Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Plan of Correction
Deficiencies: 0
Oct 14, 2025
Visit Reason
The document is a plan of correction related to a facility reported incident dated 9/13/2025, referencing substantiated complaints IL 197444/2578639 and IL 197541/2578839.
Findings
The report notes that the facility reported an incident on 9/13/2025 which was substantiated, and that the referenced complaints exited on 9/16/2025 for violations cited.
Complaint Details
The visit relates to substantiated complaints IL 197444/2578639 and IL 197541/2578839.
Report Facts
Complaint IDs: Complaint numbers IL 197444/2578639 and IL 197541/2578839 referenced
Incident date: Facility reported incident on 9/13/2025
Inspection Report
Complaint Investigation
Census: 86
Deficiencies: 3
Sep 18, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of inappropriate resident behavior, verbal abuse by staff, and failure to report abuse incidents timely.
Findings
The facility failed to ensure one resident met residency requirements, resulting in inappropriate sexual behavior. Another resident experienced verbal abuse from a caregiver. Additionally, the facility failed to report an alleged sexual/mental abuse incident to the Department within 24 hours as required.
Complaint Details
The complaint investigation involved allegations of inappropriate sexual behavior by resident R1, verbal abuse by caregiver E4 towards resident R3, and failure to timely report an alleged sexual/mental abuse incident involving R1. The investigation found substantiated verbal abuse and failure to report incidents within required timeframes.
Severity Breakdown
Type 1 Violation: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure resident meets residency requirements, resulting in inappropriate sexual behavior. | Type 1 Violation |
| Failed to ensure residents are free from verbal abuse by staff. | Type 1 Violation |
| Failed to report alleged sexual/mental abuse incident to the Department within 24 hours. | Type 1 Violation |
Report Facts
Residents in facility: 86
Residents reviewed: 3
Resident R1 move-in date: Apr 25, 2025
Resident R3 move-in date: Feb 26, 2023
Date of alleged abuse report: Sep 13, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing | Named in findings related to resident sexual behavior and failure to report abuse |
| E3 | Resident Care Coordinator/Scheduler | Reported resident sexual behavior and involved in abuse investigation |
| E4 | Caregiver | Involved in verbal abuse incident towards resident R3 |
| E5 | Certified Nursing Assistant | Reported resident sexual behavior |
| E6 | Caregiver | Reported resident sexual behavior |
| E12 | Registered Nurse | Reported alleged sexual abuse and involvement in investigation |
Inspection Report
Annual Inspection
Deficiencies: 4
Aug 19, 2025
Visit Reason
Annual Licensure Survey conducted to assess compliance with residency requirements, service plans, Alzheimer's and dementia program training, and resident rights.
Findings
The facility was found deficient in multiple areas including failure to ensure residency requirements were met for one resident, inadequate revisions and documentation in service plans for another resident, incomplete dementia-specific training for newly hired staff, and failure to prevent physical abuse of a resident during care.
Severity Breakdown
Type 3 Violation: 1
Type 2 Violation: 2
General Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure prior to admission that one resident met all residency requirements, including appropriate services and staffing. | Type 3 Violation |
| Failed to revise service plans to address unwitnessed falls, physical therapy services, and coordination of care for one resident. | Type 2 Violation |
| Failed to ensure required dementia-specific orientation and on-the-job training for newly hired direct and non-direct care staff. | Type 2 Violation |
| Failed to prevent physical abuse of a resident during incontinence care, resulting in termination of the caregiver involved. | General Violation |
Report Facts
Residents reviewed: 5
Unwitnessed falls: 12
Newly hired employees reviewed: 8
Direct care employees lacking training: 5
Non-direct care employees lacking training: 2
Residents reviewed for rights: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Caregiver | Named in physical abuse incident involving resident R1; terminated following investigation |
| E2 | Director of Nursing | Interviewed regarding resident care and abuse incident; involved in investigation and administrative actions |
| E3 | Caregiver | Provided statement regarding E1's behavior and resident care |
| E4 | Registered Nurse | Witnessed incident involving E1 and resident R1; provided statement |
| E5 | Housekeeper | Provided statement regarding incident involving E1 and resident R1 |
| E6 | Caregiver | Witnessed physical abuse incident involving E1 and resident R1 |
| E7 | Assistant Director of Nursing | Reported incident to administration and involved in investigation |
| E8 | Caregiver | Named among newly hired staff lacking required dementia training |
| E10 | Assisted Executive Director | Reviewed personnel files and could not explain training deficiencies |
| E11 | Executive Director | Interviewed during exit conference regarding service plan concerns |
Inspection Report
Follow-Up
Deficiencies: 6
Aug 8, 2024
Visit Reason
Follow-up to the annual survey conducted on 08/08/2024 to verify correction of previously identified deficiencies related to emergency preparedness, accident and incident reporting, quality improvement program, dementia training, resident records, and environmental requirements.
Findings
The report details action plans addressing multiple deficiencies including fire extinguisher training for new hires, failure to report ingestion of hazardous substances, lack of a quality improvement program, dementia training requirements, documentation of isolation for a resident, and proper storage of chemical hazards. Systemic changes and monitoring processes were implemented to ensure compliance.
Deficiencies (6)
| Description |
|---|
| Failed to ensure fire extinguishers training for 4 employees, recent hires. |
| Failed to report to the department involving ingestion of a hazardous substance. |
| Failed to have a Quality Improvement Program. |
| Failed to ensure Dementia Training Requirement for 3 direct care employees. |
| Facility failed to document initiation of isolation for one resident. |
| Facility failed to ensure chemical hazards were locked up/out of reach of residents. |
Report Facts
Number of employees not trained on fire extinguishers: 4
Number of direct care employees lacking dementia training: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Matt Gonzalez | Executive Director | Named as instructor and responsible party in multiple action plans and trainings |
| Monique Middleton | Named as instructor for resident records documentation training |
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