Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Joliet Living & Rehab Center during CMS and state inspections, most recent first.
A resident with a history of paranoid schizophrenia, bipolar disorder, and PTSD reported that staff conducted a random search of his room and jacket pocket without his presence or permission. A grievance documented his concern about the unaccompanied search, and the Psychosocial Rehabilitation Services Coordinator confirmed she performed the room check alone while the resident was not present. This action conflicted with the facility’s own inspection policy, which requires the resident to be present during room searches and to personally turn out their own pockets.
The facility implemented new house rules that prohibited residents from visiting other residents’ rooms if they lived on different wings, directing them instead to visit only in the dining room and providing no alternative space for private visits. This change conflicted with the facility’s own Resident Rights document, which states that residents have the right to private visits unless limited by a physician. Multiple residents, including those with anxiety, depression, and chronic migraine headaches, reported that they could no longer have private time with friends or intimate partners, felt their rights were violated, and described feeling depressed, anxious, and like prisoners due to the loss of privacy. The Administrator confirmed the rule was added to address resident smoking in rooms and that most residents had signed the new agreement.
Failure to prevent verbal abuse by a staff member. A resident with Bipolar D/O, GAD, and suicidal ideations reported being called a derogatory name in a loud tone, while another resident was reportedly mocked by the same staff member and a third resident said she did not like his tone. Other staff described the employee as swearing, telling residents to shut up, and speaking in an aggressive, dismissive manner, but the incidents were not consistently reported as abuse or investigated as such.
Failure to Report Allegations of Verbal Abuse and Mistreatment: A psychosocial rehab aide was reported to have called a resident a derogatory name, mocked another resident, and spoken to a third resident in a loud, aggressive, and profane manner. Residents and staff described the aide as dismissive and easily agitated, but some concerns were not reported as abuse to the administrator or included in abuse investigation records, despite the facility policy requiring immediate reporting of any suspected abuse or mistreatment.
Failure to investigate allegations of verbal abuse and mistreatment: A psychosocial rehab aide was reported to have used derogatory, loud, mocking, and aggressive language toward multiple residents, including calling one resident a name, mocking another, and yelling at a third about banking assistance. Staff described the aide as dismissive and easily agitated, but not all incidents were reported to the administrator as potential abuse or included in abuse investigation records, despite the facility policy requiring prompt investigation of all allegations.
Two residents with behavioral health diagnoses were involved in a verbal and physical altercation after repeated complaints about one resident's disruptive behavior were not addressed by staff. Despite awareness of the issue, no interventions or care plan updates were made, resulting in both residents sustaining injuries and requiring hospital evaluation.
The facility did not identify water systems requiring Legionella control measures or assess the risk of hazardous conditions as outlined in its water management program. Staff could only provide water flushing logs and a general policy, with no documented risk assessment or system identification, affecting all 88 residents.
Several cognitively intact residents reported and were observed to have room windows without screens, leading to concerns about insects and other objects entering when windows were open. The Maintenance Director confirmed the absence of screens throughout the facility, and the Administrator stated there was no policy requiring window screens, with past screens having been removed or damaged and not replaced.
The facility did not provide written notification of its bed-hold and return policy to residents or their representatives before hospital transfers, as required by policy. This deficiency was identified for four residents with complex medical and psychiatric needs who were hospitalized for various acute events, with no documentation of the required notification found in their records.
Two residents with psychiatric conditions were involved in a physical altercation after one began punching the other, leading to retaliation and injury. Staff and witnesses confirmed a pattern of aggressive and intrusive behavior by one resident, and both individuals required hospital evaluation following the incident.
Two residents with severe mental illness did not receive the necessary behavioral health services as outlined in their PASRR assessments and care plans. Both attended only minimal group sessions, with no evidence of participation in key rehabilitative programs or one-on-one interventions, and the facility failed to document refusals or efforts to provide required behavioral health care.
A resident with multiple diagnoses and intact cognition had a large piece of plywood covering a hole in the wall next to their bed for about a year after accidentally kicking the wall. Despite being told the wall would be repaired, the fix was overlooked by maintenance staff, and the plywood remained in place for 14 months, contrary to facility policy requiring timely repairs and maintenance.
Three residents with psychiatric diagnoses and cognitive intactness were involved in incidents where one resident was sexually abused by another after consuming alcohol, and subsequently physically assaulted her boyfriend, believing he allowed the abuse. The facility failed to prevent these instances of sexual and physical abuse, contrary to its stated abuse prevention policy.
A resident with multiple medical conditions and a need for assistance with ADLs did not receive timely podiatry care, resulting in long, discolored, and curled toenails. Despite being on the podiatry list and requesting care, the resident was not seen by the podiatrist as scheduled, and there was no documentation of refusal or alternative arrangements for foot care, contrary to facility policy.
