The most recent inspection on October 21, 2025, identified deficiencies related to incident reporting, updating service plans after resident falls, and timely response to a call light that resulted in a fall and injury. Earlier inspections in January and February 2025 found the facility in compliance with applicable assisted living regulations and did not note deficiencies. The main issues involved failure to report significant incidents within 24 hours, failure to revise service plans promptly after changes in residents’ conditions, and delayed staff response contributing to a resident fall and hip fracture. The complaint investigation substantiated these findings, triggered by multiple reported resident falls and injuries. The inspection history shows a recent emergence of these issues following a period of compliance.
Deficiencies (last 1 years)
Deficiencies (over 1 years)3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The inspection was conducted as a complaint investigation related to multiple reported incidents involving resident falls and injuries at Arbor Terrace Highland Park.
Findings
The facility failed to report significant incidents within 24 hours for 2 of 3 residents reviewed, failed to update service plans after resident falls for 3 of 6 residents, and neglected to respond timely to a resident's call light resulting in a fall and hip fracture. These failures created substantial probabilities of harm to residents.
Complaint Details
The complaint investigation was triggered by multiple reported incidents involving residents R3 and R4 who sustained injuries from falls. The facility failed to report these incidents timely and failed to update service plans accordingly. Additionally, neglect in responding to a call light led to a resident fall and hip fracture.
Severity Breakdown
Type 3 Violation: 1Type 2 Violation: 2
Deficiencies (3)
Description
Severity
Failure to report serious incidents within 24 hours for 2 of 3 residents reviewed.
Type 3 Violation
Failure to review and revise service plans immediately after significant changes in residents' conditions for 3 of 6 residents reviewed.
Type 2 Violation
Failure to respond timely to a resident's call light resulting in a fall and injury.
Type 2 Violation
Report Facts
Residents reviewed for incidents: 6Residents with unreported incidents: 2Residents reviewed for service plans: 6Residents with service plan update failures: 3Minutes call light was unanswered: 29Falls documented for R2: 3
Employees Mentioned
Name
Title
Context
E5
Resident Care Director Assisted Living
Provided statements regarding incident reporting and service plan updates
E6
Resident Assistant
Reported seeing resident R3 after fall and involved in call light neglect
Inspection Report Deficiencies: 0Feb 4, 2025
Visit Reason
Investigation IL00184838 & IL00185272 conducted from 2025-01-23 to 2025-02-04 to assess 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 to be in compliance with the applicable assisted living regulations and administrative codes during this investigation.
Annual Licensure Survey conducted to assess 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 to be in compliance with the applicable assisted living regulations during the annual licensure survey.
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