Inspection Report Summary
The most recent inspection on October 28, 2025, identified a deficiency related to staff not following a resident’s dementia care service plan during a combative incident. Earlier inspections showed a pattern of deficiencies involving resident care plans, staff conduct, and licensing issues, with prior citations for failure to follow fall interventions, employee training, and operating with an expired license. Complaint investigations were mostly unsubstantiated except for the substantiated fall incident that caused injury and the dementia care issue noted in the latest inspection. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with adherence to care plans and staff training, with no clear improvement trend evident.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
29% better than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 28, 2025
Visit Reason
The inspection was conducted following a facility-reported incident on 10/5/2025 concerning dementia care for a resident who became combative and aggressive during cares.
Complaint Details
The complaint investigation was triggered by a facility-reported incident on 10/5/2025 involving a resident with Alzheimer's disease and behavioral disturbances who became combative during incontinence care. The investigation found staff did not follow the resident's service plan, which included instructions to leave and reapproach the resident if combative. Staff engaged with the resident despite agitation, leading to aggressive behavior and potential harm.
Findings
The facility failed to ensure staff followed a resident's service plan for dementia care, resulting in a combative incident with one resident. Staff did not appropriately de-escalate the situation as outlined in the resident's service plan, which included guidance on cognitive stimulation, behavior management, and redirection.
Deficiencies (1)
Failure to ensure staff followed a resident's service plan for dementia care when the resident became combative and aggressive during cares.
Report Facts
Residents reviewed for dementia care: 4
Date of incident: Oct 5, 2025
Date of survey completion: Oct 28, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E7 | Lead Care Manager | Memory care unit staff who described resident behavior and care instructions |
| E6 | Care Manager | Staff involved in care during the incident and interviewed about the event |
| E5 | Care Manager | Staff involved in care during the incident and interviewed about the event |
| E1 | Executive Director | Provided statements about staff training and care expectations |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 21, 2025
Visit Reason
The inspection was conducted as a complaint investigation for multiple complaint numbers: #2579843/IL197970, #25710050/IL198050, #25710085/IL198078, and #25710220/IL198131.
Complaint Details
Complaint Investigation #2579843/IL197970, #25710050/IL198050, #25710085/IL198078, and #25710220/IL198131 were all investigated with no deficiencies cited.
Findings
No deficiencies were cited in any of the complaint investigations. 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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a facility reported incident dated 2025-09-09.
Complaint Details
Complaint Investigation 2579511/IL197801 related to a facility reported incident on 2025-09-09/IL197482. The facility was found in compliance.
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.
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 1
Date: Aug 10, 2025
Visit Reason
Annual Licensure Survey conducted with multiple complaint investigations resulting in no findings.
Complaint Details
Multiple complaint investigations were conducted with no findings.
Findings
The facility was found to be operating with an expired license as of June 2025, which was not displayed during the survey. The Executive Director reported difficulties applying for a new license online.
Deficiencies (1)
Facility did not have an updated facility license on display, operating on an expired license.
Report Facts
Residents affected: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Reported difficulty applying for license online |
Inspection Report
Deficiencies: 1
Date: Apr 15, 2025
Visit Reason
The inspection was conducted due to an entity reported incident involving a violation of employee orientation and ongoing training requirements, specifically related to staff conduct and fraternization with residents.
Findings
The facility failed to ensure policies and procedures regarding staff fraternization with residents were followed, resulting in the probable exploitation of one resident (R1). An investigation revealed that a terminated Lead Care Manager (E2) engaged in inappropriate conduct with R1, including fraternization and sending sexually explicit text messages.
Deficiencies (1)
Failure to ensure employee orientation and ongoing training requirements were met, specifically regarding staff conduct and fraternization with residents.
Report Facts
Age of resident: 75
Date resident moved in: Oct 3, 2024
Date of employee hire: Apr 30, 2020
Date of employee termination: Apr 1, 2025
Date of inspection visit: Apr 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Terminated Lead Care Manager | Named in fraternization and exploitation finding |
| E1 | Executive Director | Conducted investigation and provided statements regarding the incident |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 29, 2025
Visit Reason
This document is a plan of correction following an entity reported incident survey.
Findings
The survey found no deficiencies and the establishment was in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation following a facility reported incident involving a resident fall resulting in injury.
Complaint Details
Facility Reported Incident #IL182812 was substantiated. Two other incidents (#IL180978 and #IL181705) were not substantiated.
Findings
The facility failed to ensure fall interventions in the resident's service plan were explicitly followed, contributing to a resident's fall incident that caused laceration and head injury requiring hospitalization.
Deficiencies (1)
Failure to ensure fall interventions in the resident's service plan were followed, contributing to a fall incident with injury.
Report Facts
Resident age: 94
Date of fall incident: Dec 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Provided statements regarding the resident's hospitalizations and corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 26, 2024
Visit Reason
This document is a Plan of Correction submitted in response to regulatory findings related to resident rights at the facility.
Findings
The plan addresses concerns regarding resident safety and communication about unsafe behavior, with specific corrective actions including staff training, monitoring of residents with fall risks, and ongoing review of service plans.
Deficiencies (1)
Resident rights violation related to unsafe resident behavior and fall risk interventions.
Report Facts
Inspection date: Dec 26, 2024
Plan of correction submission date: Feb 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Douglas Seebach | Sr General Manager | Legal Entity Representative signing the Plan of Correction |
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