Inspection Reports for Alto Wheaton
219 Parkway Dr, Wheaton, IL 60187, United States, IL, 60187
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Inspection Report
Complaint Investigation
Deficiencies: 2
Dec 5, 2025
Visit Reason
The inspection was conducted following a facility-reported incident dated 11/4/25 to investigate compliance with residency and care requirements for residents in an assisted living or shared housing environment.
Findings
The facility failed to ensure residents were appropriate for assisted living residency, specifically two residents (R2 and R4) required total assistance with multiple activities of daily living, which is against the facility's resident selection criteria. Additionally, the facility failed to provide appropriate care for resident R2, leading to deterioration of her physical condition including worsening wounds and unaddressed dysphagia over a 21-day period.
Complaint Details
The visit was complaint-related based on a facility-reported incident on 11/4/25. The investigation found substantiated violations related to residency requirements and care provision.
Severity Breakdown
Type 3 Violation: 1
Type 2 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents are appropriate to live in an assisted living or shared housing environment, as two residents required total assistance with two or more activities of daily living. | Type 3 Violation |
| Failure to provide appropriate care in Alzheimer's and Dementia programs, resulting in deterioration of resident R2's physical condition including wounds and dysphagia. | Type 2 Violation |
Report Facts
Residents reviewed for residency requirements: 4
Residents with deficiencies: 2
Residents reviewed for injuries and supervision: 3
Days dysphagia not addressed: 15
Days without appropriate wound care: 21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E5 | Licensed Practical Nurse (LPN) | Named in findings related to resident R2's care and mobility |
| E2 | Assistant Residence Services Director (ARSD) | Provided statements regarding resident R2's care needs and condition |
| E1 | Executive Director (ED) | Provided statements regarding resident R4's condition and care |
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 15, 2025
Visit Reason
The inspection was conducted to investigate a reported incident involving failure to report a serious fall with injury and failure to update service plans with fall prevention interventions for residents.
Findings
The facility failed to report a serious fall with injury for one resident and failed to immediately update service plans with fall prevention interventions for three residents, resulting in severe harm to one resident. The facility also lacked policies on incident reporting and service plan updates.
Complaint Details
The investigation was triggered by a reported incident on 10/8/25. The complaint involved failure to report a fall with injury on 9/10/25 and failure to update service plans after falls for residents R1, R2, and R3. The complaint was substantiated based on record review and interviews.
Severity Breakdown
Type 3 Violation: 1
Type 1 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report a serious incident or accident involving a resident fall with injury. | Type 3 Violation |
| Failure to immediately implement interventions into service plans to prevent falls for three residents, resulting in severe harm to a resident. | Type 1 Violation |
Report Facts
Residents reviewed for incident reporting: 4
Residents reviewed for falls: 4
Falls for resident R1: 2
Falls for resident R2: 3
Falls for resident R3: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing | Interviewed regarding incident reporting and service plan updates; unable to provide proof of incident report or policy. |
| E6 | Licensed Practical Nurse | Interviewed regarding service plan updates after resident falls. |
Inspection Report
Annual Inspection
Deficiencies: 3
Sep 10, 2025
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with state regulations for the facility.
Findings
The facility was found to have multiple violations including admitting a resident with an unstageable pressure injury, inadequate staffing and supervision leading to falls and injuries, failure to conduct comprehensive assessments and develop individualized service plans, and failure to update service plans after significant changes in residents' conditions. These deficiencies caused severe harm to residents and posed a substantial probability of harm to others.
Severity Breakdown
General Violation: 1
Type 1 Violation: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Admitted a resident (R6) with an unstageable pressure injury, violating residency requirements. | General Violation |
| Failed to provide sufficient qualified staff and supervision to meet residents' needs, resulting in falls and injuries to resident R2. | Type 1 Violation |
| Failed to develop and implement individualized service plans addressing fall risk and skin alterations for residents R1, R2, and R3, and failed to update plans after significant changes. | Type 1 Violation |
Report Facts
Dates of incidents: 4
Wound measurements: 1.8
Wound measurements: 1.2
Wound measurements: 0.9
Wound measurements: 2.5
Fall incident dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | E1, involved in interviews and confirming findings related to resident admissions and service plan deficiencies. | |
| Resident Services Director | E2, involved in interviews and confirming findings related to resident conditions and service plans. | |
| Assistant Resident Services Director | E3, involved in interviews and confirming findings related to resident conditions and service plans. |
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