Inspection Reports for Autumn Leaves of Orland Park
8021 151st St, Orland Park, IL 60462, United States, IL, 60462
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 9, 2025, identified deficiencies related to the facility’s failure to report a resident fall incident within the required 24-hour timeframe and to obtain resident representative signatures on service plans. Earlier inspections showed a mix of compliance and issues, including a substantiated complaint of physical abuse by a caregiver in December 2024, which led to staff termination and corrective actions, as well as unsubstantiated and compliant complaint investigations in October 2025. The main themes across deficiencies involved incident reporting, resident rights, and documentation related to service plans and abuse prevention. There were no fines, immediate jeopardy findings, or license actions listed in the available reports. The facility appears to have taken steps to address abuse concerns with staff training and monitoring, but recent findings indicate ongoing challenges with timely reporting and administrative compliance.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 9, 2025
Visit Reason
The inspection was conducted following a facility-reported incident involving a resident fall on 10/18/2025, focusing on compliance with incident reporting and service plan requirements.
Complaint Details
The visit was complaint-related due to a facility-reported incident involving a resident fall on 10/18/2025. The complaint was substantiated as the facility failed to report the incident within the required timeframe.
Findings
The facility failed to report a serious incident involving a resident fall to the Illinois Department of Public Health within the required 24-hour timeframe. Additionally, the facility failed to obtain resident representative signatures on service plans for two residents reviewed.
Deficiencies (2)
Failure to report a serious incident (resident fall) to the Department within 24 hours as required by regulation.
Failure to obtain resident representative signatures on service plans for two residents.
Report Facts
Incident reporting delay: 4
Number of residents reviewed for service plan compliance: 3
Number of residents affected by missing signatures: 2
Age of resident R1: 96
Age of resident R2: 88
Age of resident R3: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Licensed Practical Nurse (LPN) | Nurse who responded to resident fall incident and documented assessment |
| E1 | Executive Director | Reported incident to state and provided statements regarding incident reporting process |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation survey to determine compliance with Part 295 Assisted and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Complaint Details
Complaint Investigation Survey 25910239/IL198146; establishment found in compliance.
Findings
The establishment was found to be in compliance with the applicable assisted living and shared housing regulations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 16, 2025
Visit Reason
The visit was conducted as a complaint investigation identified as 2599461/IL197862.
Complaint Details
Complaint Investigation 2599461/IL197862 unsubstantiated
Findings
The complaint investigation was unsubstantiated, and the establishment was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation following allegations of physical abuse of a resident by a caregiver.
Complaint Details
Complaint investigation #IL181928 was substantiated for physical abuse by caregiver E2 against resident R1. Complaint #IL179646 was unsubstantiated.
Findings
The investigation substantiated that a caregiver (E2) physically abused resident R1 by handling them roughly. The caregiver was suspended and subsequently terminated. Additionally, staff failed to report observed abuse, creating a substantial probability of harm to residents.
Deficiencies (2)
Facility failed to ensure all residents remain free of physical abuse.
Facility staff failed to report observations of resident being handled roughly by caregiver.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Provided statements regarding the abuse complaint and investigation. |
| E2 | Caregiver | Alleged and substantiated abuser of resident R1; terminated after investigation. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 24, 2024
Visit Reason
The document is a Plan of Correction submitted in response to a complaint survey conducted at Autumn Leaves of Orland Park.
Complaint Details
The Plan of Correction responds to a complaint survey conducted at Autumn Leaves of Orland Park. It notes that E2 was terminated, R1 discharged, all staff were in-serviced on 11/26/2024 about abuse and resident rights, and no abuse allegations have occurred since the last occurrence.
Findings
The Plan of Correction addresses alleged deficiencies related to resident rights, abuse, neglect, and financial exploitation, outlining corrective actions, staff education, monitoring, and communication improvements to ensure compliance and resident safety.
Report Facts
Date of complaint survey exit: Dec 24, 2024
Staff in-service date: Nov 26, 2024
Plan of Correction completion date: May 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peace Igbinovia | Executive Director | Signed the Plan of Correction letter |
| Edward Pitts | RN-BSN, PSA | Illinois Department of Public Health, Division of Assisted Living, recipient of Plan of Correction |
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