A resident with multiple medical and psychiatric diagnoses, who was cognitively intact and required supervision for ADLs, was denied a second cup of coffee by a CNA despite there being no facility rule limiting coffee servings. The resident observed another individual receiving a second cup and was not informed of any restrictions, leading to feelings of frustration and being singled out. Staff and administration confirmed that no such rule existed and that residents were generally allowed additional coffee.
Multiple incidents occurred in which residents engaged in physical altercations following staff discussions about resident behavior within earshot of others and insufficient supervision during smoke breaks. These events led to residents confronting and physically assaulting each other, in violation of the facility's policy prohibiting abuse.
A resident with multiple medical conditions did not receive a Nurse Practitioner's ordered Basic Metabolic Panel (BMP) lab test, despite the order being confirmed by an RN. The facility lacked documentation that the test was completed, even though prior labs showed abnormal sodium and bilirubin levels. The resident was later hospitalized with further abnormal lab findings, and staff confirmed the test should have been done according to facility policy.
Two residents, both diagnosed with schizoaffective disorder and generalized anxiety disorder, were involved in a physical altercation when one resident slapped the other in a shared bathroom. The incident occurred due to a misunderstanding, as the resident who slapped perceived an insult. Despite the facility's abuse policy, the altercation was not prevented, highlighting a deficiency in protecting residents from abuse.
The facility failed to maintain cleanliness in the food preparation area and equipment storage, affecting all 92 residents. Staff were observed with improper hair restraints and inadequate hand hygiene. The kitchen had dust-covered vents, stained pans, and dusty storage racks. Facility policies on safe food preparation and cleaning schedules were not followed.
The facility failed to provide a safe, clean, and comfortable environment for its residents, as evidenced by multiple deficiencies such as difficult-to-open bathroom doors, insufficient water pressure in showers, broken drawers, peeling paint, and wobbly toilets. These issues had been reported by residents but remained unresolved for extended periods, affecting their quality of life.
The facility failed to invite four residents to their care plan meetings, despite their cognitive abilities being intact or moderately impaired. Observations, interviews, and record reviews confirmed the absence of documentation for care plan meetings or invitations for these residents. The facility's policies require the development of a person-centered care plan with resident participation, but this was not adhered to, as evidenced by the lack of invitations and documentation.
The facility failed to prevent a resident from accessing unprescribed medications and did not adequately monitor smoking residents. One resident was found with five different pills, and multiple residents reported insufficient supervision during smoking breaks, contrary to facility policy.
The facility failed to maintain dignity and privacy for two residents with intact cognition. Staff entered rooms without waiting for permission, administered incontinence briefs in public areas, and shared dressers exposed personal belongings. The DON acknowledged these concerns, emphasizing the need for staff to knock and wait for permission before entering and to avoid public distribution of incontinence briefs.
The facility failed to maintain proper documentation for Advanced Directives for three residents, resulting in discrepancies between the residents' wishes and their medical records. The facility's policy mandates congruent documentation and timely updates, which were not followed.
The facility failed to follow physician orders for one resident by administering an incorrect dosage of Tylenol and did not monitor another resident's blood glucose levels despite her being on diabetic medications. The Director of Nursing confirmed these deficiencies, highlighting the need for proper medication administration and monitoring.
The facility failed to update the EMR to include a resident's medical diagnoses. The DON confirmed that the admitting nurse is responsible for entering the diagnoses and the MDS Coordinator should have reviewed them. The facility did not have a policy or procedure guide for updating resident records.
Resident Rights Violated During Unaccompanied Room and Belongings Search
Penalty
Summary
The facility failed to honor a resident’s right to be treated with respect and dignity and to retain and use personal possessions when staff conducted a room search without the resident’s presence or permission. The affected resident is an adult male with a history of paranoid schizophrenia, bipolar disorder, and post‑traumatic stress disorder, admitted on June 1, 2023. On interview, the resident reported that his room was searched randomly, that he was not present, and that he had not given permission for the search; he also stated that his jacket, which was lying on his bed, had its pocket searched. A grievance form dated April 20, 2026 documented the resident’s concern about his room being searched without him present. During interview, the Psychosocial Rehabilitation Services Coordinator acknowledged that she performed a random room check of this resident’s room on April 20, 2026, did so alone, and confirmed the resident was not present during the search. The facility’s Inspection Policy states that residents must be present during room searches and that residents’ pockets may only be checked by the resident turning their own pockets inside out, which was not followed in this instance. This sequence of events, including the staff member’s admission and the documented grievance, demonstrates that the facility did not adhere to its own policy or to resident rights regarding privacy and personal possessions during the room and clothing search for this resident.
