Parc Joliet
PARC JOLIET in JOLIET, IL — inspection on August 28, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
partial/moderate assistance with showering, dressing, and bed mobility. R2 is occasionally
admission dated July 29, 2025 at 7:50 PM, and completed by V17 (LPN) shows, [AGE] year-old male
causing skin tear/injury at 1727 (5:27 PM). On July 29, 2025 at 8:13 PM, V17 (LPN) documented, [R2] discharged to [hospital].
Reason for transfer: increased confusion, aggression, physical altercation.
R2's hospital discharge documentation, dated July 29, 2025 at 8:36 PM shows: You were seen today for: agitation.
You were seen in the emergency room for an episode of agitation and a fight.
There are no signs of serious injury from the fight.
There are no signs of serious psychiatric illness that would require any sort of inpatient admission.
Your labs are normal.
You are being discharged . On August 21, 2025 at 2:38 PM, V14 (LPN) said she was sitting at the nurse's station when R2 and R3 had an altercation at the end of the hall, including arguing and physical hitting. V14 continued to say, [R2] has been having a lot of behaviors. I saw the two residents struggling.
The police came to the facility as well. V14 continued to say the nurse assigned to R2 (V17) was on break at the time of the incident and was not present on the resident floor. On August 25 2025 at 9:50 AM, V2 (DON-Director of Nursing) and V1 (Administrator) said, they did not feel the allegation of abuse between R2 and R3 was substantiated despite V14's nursing documentation and the fact nursing staff petitioned R2 out of the facility due to his behaviors. V1 and V2 responded by saying their staff are very dramatic.
The facility's final incident report to the State Agency, dated August 4, 2025 shows the original incident was an allegation of resident-to-resident altercation on July 29, 2025.
Witness statements were obtained from R2, R3, V14 and V17.
The facility does not have any documentation to show any other residents or facility staff were interviewed during the abuse investigation, or that facility surveillance cameras were used to determine the outcome of the facility's investigation.
The facility's Abuse Prevention Program Facility Policy and Procedure, reviewed 4-Jan-19 shows, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish.
Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.
Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.
Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
145221 08/28/2025
Parc Joliet 222 North Hammes Joliet, IL 60435
there was an arm injury, and she was sent to the hospital where she was found to have an arm
fracture. It is safe to say the incident where the mechanical lift tipped over and she hit the wall
mechanical lift device involved in R4's incident on July 28, 2025.
The mechanical lift was sitting outside next to the facility's dumpster. V13 said the mechanical lift was taken out of service and placed in the trash.
The mechanical lift device had a property identification sticker affixed to it identifying the lift as lift number 107. V13 demonstrated how the shifter lever on the mechanical lift is used to open and close the legs of the mechanical lift base for stability when lifting and transferring the resident. V13 said, The shifter lever is broken.
The shifter lever comes right off in your hand, which it is not supposed to do.
Also, the shifter lever does not stay in the locked position because it is broken, so facility staff are unable to lock the legs of the base in place before moving the resident.
The lift is so old, we just decided to throw it away after the incident. V13 demonstrated how the support legs of the mechanical lift would not stay in a locked position and how unstable the mechanical lift became when being moved with the support legs unlocked. V13 said the mechanical lifts in the facility are supposed to be inspected monthly. V13 said he started working at the facility on July 1, 2025 and had not inspected the mechanical lifts until July 30, 2025. V13 provided documentation to show the lift involved in the incident with R4 on July 28, 2025, lift number 107, had not been inspected since March 5, 2025. On August 26, 2025 at 1:00 PM, V1 (Administrator) said facility staff should inspect the mechanical lift prior to using it and remove the mechanical lift from service if the mechanical lift is in need of repairs.
The undated mechanical lift User Manual provided by V1 (Administrator) shows, the shifter handle must be locked when transferring the resident.
Maintenance of the mechanical lifts should include an initial inspection, and monthly inspections and adjustments when used in an institutional setting.
