Deficiency in Room Level Compliance
Summary
The facility failed to provide resident bedrooms that are at or above ground level in six of the 70 rooms, specifically rooms 101, 103, 105, 107, 109, and 111. During an environmental tour, it was observed that these rooms were below grade level, with windows that had a visual line of sight looking up and out, indicating that the ground leveled out at the base of the windows. An interview with the Housekeeping and Laundry Director revealed that these rooms had been in this condition for several years but are no longer in use. No water damage was observed in these rooms during the survey.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 13 residents. During a facility tour, it was observed that seven rooms were below ground level. The administrator acknowledged the noncompliance and mentioned a waiver application, but no waiver was provided, and a letter from the Illinois Department of Public Health indicated no waiver had been awarded.
The facility was found to have resident rooms below ground level, affecting all residents reviewed. The administrator confirmed that the facility's structure has not changed since its inception, and this deficiency is cited annually.
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 25 residents who were observed residing on a lower-level floor below ground. The Regional Administrator acknowledged the noncompliance and admitted that the facility had not obtained a building waiver for these rooms.
Noncompliance with Room Location Requirements
Penalty
Summary
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 13 residents. During an initial tour of the facility, it was observed that seven rooms (101, 102, 103, 104, 105, 106, and 107) were situated below ground level. The facility's Resident Roster confirmed that the affected residents were residing in these below-ground-level rooms. The facility's administrator acknowledged awareness of this noncompliance and mentioned that an application for a waiver had been submitted. However, no waiver was provided, and a letter from the Illinois Department of Public Health indicated that no waiver had been awarded for these rooms.
Resident Rooms Below Ground Level
Penalty
Summary
The facility failed to ensure that resident rooms were at or above ground level, affecting all 36 residents reviewed for physical environment. Observations and interviews revealed that rooms B1 through B14 were located below the garden or ground level. The facility administrator acknowledged that the structure has remained unchanged since the facility's inception, and this deficiency has been cited annually during surveys.
Residents Housed Below Ground Level Without Waiver
Penalty
Summary
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 25 residents. During an initial tour, it was observed that these residents were residing on a lower-level floor in rooms below ground level. The facility's Resident Roster confirmed that these residents were indeed housed in rooms on the lower floor. The Regional Administrator acknowledged the noncompliance and admitted that the facility had not obtained a building waiver for these rooms located below ground level.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
