Inspection Report Summary
The most recent inspection on October 10, 2025 found no deficiencies and the complaint investigation related to a reported incident was unsubstantiated. Earlier inspections identified deficiencies including incomplete employee orientation documentation, a failure to report a resident fall with injury within the required timeframe, and inadequate staff skills and service provision for a resident with complex wounds. These issues primarily involved employee training, incident reporting, and resident care related to wound management. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility appears to be addressing prior deficiencies, as the latest inspection showed compliance and no new issues were cited.
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: 0
Date: Oct 10, 2025
Visit Reason
Investigation of a facility reported incident dated 2025-09-23.
Complaint Details
Investigation was related to a facility reported incident on 2025-09-23; the complaint was found to be unsubstantiated as the facility was in compliance.
Findings
The establishment was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and ILCS 9/1 Assisted Living and Shared Housing Act.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 1, 2025
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with state regulations regarding employee orientation and ongoing training.
Findings
The facility failed to provide documentation that all required orientation topics were completed by all employees within the required 10 and 30 days from their hire date. Orientation forms were missing, incomplete, unsigned, or not returned to Human Resources for 8 of 9 employees reviewed.
Deficiencies (1)
Failed to provide documentation that all required topics of employee orientation were completed within the required time frames.
Report Facts
Employees reviewed for orientation: 9
Employees with deficient orientation documentation: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Server | Employee record lacked documentation of completed orientation topics within required timeframe |
| E3 | LPN | Orientation checklist missing documentation of required topics |
| E4 | Housekeeper | Orientation checklist missing documentation of required topics |
| E5 | Care Partner | Orientation checklist missing documentation of required topics |
| E6 | Resident Services Director | No documentation of orientation conducted within required timeframe |
| E7 | Care Partner | No documentation of orientation conducted within required timeframe |
| E8 | Housekeeper | Orientation training plan and checklist not signed and dated by employee |
| E9 | Server | Orientation training plan and checklist not signed and dated by employee |
| E10 | Human Resources Assistant | Explained some employees took forms home and did not return them to HR |
| E1 | Executive Director | Acknowledged deficiencies and committed to corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 1, 2025
Visit Reason
This document is a Plan of Correction submitted in response to the IDPH Annual Licensure inspection conducted on 8/1/2025 at Brookdale Glen Ellyn Assisted Living.
Findings
The Plan of Correction addresses deficiencies related to employee orientation and ongoing training, outlining specific corrective actions including auditing associate files and providing comprehensive orientation and job-specific training to new hires and staff.
Deficiencies (1)
Employee Orientation and Ongoing Training
Report Facts
Inspection date: Aug 1, 2025
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 13, 2025
Visit Reason
The inspection was conducted due to a reported incident involving a resident fall with injury that was not properly reported to the Illinois Department of Public Health within the required 24-hour timeframe.
Findings
The facility failed to report a resident fall with injury within 24 hours as required by regulation. Resident R1 fell in the bathroom, sustained a head laceration and knee contusion, was sent to the emergency room, but the initial fall was not reported to the Department. The Director of Nursing confirmed the report was only sent for a later change in condition, not the initial fall.
Deficiencies (1)
Failure to report a resident fall with injury to the Department within 24 hours as required by Section 295.2050 Incident and Accident Reporting.
Report Facts
Resident sample size: 3
Resident falls not reported: 1
Date of incident: May 4, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding failure to report incident |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 11, 2024
Visit Reason
The inspection was conducted as an Annual Licensure Survey to assess compliance with residency requirements and appropriate service provision at the assisted living facility.
Findings
The facility failed to have staff with appropriate skills and failed to provide the required level of service for a resident (R2) admitted with puncture wounds, resulting in harm to the resident and a substantial probability of harm to others. Documentation and wound care were insufficient, and the complexity of the resident's wounds exceeded the facility's licensed capabilities.
Deficiencies (1)
Failed to have staff with appropriate skills and failed to provide a level of service required for a resident admitted with puncture wounds.
Report Facts
Resident age: 74
Admission date: Jul 11, 2024
Wound size: 1
Wound size: 2.5
Wound size: 3.5
Wound size: 1.5
Antibiotic dosage: 300
Wound care frequency: 3
Wound care frequency: 5
Length of stay: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Provided statements regarding resident R2's wound care and assessments |
Viewing
Loading inspection reports...