The facility's policy entitled Limited Lifting Resident Handling, revised on 1/25 shows: Policy: This facility will use mechanical lifting devices when lifting and moving the residents when indicated and as ordered by the physician.
Purpose: To protect the safety and well-being of the staff and residents.
Procedure: .4.
Mechanical lift equipment shall undergo routine maintenance checks and be accessible to staff 24 hours a day.8.
The policy will be followed at all times.
Failure to comply will result in disciplinary action at management's discretion.
The facility's undated Validation of Competency - Total (Full Body) Mechanical Lift Transfer shows the facility's expected performance criteria.
The Validation of Competency shows facility staff are expected to know a mechanical lift pre-operations check should be completed including, checking the weight limit of the mechanical lift and the sling size/style to verify they are appropriate for the resident, confirm the battery is charged, inspect the lift condition and check the operation, inspect slings for frays, tears, or other signs of wear, and state the reason and process for removing lift equipment and slings from service.
The staff competency also shows facility staff are expected to know to clear a pathway to allow the lift to pivot and move freely.
145221 08/28/2025
Parc Joliet 222 North Hammes Joliet, IL 60435
V1 (Administrator) and V2 (DON-Director of Nursing) said V8's documentation was inadvertently
figure out a way to rewrite them. On August 27, 2025, at 12:25 PM, V18 (Restorative Nurse), The risk
entered the information into risk management as a fall. I was told by the corporate consultant to strike out the incident and label it as inaccurate documentation because the incident was not considered to be a fall because the resident was intentionally lowered to the ground. I only struck out the risk management report for the fall in the EMR. I did not realize by striking out the risk management documentation, that the nurse's documentation would be struck out and marked as incorrect documentation as well.
That seems like an issue when the nursing documentation gets struck out. I was not aware the progress notes were struck out.
The facility's policy entitled Medical Record Policy, dated 6/2025 shows, Purpose: To ensure that a complete, accurate and legal record of the resident's care that's maintained contains justification of diagnoses, treatment results.
The record is readily accessible systematically organized to provide a medium of communication among health care professionals involved in the resident's care and to facilitate retrieval of information.
Policy: It is the policy of this facility that an organized, accurate, and complete written record will be maintained for each resident in accordance with applicable State and Federal guidelines and laws.
Standards: .5.
Progress notes shall be written/entered to ensure an ongoing resident record including progression toward and regression from established resident goals is maintained.
Progress notes shall indicate significant changes in the resident's condition and be recorded upon occurrence by the staff person observing the change.
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Parc Joliet 222 North Hammes Joliet, IL 60435
found in a common area of the second floor. V13 was unable to lock the mechanical lift shifter lever in
used. On August 25, 2025, at 11:53 AM, a general tour of the facility was completed with V2
and common areas, available for all facility staff to use. V2 said after the incident involving R4 and the mechanical lift, she asked V13 to inspect all mechanical lift devices and label each lift with an identifier to correspond to the inspection sheets.
The inspection sheets provided by V13 were shown to V2.
The inspection sheets did not correspond with identifier numbers on any of the mechanical lifts observed with V2. V2 was unable to identify if any of the mechanical lifts in use had been inspected.
The mechanical lift with the broken shifter lever, observed with V13 at 10:53 AM, remained in the common area of the second floor and was not labeled with any resident name or a sign to show not to use the device.
The undated mechanical lift User Manual provided by V1 (Administrator) shows, the shifter handle must be locked when transferring a resident.
Maintenance of the mechanical lifts should include an initial inspection, and monthly inspections and adjustments when used in an institutional setting.
The facility's policy entitled Limited Lifting Resident Handling, revised on 1/25 shows: Policy: This facility will use mechanical lifting devices when lifting and moving the residents when indicated and as ordered by the physician.
Purpose: To protect the safety and well-being of the staff and residents.
Procedure: .4.
Mechanical lift equipment shall undergo routine maintenance checks and be accessible to staff 24 hours a day.8.
The policy will be followed at all times.
Failure to comply will result in disciplinary action at management's discretion.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.