Inspection Reports for Cedar Trails Senior Living

The visit was conducted as an annual licensure inspection to ensure 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 assisted living regulations during this annual licensure survey.

The inspection was conducted as a complaint investigation for complaint number 2546819/IL196565.

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 investigation 2546819/IL196565 found the establishment in compliance with applicable assisted living regulations.

Facility Report Incident Investigation related to an incident dated 05/25/25 IL194917.

The establishment was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210ILCS 9/1 Assisted Living and Shared Housing Act.

The inspection was conducted following a facility reported incident investigation regarding fall prevention and resident rights violations related to individualized service plans and fall management.

The facility failed to ensure individualized fall prevention approaches were developed post-fall and did not follow facility policy on fall prevention for residents at risk. Multiple falls of a resident were documented with inadequate post-fall incident investigations and failure to update care plans accordingly.

The visit was complaint-related, triggered by a facility reported incident investigation IL183922 concerning fall prevention and resident rights violations.

This document is a Plan of Correction submitted by Cedar Trails Senior Living following a survey conducted on January 24, 2025, to address cited deficiencies.

The plan addresses the correction of deficiencies related to a resident no longer residing at the community and outlines procedures for ongoing compliance including staff training, audits, and monitoring by the Director of Wellness or designee.

The inspection was conducted as an annual licensure survey to assess compliance with personnel requirements including CPR coverage and initial tuberculosis (TB) screening procedures.

The facility was found deficient for failing to ensure at least one currently CPR certified direct care staff was on duty at all times, specifically on several night shifts. Additionally, the facility failed to provide timely initial TB screening for newly hired employees, with multiple employees having screenings outside the required time frames.

The inspection was conducted following a facility-reported incident involving a resident fall with injuries on 11/09/2024, to assess compliance with employee orientation and ongoing training requirements and adherence to facility policies.

The facility failed to follow its own policies regarding monitoring a resident after a fall, specifically failing to reproduce evidence of required monitoring. Employees did not follow standards of care related to fall prevention and management.

The inspection was conducted as a survey to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Code.

No violations were cited during the survey. The facility was found to be in compliance with the applicable regulations.

The plan of correction was submitted in response to findings from a survey conducted on 9/11/2024 related to narcotic medication administration irregularities noted during a shift change narcotics count on 8/26/2024.

During the narcotics count on 8/26/2024, nurses noted that residents who do not normally request pain medication had received narcotics during the previous shift. The Director of Wellness and Executive Director investigated, interviewed affected residents, completed incident reports, and notified the police.

The inspection was conducted following substantiated reports of falls and narcotic diversion/theft at Cedar Trails Senior Living, specifically investigating allegations of narcotic theft by an agency nurse on 8/25/24.

The facility failed to ensure residents were protected against narcotic theft/diversion. Multiple residents reported not receiving pain medication despite documentation showing narcotics were signed out. Video surveillance and witness statements confirmed the nurse did not administer the medications. The facility initiated an internal investigation and notified law enforcement.

The complaint investigation was substantiated regarding narcotic diversion/theft by an agency nurse on 8/25/24. Falls reports were substantiated but no violations were cited for those incidents.