Restriction of In-Room Visitation and Loss of Resident Privacy Rights
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to private visits and a dignified existence when it implemented new house rules restricting in-room visitation between residents from different wings. The facility’s written Resident Rights document states that residents have the right to private visits unless limited by a physician for medical reasons. However, effective January 23, 2026, the facility implemented a new House Rules and Behavior Expectations agreement, including a rule that residents are prohibited from going onto another unit or floor where they do not reside and directing them to use the dining room if they wish to visit a co-resident. The Administrator confirmed that this rule was added to make it easier to identify residents who were smoking in their rooms and that it was implemented permanently, with 80 of 92 residents signing the new agreement. The Administrator also acknowledged that there is currently no place where residents from different wings can visit privately. Multiple residents reported that this new rule removed their ability to have private visits in their rooms, particularly with significant others and friends who live on different wings. One resident stated she could no longer have her boyfriend or friends in her room and that they could not be intimate due to lack of privacy. Another resident reported that the rule violated his rights, increased his depression, and that he does not like leaving his room. Other residents described the rules as unconstitutional, said they could no longer play video games with friends in private, and reported feeling annoyed, depressed, anxious, and like prisoners because they could not have private time with friends or partners. One resident with chronic migraine headaches stated she prefers to stay in her room and now has limited time with her boyfriend because she does not like to go to the dining area. Staff confirmed that the new rule prohibiting residents from entering rooms on other wings had recently started and that residents were complaining about it.
Failure to Prevent Verbal Abuse by Staff Member
Penalty
Summary
The facility failed to protect residents from verbal abuse by a Psychosocial Services Rehabilitation Coordinator/Assistant, affecting three residents reviewed for abuse concerns. The report states that one resident with a history of Bipolar Disorder, Generalized Anxiety Disorder, and suicidal ideations said the staff member called him a derogatory name in a loud tone after a miscommunication, and the resident felt insulted by the interaction. The same resident also reported that the staff member questioned him about his military clothing and background in a way he found offensive. A second resident was reported by staff and peers to have been mocked by the same staff member during a smoke break, including behavior described as mocking while wearing a bag over his head. Another resident reported not liking the way the staff member spoke to her when she asked for help with a bank trip, and staff described the tone as loud. Additional staff members said they had observed the staff member swear in front of residents, tell residents to shut up, talk badly about residents with other residents, and become impulsive, easily agitated, dismissive, and overwhelmed when approached by residents. The facility’s own interviews showed that concerns about the staff member’s communication style had been raised before, including reports from residents and staff that he spoke to residents in a playful but aggressive tone and that some residents were confused or did not like how he talked to them. The administrator stated that all allegations of abusive behavior should have been reported and investigated, and that if the staff member had been reported as yelling or swearing at a resident, the matter would have been investigated as abuse. The abuse investigation records reviewed did not include a report for one resident’s incident, and the administrator stated she was not informed of all of the abusive behavior described by staff and residents.
Failure to Report Allegations of Verbal Abuse and Mistreatment
Penalty
Summary
The facility failed to report incidents and allegations of abuse and mistreatment involving three residents. The deficiency involved a psychosocial rehabilitation services aide who was reported to have spoken to residents in a verbally abusive, mocking, loud, and aggressive manner, including calling one resident a derogatory name and mocking another resident during a smoke break. The facility’s own abuse policy required employees and supervisors to immediately report any incident, allegation, or suspicion of potential abuse or mistreatment to the administrator and to initiate an investigation, and required all incidents to be documented and reported to the Department of Public Health regional office when abuse or mistreatment was alleged. One resident, a male with a history of Bipolar Disorder, Generalized Anxiety Disorder, and Suicidal Ideations, reported that the aide called him a derogatory name after a miscommunication and that he felt insulted by the aide’s behavior. He said he reported the incident to a CNA, who informed the administrator. Another resident, a male with a history of Depressive Type Schizoaffective Disorder and Generalized Anxiety Disorder, stated he did not feel safe at the facility because staff had hurt him emotionally. The abuse investigation record showed the aide had been hired shortly before these events. A third resident reported to staff that she did not like the way the aide spoke to her when she asked for help with banking, and staff overheard the aide raising his voice and using profanity toward her. Multiple staff members described the aide as speaking to residents in a playful but aggressive tone, becoming easily agitated, and needing redirection and coaching on how to interact with residents. Although staff discussed concerns about the aide’s behavior, one supervisor stated she did not report some of the incidents to the abuse coordinator or administrator because she did not think they were severe enough, and the abuse investigation reports from the relevant period did not include a report for the third resident.
