to resident rights violations, neglect, and failure to properly report incidents within the facility.
Findings
The facility was found deficient in ensuring residents' rights to be free from neglect and in timely reporting of incidents to the Department of Health. Corrective actions including staff re-education, audits, and improved reporting procedures were planned and implemented.
Complaint Details
Complaint investigation related to resident rights violations and incident reporting deficiencies. The facility submitted a Plan of Correction and corrective actions to address the issues.
Deficiencies (2)
| Description |
|---|
| Failure to ensure residents' rights to be free of neglect and proper monitoring of resident needs. |
| Failure to report incidents and accidents to the Department of Health within the required 24-hour timeframe. |
Report Facts
Date of survey: Sep 18, 2024
Systemic change completion date: Oct 1, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director (ED) | Responsible for audits, incident report reviews, and ensuring compliance with corrective actions |
| Health Service Director | Health Service Director (HSD) | Responsible for audits, incident report reviews, staff education, and ensuring compliance with corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 1
6025928 View POC 004 SOC
Visit Reason
The document is a Plan of Correction submitted in response to a complaint investigation regarding resident rights, specifically related to financial exploitation concerns at Trustwell Living at Springfield Place Assisted Living.
Findings
The facility identified a deficiency related to the right of residents to be free from financial exploitation. Corrective actions include staff training on resident rights and exploitation recognition, audits of residents to ensure no exploitation occurred, and systemic changes to prevent recurrence.
Complaint Details
The visit was complaint-related focusing on allegations of financial exploitation of residents. The Plan of Correction addresses corrective actions and monitoring to prevent exploitation.
Deficiencies (1)
| Description |
|---|
| Violation of resident rights related to financial exploitation or risk thereof. |
Report Facts
Systemic changes completion date: Nov 30, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director (ED) | Responsible for conducting audits and monitoring compliance related to financial exploitation prevention |
| Health Service Director | Health Service Director (HSD) | Responsible for conducting audits and monitoring compliance related to financial exploitation prevention |
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