Inspection Reports for Chapters Edwardsville OpCo DBA Chapters Living of Edwardsville
7108 Marine Road, Edwardsville, IL, 62025
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 7, 2025, found the facility in compliance with assisted living and shared housing regulations and identified no deficiencies. Earlier inspections showed a mixed record, with some deficiencies related to resident safety in the Memory Care unit, physician assessment documentation, staff training, and emergency procedures. Inspectors cited issues including failure to prevent unmonitored resident exit, incomplete physician assessments after significant condition changes, lack of CPR-certified staff on certain shifts, and delays in incident reporting. Complaint investigations were mostly unsubstantiated, except for one substantiated finding regarding physician assessment requirements, and enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history suggests some ongoing challenges in compliance, but the most recent report indicates the facility has addressed prior concerns.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
71% better than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 7, 2025
Visit Reason
The inspection was conducted in response to Complaint 2547098 / IL196699 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.
Complaint Details
Complaint 2547098 / IL196699 was investigated and found to be unsubstantiated as the facility was in compliance with relevant regulations.
Findings
The establishment was found to be in compliance with the applicable assisted living and shared housing regulations during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2025
Visit Reason
The inspection was conducted following a reported incident involving a resident (R1) who eloped from the secured Memory Care facility on 4/6/2025, prompting an investigation into the facility's environmental safety and elopement prevention measures.
Complaint Details
The visit was complaint-related due to an incident on 4/6/25 where resident R1 eloped from the facility. The resident had no prior history of elopement, was recently admitted, and was found at a nearby nursing home. The facility conducted an elopement risk assessment scoring R1 at risk (score of 14). Exit alarms were recalibrated and cameras checked but found non-functional. Notifications were made to the resident's physician and Power of Attorney.
Findings
The facility failed to ensure a safe and secure environment to prevent unmonitored/unsupervised exit of residents in the Memory Care unit, creating a substantial risk of harm. Specifically, a resident was able to exit through a door within the 15-second exit delay window without triggering an alarm, and cameras monitoring exit doors were found to be non-functional.
Deficiencies (1)
Failure to ensure residents in a secured Memory Care facility are provided a safe and secure environment to prevent unmonitored/unsupervised exit.
Report Facts
Elopement Risk Assessment Score: 14
Exit Alarm Delay: 15
Exit Alarm Delay: 5
Admission Timeframe: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Care Manager | Reported seeing resident R1 in the enclosed patio and described circumstances of elopement |
| E2 | Director of Nursing | Received report of elopement, coordinated alarm recalibration, camera checks, and notifications to physician and Power of Attorney |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 8, 2025
Visit Reason
The inspection was conducted in response to Complaint #2542982 / IL189571 to assess compliance with the Assisted Living and Shared Housing Establishment Code.
Complaint Details
Complaint #2542982 / IL189571 was investigated and the facility was found to be in general compliance.
Findings
Addington Place of Edwardsville was found to be in general compliance with the requirements of the Assisted Living and Shared Housing Establishment Code for this survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 22, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations concerning the facility's compliance with physician assessment requirements.
Complaint Details
Complaint #IL181030 allegations substantiated with violation cited; Complaint #IL181043 allegations not substantiated with no violation cited.
Findings
The facility was found to have failed to ensure a physician assessment certification was completed for a resident with a significant change in condition, resulting in a substantiated violation of Section 295.4000.
Deficiencies (1)
Failure to ensure a physician assessment certification was completed for a resident with a significant change in condition.
Report Facts
Admission date: Oct 14, 2024
Hospice admission date: Nov 8, 2024
Hospice transfer date: Nov 14, 2024
Physician Assessment Certification date: Nov 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse/LPN | E3 stated resident condition and therapy status | |
| Executive Director | E1 stated resident had hospice certification but no physician assessment certification at hospice admission and later presented the certification |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 23, 2024
Visit Reason
The document is a plan of correction related to a facility report incident investigation dated 10.06.24 for the Villas of Holly Brook Harrisburg.
Findings
The facility 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: 4
Date: 6020086 View POC 001 SOC Annual State Survey AP Edwardsville 10 23 24
Visit Reason
This document is a Plan of Correction submitted by Addington Place of Edwardsville following an Annual Licensure Survey conducted on 10-23-24.
Findings
The facility was cited for deficiencies including failure to provide orientation on emergency and evacuation plans within 10 days of admission, late reporting of an incident involving a resident injury, lack of CPR certified staff on certain shifts, and failure to ensure food handlers received safe food handling training within 30 days of employment.
Deficiencies (4)
Failure to ensure residents and/or their representatives are provided orientation to the emergency and evacuation plans of the facility within 10 days of admission.
Incident on 10.18.24 involving a resident found on the floor with a 4cm laceration was reported late.
Four shifts in September and October 2024 had no CPR certified team member on schedule.
Food handlers must receive or obtain training in basic safe food handling principles within 30 days of employment.
Report Facts
Incident date: Oct 18, 2024
Laceration size: 4
Number of shifts without CPR certified staff: 4
Days for emergency orientation: 10
Days for food handler training: 30
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 6020086 View POC 003 SOC Addington Place of Edwardsville survey 11 22 24
Visit Reason
The document is a plan of correction addressing a deficiency related to the requirement that a physician's assessment be completed upon identification of a significant change in a resident's condition.
Findings
The deficiency identified was the failure to complete a physician's assessment upon a significant change in a resident's condition. The plan of correction includes referral for hospice services based on a physician order and modification of the critical incident tracking mechanism and protocol.
Deficiencies (1)
Failure to complete a physician's assessment upon identification of a significant change in the resident's condition as required by Section 295.4000 Physicians Assessment.
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