Failure to Investigate Allegations of Verbal Abuse and Mistreatment
Penalty
Summary
The facility failed to investigate incidents and allegations of abuse and mistreatment involving three residents. The report identified that a psychosocial rehabilitation services aide used verbally abusive and disrespectful language toward residents, including calling one resident a derogatory name and speaking to residents in an aggressive, mocking, and loud manner. The facility’s own abuse policy required prompt investigation of all reports and allegations of abuse or mistreatment, immediate removal of accused employees from resident contact, and notification to the administrator and public health when potential abuse was reported. One resident, a male with a history of Bipolar Disorder, Generalized Anxiety Disorder, and Suicidal Ideations, reported that the aide called him a derogatory name after a miscommunication and that he felt insulted by the aide’s behavior. Another resident, a male with Depressive Type Schizoaffective Disorder and Generalized Anxiety Disorder, stated he did not feel safe because staff had hurt him emotionally. Staff interviews and an abuse investigation report showed the aide was observed mocking this resident during a smoke break, and the aide was later terminated after the allegations were confirmed. A third resident reported that the aide yelled at her and told her she could tell somebody else to take her to the bank. Multiple staff members described the aide as loud, aggressive, dismissive, impulsive, and easily agitated when interacting with residents. Although staff discussed concerns about the aide’s communication style and gave him feedback, the administrator stated she was not informed of all incidents as potential abuse and that the incidents involving loud, rude, yelling, and swearing behavior should have been reported and investigated. The abuse investigation reports from October to November 2025 did not include a report for the third resident.
Failure to Implement Interventions Following Behavioral Complaints Led to Resident Altercation
Penalty
Summary
The facility failed to protect two residents from abuse by not implementing interventions in response to repeated behavioral concerns and a resident complaint. One resident, with a history of mood disorder, depression, anxiety, and chronic pain, exhibited verbally threatening behaviors almost daily and demonstrated depressive moods. Another resident, diagnosed with schizoaffective disorder, PTSD, anxiety disorder, and bipolar disorder, also experienced depressive moods. Despite ongoing complaints from residents and staff about one resident's behavior of placing meal trays on another table, no interventions or care strategies were documented or implemented to address the issue. An altercation occurred during dinner when one resident struck another after being verbally provoked, resulting in both sustaining injuries that required first aid and hospital evaluation. Multiple interviews confirmed that staff were aware of the ongoing behavioral issue and resident complaints but failed to act or document any interventions. The facility's abuse prevention policy requires timely response to consumer concerns, but records showed no evidence of such actions prior to the incident.
Failure to Implement Comprehensive Water Management and Legionella Risk Assessment
Penalty
Summary
The facility failed to follow its own water management program by not identifying building water systems that require Legionella control measures and not assessing the level of risk posed by hazardous conditions in those systems. During the survey, the facility was unable to provide documentation or evidence of a risk assessment or identification of specific water systems at risk for Legionella, as required by their policy. The only information provided consisted of a log for water flushing in unoccupied rooms, a general water management program policy, and screenshots of water flushing logs. The policy referenced a diagram (Figure A) for system identification, but no such diagram was attached or available. Interviews with the Administrator, Maintenance Director, and Regional Maintenance confirmed that no additional documentation or assessment existed beyond the flushing logs and policy. The staff stated that the water flushing logs constituted their assessment, but there was no written or otherwise documented evaluation of the facility's water systems or the risks associated with Legionella. This deficiency affected all 88 residents residing in the facility, as indicated by the facility census.
Failure to Provide Window Screens in Resident Rooms
Penalty
Summary
The facility failed to provide window screens in resident rooms, resulting in a lack of a safe, clean, and comfortable environment for residents. Multiple cognitively intact residents reported that their room windows did not have screens, and observations confirmed the absence of screens, as well as the presence of warped or damaged screens in several rooms. Residents expressed concerns about insects and other objects entering their rooms when windows were open for ventilation. In one instance, a resident reported that a maintenance staff member installed a wooden block to prevent the window from opening fully due to safety concerns, but did not address the missing screen despite being informed about it. Another resident's window screen was found lying outside on the grass, broken and ripped, and had not been replaced for over two weeks. The Maintenance Director confirmed that, to his knowledge, none of the facility's windows had screens since he began working there three years prior. The Administrator stated there was no facility policy regarding window screens and indicated that screens had previously been removed or damaged by residents, leading to the decision not to reinstall them. These actions and inactions resulted in the ongoing absence of window screens in resident rooms, despite residents' requests and concerns.
