Inspection Reports for Cedarhurst of Frankfort
21507 S Wolf Road, Frankfort, IL, 60423
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 7, 2026, found the facility in compliance with applicable assisted living regulations and identified no deficiencies. Earlier inspections showed some deficiencies related to updating residents’ service plans after falls, providing appropriate interventions, and ensuring dementia-specific staff training. Prior reports also noted issues with staff background checks and a substantiated complaint involving verbal abuse by an employee who was subsequently terminated. Complaint investigations mostly involved service plan and resident care concerns, with one substantiated case of verbal abuse. The facility’s recent passing inspection suggests improvement following previous citations in resident care and staff compliance areas.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% better than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 7, 2026
Visit Reason
The document is a plan of correction following a facility reported incident IL198655/FRI 11.5/25 for Cedarhurst of Frankfort.
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
Complaint Investigation
Deficiencies: 2
Date: Oct 11, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to a facility-reported incident and concerns about the facility's failure to update residents' service plans and implement appropriate interventions after falls.
Complaint Details
The visit was complaint-related under Complaint Investigation IL197431 and Facility Reported Incident IL197975.
Findings
The facility failed to update service plans and implement appropriate fall interventions immediately after falls for two residents with moderate to severe dementia, potentially causing harm. Additionally, the facility failed to provide eating utensils to a resident, compromising dignity.
Deficiencies (2)
Failed to implement appropriate interventions and update the resident's service plan immediately after a fall for two residents.
Failed to provide eating utensils for one resident, compromising resident dignity.
Report Facts
Mini-Mental State Exam score: 14
Mini-Mental State Exam score: 6
Fall dates: 2
Fall dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Confirmed care plan update timing and appropriateness of fall interventions | |
| Wellness Director | Confirmed care plan update timing and appropriateness of fall interventions | |
| Caregiver | Observed not providing eating utensils to resident R5 |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 1, 2025
Visit Reason
The inspection was conducted as an annual licensure survey combined with a complaint investigation (IL189489) at Cedarhurst of Frankfort.
Complaint Details
Complaint investigation IL189489 was part of the survey, focusing on service plan deficiencies and dementia program compliance.
Findings
The facility failed to review and revise service plans for residents with falls, pressure ulcers, and behavioral issues, and did not ensure required dementia-specific training for staff and the memory care director. These deficiencies have the potential to affect all residents in Assisted Living and Memory Care units.
Deficiencies (2)
Failure to review and revise service plans addressing falls, pressure ulcers, home health care, exit seeking, and elimination behaviors for residents R1, R4, and R5.
Failure to comply with Alzheimer's and Dementia program requirements including staff training and supervision.
Report Facts
Unwitnessed falls: 10
Dementia-specific orientation hours completed: 1
Dementia-specific orientation hours completed: 1.5
Dementia-specific orientation hours completed: 0
Dementia-specific orientation hours completed: 1
Annual dementia training hours completed: 0
Direct care staff supervision and training hours: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E10 | Assisted Living Nursing Director | Provided information about resident R1's caregiver and was present at exit conference. |
| E11 | Associate Executive Director | Reviewed personnel files and was present at exit conference; could not explain why required dementia training was incomplete. |
| E1 | Registered Nurse | Newly hired staff with incomplete dementia-specific orientation and training. |
| E2 | Resident Aide | Newly hired staff with incomplete dementia-specific orientation and training. |
| E3 | Licensed Practical Nurse | Newly hired staff with incomplete dementia-specific orientation and training. |
| E4 | Server | Newly hired staff with incomplete dementia-specific orientation. |
| E5 | Resident Aide | Newly hired staff with incomplete dementia-specific orientation and training. |
| E6 | Certified Nursing Assistant, Resident Care Manager | Newly hired staff with incomplete dementia-specific orientation and training. |
| E7 | Life Enrichment Staff | Newly hired staff with incomplete dementia-specific orientation. |
| E8 | Housekeeping | Newly hired staff with incomplete dementia-specific orientation. |
| E9 | Licensed Practical Nurse, Memory Care Director | No documentation of completing required annual dementia training. |
Inspection Report
Deficiencies: 0
Date: Mar 6, 2025
Visit Reason
The survey was conducted as a facility reported incident #184934 to assess compliance with Part 285 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.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 24, 2024
Visit Reason
The inspection was conducted based on a substantiated incident report (IL181746) involving allegations of resident abuse by an employee (E3). The visit aimed to investigate compliance with the Health Care Worker Background Check Act and Resident Rights regulations.
Complaint Details
The complaint investigation was substantiated (IL181746). The incident involved verbal abuse of resident R1 by employee E3, who was terminated following the incident. Multiple staff members provided statements confirming the abuse and the resident's distress.
Findings
The facility failed to complete required 6 Registry background checks for one employee (E3) who was terminated following an abuse allegation. Additionally, the facility failed to ensure one resident (R1) was free from abuse, as documented by multiple staff statements describing verbal abuse by E3 towards R1. The incident was investigated and reported, and E3 was terminated.
Deficiencies (2)
Failure to complete the 6 Registry background check for one employee (E3) as required by the Health Care Worker Background Check Act.
Failure to ensure one resident (R1) was free from abuse, evidenced by verbal abuse and yelling by employee E3.
Report Facts
Fine amount: 500
Resident age: 89
Resident count reviewed: 4
Employee hire date: Jul 3, 2024
Employee termination date: Nov 27, 2024
Incident date: Nov 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Terminated Resident Assistant | Employee who failed to have required background checks and was involved in verbal abuse of resident R1. |
| E1 | Executive Director | Interviewed regarding background check compliance for employee E3. |
| E2 | Regional Operations Specialist | Reported termination of E3 and confirmed verbal abuse incident. |
| E4 | Resident Assistant | Witnessed and documented verbal abuse incident involving E3 and resident R1. |
| E5 | Resident Assistant | Witnessed and described verbal abuse incident involving E3 and resident R1. |
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