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| Deficiency Category | Inspection Date: 11/22/24 Complaint Reporting Period: 4/1/24 - 3/31/25 | Inspection Date: 10/18/23 Complaint Reporting Period: 4/1/23 - 3/31/24 | Inspection Date: 9/21/22 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: | 11/22/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25 | 11/2/24Read the full report (PDF) 7/26/24Read the full report (PDF) 5/14/24Read the full report (PDF) 4/18/24Read 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: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Protect each resident from the wrongful use of the resident's belongings or money. | 4/18/24 | 5/10/24 | 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 care or services that was trauma informed and/or culturally competent. | 11/22/24 | 12/9/24 | 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. | 11/2/24 | 11/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 11/22/24 | 12/6/24 | 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. | 11/22/24 | 12/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 11/22/24 | 12/6/24 | 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 necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | 11/22/24 | 12/9/24 | 2 - Minimal harm or potential for actual harm | Few |
| No Nursing and Physician Services 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) |
|---|---|---|---|---|
Allow residents to self-administer drugs if determined clinically appropriate. | 11/22/24 | 12/6/24 | 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 sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | 7/26/24 | 8/16/24 | 2 - Minimal harm or potential for actual harm | Many |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | 7/26/24 | 8/16/24 | 2 - Minimal harm or potential for actual harm | Many |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | 11/22/24 | 12/6/24 | 2 - Minimal harm or potential for actual harm | 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. | 7/26/24 | 8/16/24 | 4 - Immediate jeopardy to resident health or safety | 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 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. | 11/2/24 | 11/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 5/14/24 | 6/10/24 | 3 - Actual harm | Few |
| No Environmental Deficiencies were found during this inspection period. |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 10/18/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24 | 8/24/23Read the full report (PDF) 6/13/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24 | |
| 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) |
|---|---|---|---|---|
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 6/13/23 | 6/28/23 | 2 - Minimal harm or potential for actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 10/18/23 | 11/8/23 | 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. | 10/18/23 | 11/8/23 | 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 safe, appropriate pain management for a resident who requires such services. | 10/18/23 | 11/8/23 | 3 - Actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 4/5/23 | 4/30/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide or obtain dental services for each resident. | 10/18/23 | 11/8/23 | 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. | 8/24/23 | 9/11/23 | 4 - Immediate jeopardy to resident health or safety | Some |
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. | 8/24/23 | 9/11/23 | 2 - Minimal harm or potential for actual harm | Few |
| No Infection Control 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) |
|---|---|---|---|---|
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/18/23 | 11/8/23 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 10/18/23 | 11/8/23 | 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 nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | 10/18/23 | 11/8/23 | 2 - Minimal harm or potential for actual harm | Many |
| No Resident Rights 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 each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | 10/18/23 | 11/8/23 | 2 - Minimal harm or potential for actual harm | Many |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 10/18/23 | 11/8/23 | 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) |
|---|---|---|---|---|
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. | 10/18/23 | 11/8/23 | 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 | 8/24/23 | 9/11/23 | 2 - Minimal harm or potential for actual harm | Many |
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | 8/24/23 | 9/11/23 | 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. | 8/24/23 | 9/11/23 | 2 - Minimal harm or potential for actual harm | Many |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | 8/24/23 | 9/11/23 | 2 - Minimal harm or potential for actual harm | Many |
| Date of last standard health inspection: | 9/21/22Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23 | 2/23/23Read the full report (PDF) 10/29/22Read the full report (PDF) 9/28/22Read the full report (PDF) 9/14/22Read the full report (PDF) 6/10/22Read the full report (PDF) 5/29/22Read 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: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 9/28/22 | 10/26/22 | 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. | 9/21/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 9/2/22 | 10/3/22 | 2 - Minimal harm or potential for actual harm | Many |
Protect each resident from the wrongful use of the resident's belongings or money. | 9/2/22 | 10/3/22 | 2 - Minimal harm or potential for actual harm | Some |
Respond appropriately to all alleged violations. | 9/21/22 | 12/15/22 | 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) |
|---|---|---|---|---|
