Inspection Report Summary
The most recent inspection on December 22, 2025, found the facility in compliance with applicable assisted living regulations and cited no deficiencies. Earlier inspections showed a mixed record, with prior deficiencies related mainly to fall prevention and staff training, as well as issues with narcotic medication administration and employee compliance with health screening and certification requirements. Complaint investigations included a substantiated case of narcotic diversion by an agency nurse, which led to internal and law enforcement involvement, while most other complaints were found unsubstantiated or resulted in citations for procedural lapses. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows some improvement over time, with the most recent survey indicating compliance following earlier citations and corrective actions.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 22, 2025
Visit Reason
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.
Findings
The establishment was found to be in compliance with the applicable assisted living regulations during this annual licensure survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 28, 2025
Visit Reason
The inspection was conducted as a complaint investigation for complaint number 2546819/IL196565.
Complaint Details
Complaint investigation 2546819/IL196565 found the establishment in compliance with applicable assisted living regulations.
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.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 25, 2025
Visit Reason
Facility Report Incident Investigation related to an incident dated 05/25/25 IL194917.
Findings
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.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 24, 2025
Visit Reason
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.
Complaint Details
The visit was complaint-related, triggered by a facility reported incident investigation IL183922 concerning fall prevention and resident rights violations.
Findings
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.
Deficiencies (3)
Failure to develop individualized service plans based on physician's assessment and resident's choices.
Failure to ensure individualized progressive fall interventions post fall and failure to follow facility fall prevention and management policy.
Failure to conduct post fall incident investigations to identify causes and predisposing factors contributing to falls.
Report Facts
Fall incidents: 3
Dates of service plan revisions: Dec 7, 2024
Dates of service plan revisions: Jan 14, 2025
Dates of service plan initiation: Aug 4, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (E2) | Described fall alert system and monitoring. | |
| Care Partner (E3) | Described hourly checks and response to fall alerts. | |
| Care Partner (E6) | Described hourly checks and response to fall alerts. | |
| Executive Director (E1) | Described fall management system and lack of post fall incident investigations. |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jan 24, 2025
Visit Reason
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.
Findings
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.
Deficiencies (2)
Resident #1 is no longer a resident at the community.
Correction of cited deficiency related to tag A6000.
Report Facts
Date of Survey: Jan 24, 2025
Completion Date: Jan 18, 2025
Completion Date: Feb 14, 2025
Completion Date: Feb 28, 2025
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Dec 23, 2024
Visit Reason
The inspection was conducted as an annual licensure survey to assess compliance with personnel requirements including CPR coverage and initial tuberculosis (TB) screening procedures.
Findings
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.
Deficiencies (2)
Failed to ensure a minimum of one currently CPR certified direct care staff was on duty at all times in the facility.
Failed to provide evidence that initial tuberculosis (TB) screening was conducted within the required time frames for newly hired employees.
Report Facts
Dates with no CPR certified staff on night shift: 5
Number of employees with untimely initial TB screening: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Confirmed no CPR certified direct care staff on night shifts on specified dates |
| E2 | Director of Health and Wellness | Had initial TB screening outside required time frames and confirmed the untimely screenings |
| E4 | Resident Assistant | Had initial TB screening outside required time frames |
| E5 | Resident Assistant | Had initial TB screening outside required time frames |
| E6 | Resident Assistant | Had incomplete initial TB screening outside required time frames |
| E7 | Resident Assistant | Had initial TB screening outside required time frames |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Nov 21, 2024
Visit Reason
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.
Findings
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.
Deficiencies (2)
Failure to ensure employees completed orientation including internal establishment requirements and policies within 30 days of employment.
Failure to follow facility policy regarding monitoring a resident after a fall with injury, resulting in lack of reproducible evidence of required monitoring.
Report Facts
Incident date and time: Nov 9, 2024
Monitoring frequency: 30
Monitoring frequency: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Wellness Director | Interviewed regarding lack of reproducible evidence of resident monitoring after fall |
| E1 | Director | Interviewed about expectation that establishment policies be followed |
Inspection Report
Deficiencies: 0
Date: Oct 2, 2024
Visit Reason
The inspection was conducted as a survey to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Code.
Findings
No violations were cited during the survey. The facility was found to be in compliance with the applicable regulations.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 11, 2024
Visit Reason
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.
Findings
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.
Deficiencies (1)
Non-compliance with Section 295.6000 Resident Rights regarding narcotic medication administration and resident rights.
Report Facts
Date of Survey: Sep 11, 2024
Date of Incident: Aug 26, 2024
Date of Correction Completion: Aug 27, 2024
Date for Resident Rights In-service: Dec 1, 2024
Date for Audit and Medication Discontinuation: Nov 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sheila Gallagher | Executive Director | Named as responsible for auditing narcotic medication usage and ensuring ongoing compliance |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 11, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to protect residents against narcotic theft/diversion in the facility.
Report Facts
Date of narcotic diversion incident: Aug 25, 2024
Number of residents involved: 4
Shift hours of agency nurse: 12
Internal investigation timeframe: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Z1 | Agency Nurse | Named in narcotic diversion finding; signed out narcotics but did not administer them |
| E1 | Executive Director | Reviewed video footage and confirmed narcotics were not administered |
| E2 | Director of Wellness | Initiated investigation and reported to IDPH and law enforcement |
| E3 | Licensed Practical Nurse | Discovered narcotic count discrepancies and reported to Director of Wellness |
| E4 | Care Partner | Observed agency nurse on phone or sleeping during shift |
| E5 | Care Partner | Observed agency nurse on phone or sleeping during shift |
| Z2 | Chief Police Officer | Conducted initial report and investigation of narcotic diversion |
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