Inspection Reports for
The Indigo at Bartlett

The establishment failed to ensure employees had adequate skills to deescalate an aggressive dementia resident and protect residents from abuse and improper restraint. Staff failed to report injuries of unknown sources timely and did not fully follow abuse reporting procedures.

Complaint IL200026: Complaint investigation found the establishment in compliance with no violations cited.

The establishment was found in compliance with all applicable regulations during this complaint investigation.

Complaint Investigation 2576748/ IL196504 and Facility Reported Incident IL196413 of 2/28/25.

The facility failed to have qualified staff with adequate skills, education, and training to meet the needs of residents living with Dementia. The Executive Director lacked Dementia/Alzheimer's training, an LPN worked with an expired license for seven months, and there was no qualified Memory Care Unit Manager.

Complaint Investigation 2575200/IL194089 - No Violations. Facility Reported Incident 5/12/25 IL192067. Facility Reported Incident 6/10/25 IL194232. Facility Reported Incident 6/10/25 IL194236.

The establishment failed to conduct required disaster drills involving residents during night shifts and failed to document resident assistance during evacuation drills. Serious incidents involving resident falls and injuries were not reported timely to the Department. The quality improvement program and grievance process were not implemented or documented. Staff licensing and CPR certification requirements were not met, including an expired nurse license and insufficient CPR coverage. New employees did not complete required orientation and training timely. Health Care Worker Registry employment verifications were incomplete. Service plans were incomplete, unsigned, and not updated for falls or medication needs for multiple residents. Tuberculosis screening was not performed upon entry for some residents. Memory care residents were not assessed prior to admission using approved cognitive or functional tools. A resident punched another resident, constituting abuse.

Complaint #2485887/#IL176044: Not substantiated. No deficiencies written. FRI (Facility Reported Incident) #IL177118: Substantiated. FRI (Facility Reported Incident) #IL181204: Substantiated. FRI (Facility Reported Incident) #IL181841: Substantiated. FRI (Facility Reported Incident) #IL181965: Substantiated. FRI (Facility Reported Incident) #IL182122: Substantiated. FRI (Facility Reported Incident) #IL185247: Not determined as rising to the level of neglect.

The establishment failed to update fall interventions and conduct root cause analyses after fall incidents for five residents, contributing to injuries and hospitalizations. The facility also failed to prevent misappropriation of narcotic medications for two residents and did not follow a resident's service plan for safety, resulting in a serious fall. Additionally, the establishment failed to timely investigate and report missing narcotic medication and neglect allegations, violating their own policies.