Inspection Reports for Bardwell Residences

Investigation IL00199191 was conducted on 1/12/2026 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.

The establishment was found to be in compliance with the applicable Illinois Assisted Living and Shared Housing regulations during this survey.

The document is a plan of correction addressing staffing deficiencies identified during a prior inspection, specifically related to meeting the staffing needs of residents.

The facility failed to meet the staffing needs of residents, potentially affecting all 33 residents on floors 1-4. Corrective actions include verifying showers for specific residents, reviewing staffing schedules, and conducting in-servicing with direct care staff.

The inspection was conducted as a complaint investigation related to the failure to keep resident service plans updated with changes in condition and failure to integrate outside services with the facility service plan.

The facility failed to maintain updated service plans reflecting resident condition changes and did not document integration of outside services. This deficiency potentially compromised resident safety, as evidenced by multiple falls of a resident (R1) whose service plan lacked documentation of interventions and updates after falls.

The complaint investigation was substantiated. Resident R1 experienced multiple falls, including a fall resulting in a left femur fracture requiring surgery. The service plan was outdated, lacked documentation of therapy services, fall interventions, and updates after each fall. Interviews with staff confirmed awareness of outdated care plans and resident impulsiveness contributing to falls.

The document is a plan of correction addressing a failure to ensure all new employees received required dementia programming training, including a 4-hour initial training and 16 hours of on-the-job training.

The establishment failed to ensure all new employees completed the required dementia training. Corrective actions include auditing employee files for compliance and implementing routine audits and monthly QA/QI committee reviews to ensure ongoing compliance.