Failure to Provide Written Bed-Hold Policy Prior to Hospitalization
Penalty
Summary
The facility failed to provide written notification of its bed-hold and return policy to residents or their representatives prior to hospitalization, as required by its own policy. This deficiency was identified through record review and interviews, which revealed that four residents who were transferred to the hospital for various medical and behavioral reasons did not receive the required written documentation. The residents involved had complex medical and psychiatric diagnoses, including diabetes, schizoaffective disorder, bipolar disorder, PTSD, and intellectual disabilities. Each resident experienced an acute event necessitating hospital transfer, such as rib fractures with pneumothorax, abnormal diagnostic results, urinary tract infection, escalating aggressive behavior, or self-harm attempts. Despite multiple hospitalizations and clear documentation of the events leading to each transfer, there was no evidence in the residents' records that the facility provided the mandated written bed-hold and return policy prior to their departure. The facility administrator confirmed during the survey that the bed-hold forms were not being completed for residents transferred to the hospital, even though the facility's policy required this notification. The deficiency was found in all four cases reviewed for hospitalization in the sample.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents with psychiatric diagnoses. One resident, who is cognitively intact and diagnosed with paranoid schizophrenia, was seated next to another resident with moderately impaired cognition, unspecified schizophrenia, and a history of aggressive and abusive behavior. While watching a movie in the dining/day room, the resident with a history of aggression began lightly punching the other resident's arm, escalating to harder punches. The recipient of the punches did not initially report the behavior, as it was consistent with the aggressor's known conduct, but eventually retaliated by grabbing the aggressor's hand and kneeing him in the abdomen. This resulted in the aggressor losing balance and falling to the floor. Multiple staff interviews confirmed that the aggressive resident had a pattern of socially inappropriate and intrusive behavior, including touching others without consent. Staff present at the time witnessed the escalation and responded after the physical altercation had already occurred. Both residents sustained injuries and were sent to the hospital for evaluation. The incident highlights a failure to adequately supervise and intervene to prevent physical abuse between residents, particularly given the known behavioral history of one of the individuals involved.
Failure to Provide Required Behavioral Health Services to Residents with SMI
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents with severe mental illness (SMI), as required by their PASRR Level II recommendations and care plans. Both residents had diagnoses including schizoaffective disorder and schizophrenia, and their PASRR assessments specified the need for rehabilitative supports such as life skills programs, psychotherapy, and regular meetings with mental health professionals. Despite these documented needs, the facility did not ensure that the recommended behavioral health services were consistently offered or provided. For the first resident, documentation showed only two group sessions attended over a five-month period, totaling one hour of behavioral health services. The resident was not listed as a participant in key groups such as symptom management, home and self-care, or social skills, despite being assessed as able to benefit from them. Facility staff stated that the resident refused both group and one-on-one sessions, but there was no documentation of these refusals or of efforts to offer one-on-one interventions as required by the care plan and PASRR recommendations. The second resident also had a history of SMI and substance use, with PASRR recommendations for multiple rehabilitative services and psychotherapy. This resident attended only three money management group sessions and one sexual health group session over several months, with no participation in other recommended groups. Staff confirmed that the resident refused additional groups and one-on-one sessions, but again, there was no documentation of refusals or of attempts to provide individualized behavioral health interventions. Both cases demonstrate a lack of implementation and documentation of required behavioral health services for residents with SMI.
Failure to Repair Resident Room Wall in Timely Manner
Penalty
Summary
A deficiency was identified when a resident's room was not maintained in good repair, as required by facility policy. The resident, who was cognitively intact and had multiple diagnoses including schizoaffective disorder and obesity, had a large piece of plywood covering a hole in the wall next to his bed. The hole was created when the resident accidentally kicked the wall while sleeping, and the plywood had been in place for approximately a year. The resident reported that he was told the wall would be repaired, but no timeline was provided, and the repair was not completed. Interviews with facility staff confirmed that the plywood had been covering the hole for 14 months due to an oversight by the Maintenance Director. The Administrator acknowledged that the hole should have been fixed and that leaving plywood on the wall for such an extended period was inappropriate. Facility policy states that the Maintenance Department is responsible for keeping the building in good repair and free from hazards, but this was not followed in this instance.
Failure to Protect Residents from Sexual and Physical Abuse
Penalty
Summary
The facility failed to protect three residents from sexual and physical abuse. One resident, who was cognitively intact and had diagnoses including PTSD, schizoaffective disorder, anxiety, and borderline personality disorder, reported that another resident with similar psychiatric diagnoses and a history of substance use entered her room and touched her inappropriately by grabbing her breast. The incident occurred after the residents had consumed alcohol together. The resident responded by kicking the perpetrator and later reported the incident to facility staff, after which the police were called. Additionally, the same resident slapped her boyfriend, another resident, because she believed he allowed the inappropriate contact to occur. The boyfriend confirmed being slapped but denied injury or pain and declined police intervention. Both incidents were reported to the Illinois Department of Public Health. The facility's abuse policy states a commitment to protecting residents from abuse by anyone, but the events described demonstrate a failure to uphold this policy, resulting in residents being subjected to both sexual and physical abuse by peers.
