The most recent inspection on January 9, 2026, was a complaint investigation and found the facility in compliance with applicable assisted living regulations without deficiencies. Earlier inspections showed a mixed record, with some citations related to resident safety, medication supervision, and service plan updates. Key issues included failure to update service plans for residents with fall risks, non-functioning bathroom safety alarm pull cords, incomplete tuberculosis testing for new employees, and a substantiated complaint involving a resident eloping unsupervised that resulted in injury and falsified wellness check records. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have addressed many prior deficiencies, as recent complaint investigations have found it in compliance.
Deficiencies (last 3 years)
Deficiencies (over 3 years)2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
The inspection was conducted as an original complaint investigation entered on 2026-01-07 and exited on 2026-01-09.
Findings
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.
Complaint Details
Original Complaint Investigation IL199238 entered on 2026-01-07 and exited on 2026-01-09. The establishment was found to be in compliance.
Original complaint investigation #2569870/IL197991 to determine 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 administrative code.
Complaint Details
Original complaint investigation #2569870/IL197991 resulted in compliance with regulations.
Inspection Report Plan of CorrectionDeficiencies: 0Jul 25, 2025
Visit Reason
This document is a plan of correction outlining steps related to medication supervision and service plan updates following an inspection or regulatory review.
Findings
The plan addresses medication packaging requirements before switching to medication supervision, updating medication orders, and notification procedures for changes in medication administration.
Annual licensure survey conducted from June 10, 2025 to June 18, 2025 to assess compliance with health and safety regulations.
Findings
The facility failed to complete required tuberculosis testing for two employees hired in January 2025, and resident bathroom safety alarms were found with non-functioning or improperly installed pull cords in six residents' bathrooms and common areas.
Deficiencies (2)
Description
Failure to complete tuberculosis testing upon hire for two employees (E4 and E8).
Resident bathroom safety alarms had non-functioning or improperly installed pull cords for six residents (R6, R8-R12) and in common areas.
Report Facts
Residents affected: 75Residents reviewed for environment: 12Residents with bathroom safety alarm issues: 6Employees reviewed for TB test: 5
Employees Mentioned
Name
Title
Context
E4
Resident Assistant
Employee missing required tuberculosis testing upon hire.
E8
Resident Assistant
Employee missing required tuberculosis testing upon hire.
E1
Executive Director
Confirmed missing TB tests and bathroom safety alarm issues.
E7
Resident Care Assistant
Provided information about resident bathroom usage related to safety alarm issues.
The visit was conducted as an original complaint investigation (#2561518/IL187200) 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 complaint investigation.
Complaint Details
Original Complaint Investigation #2561518/IL187200; the establishment was found compliant.
Inspection Report Plan of CorrectionDeficiencies: 1Jan 20, 2025
Visit Reason
This document is a plan of correction submitted in response to a cited violation regarding failure to update service plans for residents as required by regulation.
Findings
The facility failed to update service plans for residents R1, R2, and R3 to reflect fall risks and interventions despite documented falls. Corrective actions include updating service plans, staff training, and implementing procedures to ensure timely updates following significant changes in resident conditions.
Deficiencies (1)
Description
Failure to update service plans for residents R1, R2, and R3 regarding fall risks and interventions despite documented falls.
Employees Mentioned
Name
Title
Context
Cynthia West
Executive Director
Named as the Executive Director submitting the plan of correction and responsible for oversight.
Original investigation of Complaint 2560324 / IL 184362 regarding the safety and care of a resident in the Alzheimer's and Dementia program.
Findings
The facility failed to prevent one resident (R1) from eloping outside unsupervised, resulting in frostbite and hypothermia due to prolonged exposure to cold temperatures. Staff falsified wellness check records, and the responsible caregiver's employment was terminated.
Complaint Details
Complaint 2560324 / IL 184362 was substantiated as the facility failed to ensure resident safety, leading to injury and falsification of wellness check records by staff.
Severity Breakdown
TYPE 1 VIOLATION: 1
Deficiencies (1)
Description
Severity
Failed to prevent one resident from eloping outside unsupervised, resulting in frostbite and hypothermia.
TYPE 1 VIOLATION
Report Facts
Temperature: 13Time resident was outside: 115Resident rectal temperature: 91.5Date of incident: Jan 13, 2025
Employees Mentioned
Name
Title
Context
E4
Caregiver
Assigned to resident R1, falsified wellness check records, employment terminated due to incident.
E1
Executive Director
Provided statements regarding investigation and findings.
Inspection Report Plan of CorrectionDeficiencies: 2Jan 14, 2025
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation (Complaint 2560324 / IL 184362) related to violations in Alzheimer's and dementia programs.
Findings
The investigation identified a violation involving falsified records and failure to perform required wellness checks, as well as a door alarm system failure due to a low battery that allowed a resident to exit the courtyard unsupervised.
Complaint Details
Complaint 2560324 / IL 184362 was investigated and found to involve violations related to Alzheimer's and dementia care programs, including falsified records and failure to perform wellness checks.
Deficiencies (2)
Description
Falsified records and failure to perform required wellness checks by staff member.
Door alarm system failed to activate due to low battery, compromising resident safety.
Report Facts
Date of staff shift huddles: Jan 14, 2025Date of formal in-service training: Jan 15, 2025
Employees Mentioned
Name
Title
Context
Cynthia West
Executive Director
Signed the Plan of Correction letter.
Staff member E4 responsible for falsified records and failure to perform wellness checks was terminated; full name not provided.
Inspection Report Plan of CorrectionDeficiencies: 1Jan 9, 2025
Visit Reason
The inspection was conducted to review compliance with service plan regulations, specifically to verify if service plans were updated appropriately for residents after significant changes in their condition.
Findings
The facility failed to update service plans for three residents who had multiple falls, despite interventions being implemented. The service plans did not document fall risk or preventive interventions for these residents.
Severity Breakdown
Type 3 Violation: 1
Deficiencies (1)
Description
Severity
Failed to update service plans for three residents (R1, R2, and R3) to include fall risk and interventions despite multiple falls.
Type 3 Violation
Report Facts
Number of residents with unupdated service plans: 3Number of falls for R1: 5Number of falls for R2: 2Number of falls for R3: 5
Employees Mentioned
Name
Title
Context
Wellness Director
E2 (Wellness Director) stated that fall interventions were implemented but not placed on the service plans.
Inspection Report Original LicensingDeficiencies: 0Dec 21, 2024
Visit Reason
Original investigation of FRI IL 182643 for licensing 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 administrative codes during this original licensing investigation.
Annual Licensure Survey conducted 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 facility was found to be in compliance with the applicable Illinois Assisted Living and Shared Housing regulations during this annual licensure survey.
Annual Licensure Survey conducted 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 facility was found to be in compliance with the applicable Illinois Assisted Living and Shared Housing regulations for this survey period.
Inspection Report Plan of CorrectionDeficiencies: 26021561 View POC 009 SOC 6.18
Visit Reason
This document is a Plan of Correction addressing deficiencies found related to initial health evaluations for direct care and food service employees and environmental safety requirements regarding resident bathroom safety alarm pull cords.
Findings
The facility failed to complete TB testing upon hire for two of five employees reviewed and failed to ensure functioning pull cords for resident bathroom safety alarms for six of six residents reviewed. Corrective actions and systemic changes have been implemented to address these issues.
Deficiencies (2)
Description
Failure to complete TB testing upon hire for two of five employees reviewed.
Failure to ensure functioning pull cords for resident bathroom safety alarms for six of six residents reviewed.