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 9/21/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | 9/21/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 6/10/22 | 6/25/22 | 3 - Actual harm | Few |
Provide care and assistance to perform activities of daily living for any resident who is unable. | 9/21/22 | 12/15/22 | 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. | 5/29/22 | 6/20/22 | 3 - Actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 9/14/22 | 10/3/22 | 3 - Actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 9/21/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 9/21/22 | 12/15/22 | 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. | 9/21/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 9/21/22 | 12/15/22 | 3 - 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. | 9/21/22 | 12/15/22 | 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) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 9/21/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure staff are vaccinated for COVID-19 | 9/21/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Many |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | 9/21/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | 9/21/22 | 12/15/22 | 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) |
|---|---|---|---|---|
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 9/21/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 9/21/22 | 12/15/22 | 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) |
|---|---|---|---|---|
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. | 10/29/22 | 1/6/23 | 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. | 9/21/22 | 1/6/23 | 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) |
|---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 9/21/22 | 12/15/22 | 3 - 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) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 7/8/22 | 7/29/22 | 2 - Minimal harm or potential for actual harm | Many |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | 9/21/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Many |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 9/21/22 | 12/15/22 | 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) |
|---|---|---|---|---|
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. | 9/21/22 | 12/15/22 | 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. | 2/23/23 | 3/18/23 | 2 - Minimal harm or potential for 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. | 9/21/22 | 12/15/22 | 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) |
|---|---|---|---|---|
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | 9/21/22 | 12/15/22 | 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) |
|---|---|---|---|---|
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | 9/21/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Many |
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | 9/21/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Many |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | 9/21/22 | 12/15/22 | 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) |
|---|---|---|---|---|
Protect each resident from the wrongful use of the resident's belongings or money. | 4/18/24 | 5/10/24 | 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. | 11/2/24 | 11/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | 7/26/24 | 8/16/24 | 2 - Minimal harm or potential for actual harm | Many |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | 7/26/24 | 8/16/24 | 2 - Minimal harm or potential for actual harm | 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. | 7/26/24 | 8/16/24 | 4 - Immediate jeopardy to resident health or safety | Few |
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. | 11/2/24 | 11/3/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 5/14/24 | 6/10/24 | 3 - Actual harm | Few |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | 6/13/23 | 6/28/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 4/5/23 | 4/30/23 | 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. | 8/24/23 | 9/11/23 | 4 - Immediate jeopardy to resident health or safety | Some |
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. | 8/24/23 | 9/11/23 | 2 - Minimal harm or potential for actual harm | Few |
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | 8/24/23 | 9/11/23 | 2 - Minimal harm or potential for actual harm | Many |
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | 8/24/23 | 9/11/23 | 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. | 8/24/23 | 9/11/23 | 2 - Minimal harm or potential for actual harm | Many |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | 8/24/23 | 9/11/23 | 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. | 9/28/22 | 10/26/22 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 9/2/22 | 10/3/22 | 2 - Minimal harm or potential for actual harm | Many |
Protect each resident from the wrongful use of the resident's belongings or money. | 9/2/22 | 10/3/22 | 2 - Minimal harm or potential for actual harm | Some |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 6/10/22 | 6/25/22 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 5/29/22 | 6/20/22 | 3 - Actual harm | Few |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | 9/14/22 | 10/3/22 | 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. | 10/29/22 | 1/6/23 | 2 - Minimal harm or potential for actual harm | Many |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 7/8/22 | 7/29/22 | 2 - Minimal harm or potential for actual harm | Many |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 2/23/23 | 3/18/23 | 2 - Minimal harm or potential for actual harm | Few |
| This nursing home has not been cited for any deficiencies on infection control inspections in the last 3 years. |