Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 16, 2025
Visit Reason
The inspection was conducted as a complaint investigation under case number 2519755/ IL 197937 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 the Assisted Living and Shared Housing Act.
Complaint Details
Complaint Investigation 2519755/ IL 197937; the establishment was found in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 10, 2025
Visit Reason
The inspection was conducted as a complaint investigation and facility reported survey investigation regarding compliance with incident and accident reporting and service plan requirements.
Findings
The facility failed to notify the State Agency within 24 hours of a resident's serious injury (fracture) and failed to review and revise residents' service plans after significant changes in condition, including multiple falls and fractures, for 2 of 3 residents reviewed.
Complaint Details
The complaint investigation involved allegations related to failure to report serious incidents and failure to update service plans after changes in resident condition. The complaint was substantiated based on findings.
Deficiencies (2)
| Description |
|---|
| Failure to ensure State Agency notification within 24 hours of a serious injury (fracture) for 1 of 3 residents reviewed. |
| Failure to review and revise residents' service plans after significant changes in condition, including multiple falls and fractures, for 2 of 3 residents reviewed. |
Report Facts
Number of residents reviewed for SA notification: 3
Number of residents reviewed for service plans: 3
Number of unwitnessed falls for resident R1: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| V1 | Executive Director | Stated that a bone fracture is a serious injury requiring reporting within 24 hours |
| E4 | Caregiver | Assisted resident R2 and stated resident had a fracture above the knee |
| E6 | Caregiver | Commented on resident R1's need for assistance and inability to find service plan |
| E1 | Executive Director | Explained service plan initiation and update requirements |
| E2 | Clinical Services Specialist Director | Stated resident R1's service plan had not been updated since 5/16/25 |
| E3 | Licensed Practical Nurse | Described process for updating service plans after changes in resident care |
| E5 | Caregiver | Assisted resident R2 with mobility after fracture |
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 8, 2024
Visit Reason
The inspection was conducted as an investigation of facility-related incidents reported on 7/16/24, 9/9/24, and 9/13/24, focusing on compliance with incident reporting and abuse/neglect prevention regulations.
Findings
The facility failed to report serious incidents to the Department within 24 hours for 3 residents and did not conduct or provide complete investigations and reports related to allegations of abuse and neglect for one resident. These failures represent violations of incident reporting and abuse prevention regulations.
Complaint Details
The investigation was complaint-related, substantiated by the Department. The facility failed to timely report serious incidents involving residents R1, R2, and R3, and failed to properly investigate and report an allegation of neglect involving resident R3.
Severity Breakdown
Type 3 Violation: 1
Type 2 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report serious incidents or accidents to the Department within 24 hours for 3 residents (R1, R2, R3). | Type 3 Violation |
| Failure to notify the Department within 24 hours of an allegation of abuse, neglect, or financial exploitation and failure to provide a complete written investigation report for 1 resident (R3). | Type 2 Violation |
Report Facts
Residents reviewed for incident reporting: 3
Residents reviewed for abuse/neglect reporting: 3
Incident report delay: 2
Days delayed in neglect allegation report: 4
Days delayed in final neglect report: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E10 | Associate Executive Director | Confirmed findings related to incident and abuse/neglect reporting failures. |
| E14 | Licensed Practical Nurse (LPN) | Documented R1's fall and head injury. |
| E15 | Licensed Practical Nurse (LPN) | Documented R3's fall and POA refusal to send to hospital. |
| E16 | Licensed Practical Nurse (LPN) | Documented R3's fall with skin tear and POA refusal to send to hospital. |
| E17 | Licensed Practical Nurse (LPN) | Documented R3's fall with injury and hospital transfer. |
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