Failure to Provide Timely Podiatry Services
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including schizoaffective disorder, attention deficit hyperactivity disorder, obesity, and tinea unguium, did not receive appropriate podiatry care. The resident was cognitively intact and required supervision or assistance with activities of daily living. During observation, the resident was found to have long, black, and curled toenails on the left foot and long toenails on the right foot. The resident reported that the last podiatry visit for toenail clipping was six months prior and that, despite being on the list to see the podiatrist, was not seen during the most recent visit. The resident also stated that he had informed the program manager of his need for toenail care. Interviews with facility staff confirmed that the resident should have received podiatry care and that there was no documentation of the resident refusing services. The facility's records showed the resident was added to the podiatry list for toenail trimming, but there was no documentation of the resident being seen by the podiatrist as scheduled. The facility's policy requires podiatry services, including toenail trimming, to be made available to all residents, but this was not provided in this case.
Resident Denied Second Cup of Coffee Without Justification
Penalty
Summary
A resident with multiple diagnoses, including cocaine dependence with cocaine-induced anxiety disorder, major depressive disorder, COPD, cardiac arrhythmia, back pain, and suicidal ideations, was admitted to the facility and assessed as cognitively intact and requiring supervision with all ADLs. On the day in question, the resident requested a second cup of coffee during a meal service. The CNA serving coffee refused the request, instructing the resident to wait until all others had received their first cup. The resident expressed frustration, noting that he was not informed of any such rule and observed another resident receiving a second cup. The resident attempted to obtain a second cup through his roommate, but the CNA recognized the attempt and did not provide the coffee. Interviews with staff confirmed that there were no facility rules limiting residents to one cup of coffee, and the administrator stated there had been no issues with coffee supply or restrictions on second helpings. The Psychiatric Rehabilitation Services Coordinator noted that the resident was particularly distressed that day and that a second cup of coffee could have helped. Observations on a subsequent day showed residents freely receiving additional cups of coffee, and no rules regarding coffee service were posted. The incident resulted in the resident feeling singled out and denied a personal preference without justification.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving altercations between residents. In one incident, a resident with a history of cocaine dependence, major depressive disorder, and other medical conditions requested a second cup of coffee and was denied by a CNA, leading to a verbal exchange. The CNA later discussed the incident within earshot of other residents, who then confronted the resident in his room. This confrontation escalated into a physical altercation, with one resident striking another in the face. Staff interviews confirmed that the CNA's conversation was overheard by residents, which directly contributed to the escalation of the situation. Another incident involved two residents with cognitive impairments and multiple medical diagnoses who became involved in a physical altercation during a smoke break. One resident cut in line, leading to an argument and a physical push. Staff and other residents intervened to prevent further escalation, but the initial lack of supervision allowed the altercation to occur. Documentation and staff interviews confirmed that the altercation was witnessed and that the residents were able to physically engage before being separated. In both cases, the facility's failure to prevent staff from discussing resident-related issues in the presence of other residents, as well as insufficient supervision during high-risk times such as smoke breaks, contributed to the occurrence of physical abuse. The facility's own policy affirms the right of residents to be free from abuse, yet these incidents demonstrate lapses in maintaining a safe environment and protecting residents from harm.
Failure to Complete Ordered Laboratory Test for Resident
Penalty
Summary
The facility failed to follow a Nurse Practitioner's order to obtain a Basic Metabolic Panel (BMP) laboratory test for a resident who had multiple complex medical diagnoses, including schizoaffective disorder, UTI, abnormal gait, muscle weakness, heart failure, COPD, diabetes, and others. The order to check the BMP was placed on August 31 and confirmed by a Registered Nurse on September 2, but there is no documentation that the laboratory test was ever completed. The facility's own policy requires that laboratory and diagnostic testing be performed according to provider orders, with oversight and coordination by the Director of Nursing or designee, and that requisitions be completed and filed appropriately. The resident's previous laboratory results had already shown abnormal sodium and bilirubin levels. Later, the resident was sent to the hospital, where further testing revealed a significantly low sodium level and elevated bilirubin, leading to diagnoses of hyponatremia and acute kidney injury. Interviews with facility staff confirmed that the ordered BMP should have been completed, but it was not carried out as required.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to prevent a physical altercation between two residents, R1 and R2, which occurred on October 13, 2024. R1 reported to the Administrator that R2 slapped him when he entered the shared bathroom while R2 was using it. Both residents are diagnosed with schizoaffective disorder and generalized anxiety disorder, and are cognitively intact according to their respective MDS assessments. R1 also has Parkinson's disease and experiences delusional thoughts and maladaptive behaviors, while R2 has a history of aggressive behavior and ineffective coping mechanisms. The incident was reported to have occurred because R2 was surprised and upset by R1's entry into the bathroom, which R2 perceived as an insult. The facility's abuse policy, effective since March 2022, prohibits any form of abuse, including physical abuse, which is defined as the infliction of injury that requires medical attention. Despite this policy, the facility's investigation concluded that R2 did not intend to abuse R1, attributing the incident to R2's response to internal stimuli. The Administrator confirmed the incident and noted that R2 had no previous episodes of aggression or violence, while R1 is hard of hearing and hears voices, which can lead to annoyance. The facility's failure to prevent this altercation indicates a deficiency in protecting residents from abuse, as outlined in their policy.
