Inspection Reports for
Three Oaks Assisted Living and Memory Care
1055 Silver Lake Rd, Cary, IL 60013, United States, IL, 60013
Back to Facility Profile8 Reports
Inspection Report — Jun 13, 2026
Complaint Investigation
Date: Jun 13, 2026
Visit Reason
Facility Reported Incident IL202284
Complaint Details
Facility Reported Incident IL202284: cited sections 295.4010d) and 295.6000a)5)13).
Findings
The establishment failed to ensure service plan interventions were followed for one resident, resulting in a fall with a wrist fracture. The facility neglected to provide contracted interventions in the service plan for this resident.
Deficiencies (2)
A4010 (295.4010 Service Plan) - The establishment failed to ensure service plan interventions were followed for 1 of 3 residents reviewed for falls, resulting in a fall with a wrist fracture.
A6000 (295.6000 Resident Rights) - The establishment neglected to provide interventions contracted in the service plan for 1 of 3 residents reviewed for falls, resulting in a fall with a wrist fracture.
Report Facts
Residents affected: 1
Residents reviewed: 3
Inspection Report — Apr 7, 2026
Complaint Investigation
Date: Apr 7, 2026
Visit Reason
Facility Reported Incident Survey conducted: #IL200799 - No deficiencies written. Facility Reported Incident Survey conducted: #IL201056 Violation: Section 295.4010 Service Plan a) d) e). Complaint Investigation Survey conducted: #2613272/IL200827 Violations: Section 295.8000 Food Service a) 1), Section 295.9040 Environmental Requirements d).
Complaint Details
Complaint #2613272/IL200827: Sections 295.8000 a)1) and 295.9040 d) cited. Facility Reported Incident #IL201056: Section 295.4010 a) d) e) cited. Facility Reported Incident #IL200799: No deficiencies written.
Findings
The establishment failed to address a resident's choking history and provide supervision during meals, resulting in a fatal aspiration incident. The kitchen had ongoing issues with flies and staff not wearing hair restraints, and garbage was uncovered, violating sanitation policies.
Deficiencies (3)
A4010 (295.4010 Service Plan) - The establishment failed to address a resident's history of choking incidents, lacked interventions to prevent recurrence, and did not provide supervision during mealtime, contributing to the resident's aspiration and death.
A8000 (295.8000 Food Service) - The establishment failed to ensure the kitchen was free of flies, staff wore hair restraints, and food was protected, violating food service sanitation requirements.
A9040 (295.9040 Environmental Requirements) - The establishment failed to keep garbage in covered containers near food preparation areas, allowing flies to congregate and violating sanitation policies.
Report Facts
Residents affected: 1
Inspection Report — Sep 30, 2025
Annual Inspection
Date: Sep 30, 2025
Visit Reason
Annual Licensure Survey conducted on 9/30/2025.
Findings
The establishment was cited for a repeat Type 3 violation of Section 295.4010 Service Plan due to failure to ensure service plans were signed by a registered nurse and resident or representative, revised as needed, and addressed health-related services for 7 of 8 residents reviewed.
Deficiencies (1)
A4010 (295.4010 Service Plan) - The establishment failed to ensure that service plans were signed by a registered nurse and the resident or resident representative, revised as the resident's needs changed, and addressed the amount, type, and frequency of health-related services for 7 of 8 residents reviewed.
Report Facts
Residents affected: 7
Residents reviewed: 8
Inspection Report — Sep 28, 2025
Complaint Investigation
Date: Sep 28, 2025
Visit Reason
Original investigation of FRI IL 197102.
Complaint Details
FRI IL 197102: Type 2 violation cited for failure to prevent elopement.
Findings
The establishment failed to prevent the elopement of one memory care resident due to a courtyard gate unlocking at 6:00 P.M. daily and lack of staff checks at that time. The facility plans to conduct elopement drills multiple times daily for three days and review elopement procedures with all staff.
Deficiencies (1)
A4060 (295.4060 Alzheimer's and Dementia Programs) - The establishment failed to prevent the elopement of one of one sampled memory care residents due to the courtyard gate becoming unalarmed at 6:00 P.M. and staff failing to check the patio at that time.
Report Facts
Residents affected: 1
Distance: 450
Inspection Report — Aug 5, 2025
Plan of Correction
Date: Aug 5, 2025
Visit Reason
This Plan of Correction responds to the Complaint Investigation survey completed on 2025-07-18.
Findings
The facility committed to reviewing and updating care plans for residents R1 and R2, conducting file audits to ensure care plans are current, and performing community audits by the Director of Nursing to prevent recurrence of the cited violation.
Inspection Report — Jul 18, 2025
Complaint Investigation
Date: Jul 18, 2025
Visit Reason
Complaint Investigations: Facility Reported Incident dated 6/22/25/IL195361-295.4010a)d)e), #2515009/IL193774- 295.4010a)d)e), #2515056/IL193823- 295.4010a)d)e).
Complaint Details
Facility Reported Incident dated 6/22/25/IL195361: Section 295.4010 a)d)e) cited. Complaint #2515009/IL193774: Section 295.4010 a)d)e) cited. Complaint #2515056/IL193823: Section 295.4010 a)d)e) cited.
Findings
The establishment failed to ensure service plans were reviewed and revised for fall interventions and toileting assistance for two of three residents reviewed. The service plans did not reflect recent changes in residents' conditions or needs.
Deficiencies (1)
A4010 (295.4010 Service Plan) - The establishment failed to ensure service plans were reviewed and revised for fall interventions and toileting assistance for two of three residents reviewed.
Report Facts
Residents affected: 2
Residents reviewed: 4
Inspection Report — Feb 19, 2025
Date: Feb 19, 2025
Visit Reason
Investigation IL00184255, IL00185435, IL00185472, & IL00185942 conducted on 2/19/2025. For this survey, the establishment is in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found in compliance with all applicable regulations during this investigation.
Inspection Report — Oct 1, 2024
Annual Inspection
Date: Oct 1, 2024
Visit Reason
Annual Survey conducted on 10/01/2024.
Findings
The facility failed to update service plans with the amount, type, and frequency of health-related services needed by residents and did not include a registered nurse or involve residents or their representatives in the development of service plans for seven residents reviewed.
Deficiencies (1)
A4010 (295.4010 Service Plan) - The facility failed to update service plans with the amount, type, and frequency of health-related services needed by residents and failed to include a registered nurse or resident/resident representative in the development and signing of service plans for seven residents reviewed.
Report Facts
Residents affected: 7
Viewing
Loading inspection reports...
