Inspection Reports for Villa St. Benedict
1920 Maple Ave, Lisle, IL 60532, IL, 60532
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Inspection Report
Annual Inspection
Deficiencies: 0
Oct 17, 2025
Visit Reason
Annual Licensure Survey to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living regulations and administrative codes during this annual licensure survey.
Inspection Report
Annual Inspection
Deficiencies: 3
Nov 14, 2024
Visit Reason
Annual Licensure Survey conducted to evaluate compliance with state regulations for service plans, Alzheimer's and dementia programs, and resident records.
Findings
The facility failed to develop and implement adequate service plans addressing residents' specific needs, failed to provide required dementia-specific staff training, and did not maintain complete and accurate resident records including documentation of assessments, incidents, and changes in condition. These deficiencies contributed to residents sustaining falls with major injuries and inadequate care coordination.
Severity Breakdown
Type 2 Violation- (REPEAT): 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to develop service plans addressing specific resident needs, implement interventions to minimize risks, identify staff responsible, follow fall and readmission policies, and integrate outside support services. | — |
| Failure to provide required dementia-specific orientation and on-the-job training to staff as mandated by regulations. | Type 2 Violation- (REPEAT) |
| Failure to maintain complete and accurate resident records including documentation of assessments, evaluations, incidents, and significant changes in condition. | — |
Report Facts
Fall incidents with major injuries: 3
Dementia-specific training hours required: 4
Dementia-specific training hours required: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Director of Nursing | Described resident conditions and discussed findings related to service plans and fall incidents. |
| E2 | Director of Nursing | Confirmed lack of documentation and discussed findings related to service plans, fall management, and dementia training. |
| E3 | Registered Nurse | Described resident conditions and fall risks. |
| E4 | Registered Nurse | Described resident conditions and fall risks. |
| E14 | Human Resources Director | Acknowledged non-compliance with dementia-specific training requirements. |
Inspection Report
Annual Inspection
Deficiencies: 3
Nov 14, 2024
Visit Reason
The annual licensure survey was conducted to determine compliance with the Assisted Living and shared Housing Establishment Code requirements.
Findings
The facility did not meet compliance requirements resulting in 2 violations and 1 Type 2 repeat violation related to service plans, Alzheimer's and dementia programs, and resident records. Corrective measures and training plans were outlined to address these deficiencies.
Severity Breakdown
Type 2 Violation - REPEAT: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to develop and implement adequate service plans addressing residents' specific needs and risks, including fall prevention and integration of outside support services. | — |
| Failure to provide required dementia-specific orientation and 16 hours of on-the-job training to staff, affecting care in the Memory Care Unit. | Type 2 Violation - REPEAT |
| Failure to maintain complete and accurate resident records, including documentation of assessments, incidents, and follow-up on falls and readmissions. | — |
Report Facts
Violations: 2
Repeat Violations: 1
Training hours: 4
Training hours: 16
Service plan review timeframe: 45
Clinical notes audit timeframe: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Kellogg | Executive Director | Signed the Statement of Correction letter |
| Marisol Beltran | Human Resources Director | Mentioned as HR Director involved in corrective action |
| Kathy Benjamin | Director of Nursing | Responsible party for staff training implementation in Alzheimer's and Dementia Programs |
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