Failure to Maintain Cleanliness in Food Preparation Area
Penalty
Summary
The facility failed to maintain cleanliness in the food preparation area and equipment storage, affecting all 92 residents. During an initial kitchen tour, it was observed that a cook was wearing a hair restraint improperly, with hair dangling to the earlobes, and did not change gloves or perform hand hygiene after retrieving additional vegetables from the cooler. Another dietary aide was also observed with hair dangling to the earlobes while preparing food. The air vent in the food preparation area was covered with black dust, and the floor behind the shelving had a black substance. During lunch service, five of the six pans used were stained with black grease, and the ceiling above the steam table had dust particles and food stains. The storage racks for clean equipment were covered with dust and cobwebs. A cook was also observed with an improperly covered beard while serving food from the steam table. The facility's policies on safe food preparation and handling, as well as cleaning schedules, were not followed. The policies required proper hand washing techniques and suitable hair restraints, which were not adhered to by the staff. The dietary manager confirmed that the vents above the stove are cleaned every six months by an outside company, but there was uncertainty about how to ensure full beard coverage for staff. The deficiencies in cleanliness and hygiene practices in the kitchen were evident, as staff continued to use dusty and stained equipment for food preparation and storage.
Facility Fails to Maintain Safe and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for its residents, as evidenced by multiple deficiencies observed and reported by residents. Resident R34 reported that his bathroom door was difficult to open and close, requiring significant physical effort, and had been in this condition for 3-4 months despite notifying the Maintenance Director. Similarly, R72, who shares the bathroom with R34, confirmed the issue and added that the doorknob was loose and missing screws, making it even more challenging to use the door. The Maintenance Director acknowledged being aware of the problem but had not yet addressed it adequately. Resident R53 reported that the water pressure in his shower was insufficient to rinse soap off his body, a problem that had persisted for six months since the shower head was replaced. Despite informing the Maintenance Director, the issue remained unresolved. Resident R193 expressed concerns about her room's condition, including a piece of gum stuck under her bedside table, a falling baseboard, and broken or missing drawers in her built-in closet. These issues had been reported to staff but had not been addressed, making her feel unsafe and uncomfortable in the facility. Residents R75, R42, R59, and R71 also reported various maintenance issues in their rooms, such as broken drawers, peeling paint, and wobbly toilets. These problems had been ongoing for extended periods, with some residents reporting issues that had persisted for years. The Maintenance Director admitted to being unaware of some of these concerns and acknowledged that the facility was not homelike for the residents when their rooms were in disrepair. The Administrator and Director of Nursing also recognized the deficiencies and agreed that the facility should provide a more homelike environment for its residents.
Failure to Invite Residents to Care Plan Meetings
Penalty
Summary
The facility failed to invite four residents (R55, R65, R76, and R31) to their care plan meetings, despite their cognitive abilities being intact or moderately impaired. Observations and interviews revealed that these residents had never been invited to or attended any care plan meetings. Record reviews confirmed the absence of documentation for care plan meetings or invitations for these residents. Specifically, R55, R65, and R76, all with intact cognition, reported never being invited to care plan meetings, and their electronic health records corroborated this lack of documentation. R31, with moderate cognitive impairment, also reported not being invited to a care plan meeting in over a year, and there was no documentation to show his participation or invitation to any care plan meetings. The facility's Administrator and Director of Nursing confirmed the lack of documentation and stated that the facility had only recently started documenting residents' acceptance or refusal to participate in these meetings. The facility's Care Plan policy requires the interdisciplinary team to develop and implement a person-centered care plan in consultation with the resident and their representative, with appropriate documentation of any refusals to participate. The facility's Care Planning - Interdisciplinary Team (IDT) policy mandates the development of a comprehensive care plan within seven days of the resident's assessment, encouraging the participation of the resident, their family, and/or legal representative. However, the facility failed to adhere to this policy, as evidenced by the lack of invitations and documentation for the care plan meetings of the four residents reviewed. The Psych Rehab Services Director, responsible for inviting residents and their families to care plan meetings, also confirmed the absence of documentation for R31's participation or invitation to any care plan meetings. This deficiency highlights a significant lapse in the facility's adherence to its own policies and regulatory requirements for resident care planning and documentation.
