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| Deficiency Category | Inspection Date: 5/31/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 6/8/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 4/28/22 Complaint Reporting Period: 4/1/22 - 3/31/23 |
|---|---|---|---|
| Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
| Quality of Life and Care Deficiencies | |||
| Infection Control Deficiencies | |||
| Resident Assessment and Care Planning Deficiencies | |||
| Nursing and Physician Services Deficiencies | |||
| Resident Rights Deficiencies | |||
| Nutrition and Dietary Deficiencies | |||
| Pharmacy Service Deficiencies | |||
| Environmental Deficiencies | |||
| Administration Deficiencies |
| Date of last standard health inspection: | 5/31/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 9/13/24Read the full report (PDF) 8/14/24Read the full report (PDF) 6/13/24Read the full report (PDF) 4/25/24Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Illinois: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 5/31/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide activities to meet all resident's needs. | 6/13/24 | 7/9/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide or get specialized rehabilitative services as required for a resident. | 4/25/24 | 7/31/24 | 3 - Actual harm | Few |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | 5/31/24 | 7/26/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide enough food/fluids to maintain a resident's health. | 5/31/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 5/31/24 | 7/26/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | 5/31/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 5/31/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Implement a program that monitors antibiotic use. | 5/31/24 | 7/26/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 9/13/24 | 10/11/24 | 2 - Minimal harm or potential for actual harm | Many |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | 4/25/24 | 5/24/24 | 2 - Minimal harm or potential for actual harm | Many |
Provide and implement an infection prevention and control program. | 5/31/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Some |
| No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 6/13/24 | 7/9/24 | 2 - Minimal harm or potential for actual harm | Many |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 4/25/24 | 7/9/24 | 2 - Minimal harm or potential for actual harm | Many |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 8/14/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Keep residents' personal and medical records private and confidential. | 5/31/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | 5/31/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have a policy regarding use and storage of foods brought to residents by family and other visitors. | 5/31/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 5/31/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure medication error rates are not 5 percent or greater. | 5/31/24 | 7/26/24 | 2 - Minimal harm or potential for actual harm | Some |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | 5/31/24 | 6/28/24 | 3 - Actual harm | Few |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 5/31/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 5/31/24 | 6/28/24 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 9/13/24 | 10/11/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 4/25/24 | 5/24/24 | 2 - Minimal harm or potential for actual harm | Many |
| Date of last standard health inspection: | 6/8/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 2/25/24Read the full report (PDF) 2/14/24Read the full report (PDF) 9/20/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Illinois: | |
| Average number of Health Deficiencies in the United States: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | 6/8/23 | 6/15/23 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 3/6/24 | 3/25/24 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from the wrongful use of the resident's belongings or money. | 3/6/24 | 3/25/24 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 2/25/24 | 4/10/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | 6/8/23 | 6/15/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 6/8/23 | 6/15/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide or get specialized rehabilitative services as required for a resident. | 6/8/23 | 6/15/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 6/8/23 | 6/15/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 6/8/23 | 6/15/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 2/1/24 | 7/26/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 6/8/23 | 6/15/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 2/14/24 | 2/29/24 | 2 - Minimal harm or potential for actual harm | Some |
| No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure that the resident and his/her doctor meet face-to-face at all required visits. | 9/20/23 | 10/6/23 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | 6/8/23 | 6/15/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 2/1/24 | 2/1/24 | 4 - Immediate jeopardy to resident health or safety | Some |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 3/6/24 | 3/25/24 | 2 - Minimal harm or potential for actual harm | Many |
| No Environmental Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 2/1/24 | 5/24/24 | 2 - Minimal harm or potential for actual harm | Many |
| Date of last standard health inspection: | 4/28/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 9/26/22Read the full report (PDF) 4/21/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in Illinois: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide enough food/fluids to maintain a resident's health. | 9/26/22 | 10/25/22 | 3 - Actual harm | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 9/26/22 | 10/25/22 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Few |
| No Infection Control Deficiencies were found during this inspection period. |
| No Resident Assessment and Care Planning Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 9/26/22 | 10/25/22 | 2 - Minimal harm or potential for actual harm | Many |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | 4/21/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Keep residents' personal and medical records private and confidential. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Some |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Few |
| No Environmental Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | 4/28/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide activities to meet all resident's needs. | 6/13/24 | 7/9/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide or get specialized rehabilitative services as required for a resident. | 4/25/24 | 7/31/24 | 3 - Actual harm | Few |
Provide and implement an infection prevention and control program. | 9/13/24 | 10/11/24 | 2 - Minimal harm or potential for actual harm | Many |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | 4/25/24 | 5/24/24 | 2 - Minimal harm or potential for actual harm | Many |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 6/13/24 | 7/9/24 | 2 - Minimal harm or potential for actual harm | Many |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 4/25/24 | 7/9/24 | 2 - Minimal harm or potential for actual harm | Many |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 8/14/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Some |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 9/13/24 | 10/11/24 | 2 - Minimal harm or potential for actual harm | Few |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 4/25/24 | 5/24/24 | 2 - Minimal harm or potential for actual harm | Many |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 3/6/24 | 3/25/24 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from the wrongful use of the resident's belongings or money. | 3/6/24 | 3/25/24 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 2/25/24 | 4/10/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 2/1/24 | 7/26/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 2/14/24 | 2/29/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that the resident and his/her doctor meet face-to-face at all required visits. | 9/20/23 | 10/6/23 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | 2/1/24 | 2/1/24 | 4 - Immediate jeopardy to resident health or safety | Some |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | 3/6/24 | 3/25/24 | 2 - Minimal harm or potential for actual harm | Many |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 2/1/24 | 5/24/24 | 2 - Minimal harm or potential for actual harm | Many |
Provide enough food/fluids to maintain a resident's health. | 9/26/22 | 10/25/22 | 3 - Actual harm | Some |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 9/26/22 | 10/25/22 | 3 - Actual harm | Few |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 9/26/22 | 10/25/22 | 2 - Minimal harm or potential for actual harm | Many |
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | 4/21/22 | 5/10/22 | 2 - Minimal harm or potential for actual harm | Few |
| This nursing home has not had any infection control inspections in the past 3 years. |