Inspection Report Summary
The most recent inspection on September 14, 2025, identified a deficiency related to the facility’s failure to ensure a resident was safe from sexual abuse by another resident. Earlier inspections showed a mix of compliance and deficiencies, including a January 2, 2025 annual inspection that cited multiple issues such as failure to report serious incidents, lack of CPR-certified staff on duty at all times, incomplete employee training documentation, missing physician assessments, unsigned resident service plans, and incomplete tuberculosis screening. The substantiated complaint investigation in September involved a serious incident where one resident sexually abused another, leading to the eviction of the offending resident and criminal charges. Prior complaint investigations were unsubstantiated, and no fines, license suspensions, or other enforcement actions were listed in the available reports. The inspection history shows some significant issues in early 2025 with resident safety and staff compliance, followed by a serious safety-related deficiency in the most recent report.
Deficiencies (last 1 years)
Deficiencies (over 1 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 14, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding an incident of sexual abuse involving two residents at the facility.
Complaint Details
The complaint investigation was substantiated. The incident involved R2 entering R1's room without consent, undressing, and touching R1 while she was asleep and naked. The male resident had a history of inappropriate behavior and was evicted. The family pressed charges and a rape kit was completed.
Findings
The facility failed to ensure a resident (R1) was safe from sexual abuse when another resident (R2) entered R1's room, undressed, and touched her without consent on 7/25/25. The male resident was evicted, and the family pressed charges. The investigation revealed prior inappropriate behavior by R2 and inadequate safeguards to prevent such incidents.
Deficiencies (1)
Failure to ensure a resident was safe from sexual abuse by another resident.
Report Facts
Date of incident: Jul 25, 2025
Date of survey completion: Sep 14, 2025
Resident sample size: 5
Residents reviewed for abuse: 3
Resident age: 92
Resident age: 91
Mini-mental State Examination score: 26
Date of Physician Assessment Form: Aug 5, 2025
Date of Physician Orders: Jul 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Provided statements about resident R2's condition and incident details |
| E2 | Director of Nursing (DON) | Received reports from staff about the incident and spoke with resident R2 |
| E3 | Certified Nursing Assistant (CNA) | Witnessed R2 in R1's room and reported discomfort with the situation |
| E4 | Certified Nursing Assistant (CNA) | Discovered R2 undressed on top of R1 and reported the incident |
| E5 | Licensed Practical Nurse (LPN) | Reported prior inappropriate behavior by R2 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 12, 2025
Visit Reason
Complaint investigation 2513930/IL191549 conducted on 5/12/2025.
Complaint Details
Complaint investigation 2513930/IL191549 conducted on 5/12/2025. The establishment was found to be 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
Deficiencies: 0
Date: Feb 6, 2025
Visit Reason
Investigation IL001853363 conducted on 2/6/2025 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 Illinois Assisted Living and Shared Housing regulations during this investigation.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jan 2, 2025
Visit Reason
Annual Licensure Survey conducted from 12/31/2024 to 01/02/2025 to assess compliance with Illinois Department of Public Health regulations for assisted living facilities.
Findings
The facility was found deficient in multiple areas including failure to report serious incidents, lack of CPR-certified staff on duty at all times, incomplete employee orientation and training documentation, missing annual physician assessments for residents, incomplete and unsigned resident service plans, and failure to conduct required tuberculosis screening upon resident entry.
Deficiencies (6)
Failure to report serious incidents causing emotional or physical harm to the Department as required.
Failure to ensure at least one direct care staff person with current CPR certification was on duty at all times.
Failure to document that new employees completed required orientation training within 10 and 30 days of hire.
Failure to provide documentation of annual comprehensive physician assessment for a resident.
Failure to develop and have signed resident service plans by all required individuals, and failure to address all resident needs and concerns in service plans.
Failure to conduct required two-step tuberculosis skin test screening upon entry for a resident.
Report Facts
Residents reviewed for incident reporting: 6
Residents reviewed for physician assessment: 6
Residents reviewed for service plans: 6
Employees reviewed for orientation training: 5
Dates/times without CPR certified staff on duty: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing | Named in findings related to failure to report incidents, incomplete orientation training, and confirmation of findings. |
| E1 | Executive Director | Confirmed findings related to CPR staffing and employee orientation documentation. |
| E4 | Registered Nurse | Reviewed for orientation training documentation. |
| E5 | Personal Care Attendant | Reviewed for orientation training documentation. |
| E6 | Dietary Aide | Reviewed for orientation training documentation. |
| E7 | Cook | Reviewed for orientation training documentation. |
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