Inspection Reports for Burr Ridge Senior Living
16W301 91st St, Burr Ridge, IL 60527, IL, 60527
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Inspection Report
Deficiencies: 0
Nov 9, 2025
Visit Reason
The inspection was conducted following a facility reported incident dated 2025-11-05 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 and Shared Housing regulations during this survey.
Report Facts
Incident date: Nov 5, 2025
Inspection Report
Deficiencies: 0
Oct 27, 2025
Visit Reason
The survey was conducted following a facility reported incident dated 10/10/2025 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 Illinois Assisted Living and Shared Housing regulations during this survey.
Inspection Report
Annual Inspection
Deficiencies: 3
Oct 19, 2025
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with state regulations including physician assessments and service plan requirements.
Findings
The facility failed to ensure that annual physician assessments were completed for four residents and failed to adequately supervise cognitively impaired residents, resulting in multiple unwitnessed falls and injuries. The facility also did not conduct thorough investigations into the causes of injuries. Care plans and service plans were not consistently followed or updated to address residents' needs and fall risks.
Severity Breakdown
Type 2 Violation: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure resident physical assessments were completed by a medical doctor annually for four residents. | Type 2 Violation |
| Failed to adequately supervise cognitively impaired residents in common areas and resident bedrooms, leading to falls and injuries. | Type 2 Violation |
| Failed to develop and mutually agree upon a written service plan based on physician's assessment and establishment evaluation. | Type 2 Violation |
Report Facts
Residents reviewed for physician assessment: 4
Fall risk total score: 4
Number of falls documented for R3: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Memory Care Director | Stated the care team is responsible for physician assessments and supervision of residents. |
| E2 | Director of Nursing (DON) | Acknowledged physician assessments are to be done annually and that supervision in common areas is required. |
| E9 | Wellness Nurse/RN | Responded to resident injuries and called 911 for emergency transport. |
| E12 | Resident Assistant | Observed resident injury and reported incident. |
| E5 | Wellness Nurse/LPN | Assessed resident injuries and provided statements regarding falls and bruises. |
| E7 | Resident Assistant | Provided information on resident behavior and supervision. |
| E4 | Resident Assistant | Witnessed resident fall and described supervision practices. |
| E10 | Resident Assistant | Commented on supervision practices in common areas. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on substantiated and unsubstantiated incident and complaint investigations related to resident care and service plan compliance at Burr Ridge Senior Living.
Findings
The facility failed to revise residents' service plans after falls and elopements, failed to follow service plans for assistance with showers, and did not properly inform residents' representatives of service plan changes or obtain consent for medical information requests. These deficiencies affected multiple residents and involved issues with fall prevention, resident rights, and service plan accuracy.
Complaint Details
The complaint investigations included substantiated complaints numbered 2571585/IL187134 and 2573391/IL190490. The facility also had substantiated and unsubstantiated incident investigations. The complaint investigation focused on failure to update service plans after incidents and failure to communicate changes to residents' representatives.
Severity Breakdown
Type 2 Violation: 1
Type 3 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to revise residents' service plans after falls and elopements and failure to follow service plans for assistance with showers for 4 residents (R3, R5, R6, R2). | Type 2 Violation |
| Failure to ensure residents' representatives were informed of service plan changes and cost changes, and failure to honor requests for obtaining medical information for 1 resident (R2). | Type 3 Violation |
Report Facts
Number of residents reviewed for service plans: 8
Residents affected by service plan deficiencies: 4
Residents reviewed for rights: 8
Residents affected by rights deficiency: 1
Fall incidents for R3: 5
Steps in stairwell R5 fell down: 19
Assessment score change for R2: 21
Assessment score change for R2: 166
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E7 | Assisted Living Manager / LPN | Provided information on resident falls, service plan updates, and communication with physician and POA |
| E2 | Director of Nursing | Confirmed service plan update requirements and investigated elopement incident |
| E1 | Executive Director | Provided policy information and confirmed service plan update expectations |
| E9 | LPN Night Nurse | Reported on resident R5's status during night shift |
| E4 | LPN Day Shift Nurse | Reported on resident R5 found at bottom of stairs |
| E5 | Resident Assistant | Provided information on resident R2's care and shower schedule |
| E12 | Resident Assistant | Provided information on resident R2's care and visits by POA |
| Z1 | Resident Representative / Power of Attorney | Expressed concerns about service plan changes and communication |
| Z2 | Ombudsman | Involved in concerns regarding service plan changes and communication |
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