Medication Mismanagement and Inadequate Smoking Supervision
Penalty
Summary
The facility failed to prevent a resident from accessing medications that were not prescribed to them and did not adequately monitor smoking residents. One resident, who had a history of self-harm and substance abuse, was found in possession of five different pills that were not prescribed to him. The facility's staff admitted that the medications should have been disposed of properly and that the resident should not have had access to them. This lapse in supervision could have led to serious health risks for the resident and others who missed their medications. Additionally, the facility did not properly monitor residents during smoking breaks. Multiple residents reported that staff were either not present or only monitored from inside the building, leaving lighters unattended and allowing residents to light their own cigarettes. This was against the facility's smoking policy, which required staff to be present and to light cigarettes for the residents. The lack of supervision during smoking breaks posed a significant safety hazard, especially for residents with cognitive impairments or those who were not safe smokers. The facility's staff acknowledged the deficiencies in both medication management and smoking supervision. The Director of Nursing and other staff members admitted that the current practices were not in line with the facility's policies and posed risks to the residents. The facility's failure to adhere to its own policies and ensure proper supervision contributed to the identified deficiencies.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain dignity and privacy for two residents, R17 and R71, whose cognition is intact. R17 reported that staff would knock on her door and enter without waiting for permission, which made her feel disrespected and invaded. This was observed when a CNA knocked while opening the door and entered R17's room without waiting for permission. Similarly, R71 reported that some staff would enter her room without knocking, especially at night, leaving her exposed. This was confirmed when a nurse entered R71's room without knocking to administer medication. Additionally, R71 expressed discomfort with staff giving her incontinence briefs in the dining hall and the shared dresser that allowed her roommate to see her belongings, causing her anxiety. The DON acknowledged these concerns, stating that staff should knock and wait for permission before entering and that residents should not receive incontinence briefs in public areas for dignity reasons. The facility's Resident Rights information and policies from the Illinois Department of Aging and the facility itself emphasize the residents' right to privacy and a dignified existence. The facility's policies, dated 3/2021 and 4/2020, respectively, state that residents have a right to privacy and should be treated with respect, kindness, and dignity. The observations and interviews indicate that the facility did not adhere to these policies, leading to the reported deficiencies in maintaining resident dignity and privacy.
Failure to Maintain Proper Documentation for Advanced Directives
Penalty
Summary
The facility failed to maintain proper documentation for Advanced Directives for three residents in a sample of 26. For one resident, the health records showed conflicting information between the Advanced Directives book and the electronic health record regarding the resident's code status. The Director of Nursing confirmed that staff would follow the electronic health record, which could result in actions against the resident's wishes. The facility's policy requires congruent documentation and periodic reviews, which were not adhered to in this case. Another resident did not have an Advanced Directive care plan or a POLST form uploaded into the electronic medical record upon admission. It was only after a significant delay that the POLST form was completed and uploaded. Similarly, a third resident did not have a code status order entered until much later after admission, and there was a discrepancy between the resident's stated wishes and the documentation. The facility's policy mandates that code status orders be obtained upon admission, which was not followed in these instances.
Failure to Follow Physician Orders and Monitor Blood Glucose Levels
Penalty
Summary
The facility failed to follow physician orders for one resident and did not monitor another resident's blood glucose levels as required. For the first resident, who had diagnoses including spinal stenosis and muscle weakness, the physician had ordered 1000 mg of Tylenol for pain management. However, the nurse administered only 650 mg, substituting two 325 mg tablets for the prescribed 500 mg tablets. The resident reported that this discrepancy occurred frequently, and the Director of Nursing confirmed that the nurse should have administered the correct dosage as per the physician's order to manage the resident's pain effectively. For the second resident, who had multiple diagnoses including schizophrenia and congestive heart failure, the facility failed to monitor her blood glucose levels despite her being on diabetic medications. The resident reported that her blood sugar was not being checked daily, as it had been in her previous facility. The nurse confirmed that there were no orders for blood glucose monitoring or an A1C test, and the resident's electronic medical record did not include a diabetes diagnosis. The Director of Nursing acknowledged that the resident's blood sugar levels should be monitored to prevent potential complications, given her diabetic medication regimen.
Failure to Update Resident's Medical Diagnoses in EMR
Penalty
Summary
The facility failed to update the EMR to include a resident's medical diagnoses. The resident was admitted to the facility, but during a review of the medical record, no diagnoses were listed in the EMR. The Director of Nursing confirmed that the admitting nurse is responsible for entering the diagnoses and the MDS Coordinator should have reviewed them. The diagnoses list is typically obtained from the discharge summary or admission packet received from the hospital. The facility did not have a policy or procedure guide for updating resident records.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 646 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Joliet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Joliet | 0.7 mi | ★★★★★ | 8 | 0 |
| Parc Joliet | 0.7 mi | ★★★★★ | 29 | 0 |
| Pearl Of Joliet, The | 1 mi | ★★★★★ | 3 | 0 |
| Sunny Hill Nursing Home Of Will County | 3.4 mi | ★★★★★ | 3 | 0 |
| Alden Estates Of Shorewood | 4 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.