Inspection Report Summary
The most recent inspection on October 23, 2025, found the facility to be in compliance with applicable assisted living regulations and cited no deficiencies. Earlier inspections showed some deficiencies related mainly to resident care oversight, including failure to maintain an effective quality improvement program and issues with staff training on residents’ Individual Service Plans and abuse prevention. Complaint investigations substantiated verbal abuse by a caregiver and delayed internal reporting of such incidents, leading to staff termination and retraining. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The inspection history shows some recurring issues with abuse prevention and care plan management, but the most recent survey indicates improvement.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Oct 23, 2025
Visit Reason
The survey was conducted as a plan of correction following a facility reported incident investigation dated 10/15/2025.
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
Annual Inspection
Deficiencies: 1
Date: Aug 7, 2025
Visit Reason
The visit was conducted as part of the Annual Licensure Survey to assess compliance with state regulations.
Findings
The facility failed to establish an effective quality improvement program that includes oversight, resident satisfaction, and data-driven performance monitoring. Specifically, the establishment did not provide evidence of surveying residents and their families to evaluate care quality.
Deficiencies (1)
Failure to establish an effective quality improvement program that includes resident and family feedback.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Director | Interviewed regarding lack of quality improvement surveys. |
| E6 | Business Office Manager | Interviewed regarding lack of quality improvement surveys. |
| E7 | Regional Director of Operations | Phone interview regarding the Annual survey and quality improvement regulation. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 1, 2025
Visit Reason
The inspection was conducted following a reported incident of verbal abuse by a caregiver towards residents in the memory care unit, triggered by a complaint and subsequent investigation.
Complaint Details
The complaint investigation was substantiated. The Executive Director confirmed the verbal abuse incident involving caregiver E3 towards residents R1, R2, and R3. The caregiver was suspended and later terminated. Staff interviews revealed previous unreported verbal abuse incidents. Staff received re-education and retraining on abuse prevention and reporting policies.
Findings
The facility failed to ensure residents were free from verbal abuse by a caregiver, resulting in a substantiated finding of verbal aggression towards multiple residents. The accused caregiver was terminated, and staff were re-educated on abuse policies. The facility also failed to timely report the alleged verbal abuse internally, causing delayed investigation and potential harm to residents.
Deficiencies (2)
Failure to ensure residents are free from any form of abuse including verbal abuse in the facility.
Failure to internally report an alleged staff to resident verbal abuse to the Executive Director in a timely manner.
Report Facts
Incident Date: Jun 18, 2025
Termination Date: Jun 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Conducted investigation, confirmed abuse, terminated caregiver, and provided staff re-education |
| E3 | Caregiver | Accused and substantiated caregiver for verbal abuse towards residents |
| E4 | Caregiver | Witnessed verbal abuse, failed to report immediately due to fear, received retraining |
| E5 | Caregiver | Witnessed verbal abuse, reported incident on 6/18/25, received coaching for delayed reporting |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 1, 2025
Visit Reason
The inspection was conducted as a follow-up related to a facility reported incident investigation dated 6/26/25 involving allegations of resident abuse and neglect by a caregiver.
Complaint Details
The complaint investigation was substantiated. The Executive Director was notified of verbal abuse by a caregiver on 6/18/25. The caregiver was terminated following investigation. Staff were re-educated on abuse policies and reporting requirements. Multiple staff interviews confirmed verbal aggression incidents.
Findings
The facility was found to have violated Resident Rights and Abuse, Neglect, and Financial Exploitation Prevention and Reporting regulations, with substantiated findings of verbal abuse by a caregiver towards residents. The Executive Director suspended the accused caregiver and conducted staff training on abuse prevention and reporting.
Deficiencies (2)
Violation of Resident Rights due to failure to ensure residents were free from abuse including verbal abuse.
Failure to timely report and investigate alleged verbal abuse incidents as required by Abuse, Neglect, and Financial Exploitation Prevention and Reporting regulations.
Report Facts
Fine amount: 1000
Incident date: 61825
Investigation completion date: 62325
Staff training date: 62325
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jonna Parker | Instructor | Named as instructor for staff training on Resident Abuse & Neglect, Exploitation, Investigation & Reporting on 6/23/2025. |
| E1 | Executive Director | Notified of abuse incident, conducted investigation, suspended caregiver, and led staff training. |
| E3 | Caregiver | Accused caregiver substantiated for verbal abuse and terminated. |
| E4 | Caregiver | Interviewed regarding verbal abuse incidents involving E3. |
| E5 | Caregiver | Interviewed regarding verbal abuse incidents involving E3 and reporting failures. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 17, 2025
Visit Reason
The document is a plan of correction related to a facility reported incident investigation dated 6/9/25 at Charter Senior Living of Godfrey.
Findings
The facility is reported to be in general compliance with the Requirements of the Assisted Living and Shared Housing Establishment Code for this survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 1, 2025
Visit Reason
The inspection was conducted following a facility report incident investigation related to an event on 03/09/2025 involving a resident found unresponsive on the floor.
Findings
The facility failed to ensure staff were trained and aware of residents' Individual Service Plans, specifically regarding a resident's Do Not Resuscitate (DNR) status. This failure resulted in staff not recognizing the resident's code status during an emergency, leading to inappropriate resuscitation attempts.
Deficiencies (1)
Failure to ensure staff were trained to be aware of residents' Individual Service Plans, including code status.
Report Facts
Incident date: Mar 9, 2025
Resident age: 97
Admission date: Aug 14, 2024
DNR form date: Apr 24, 2023
Chest compressions performed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Residential Aide | Found resident on floor, performed CPR |
| E4 | Residential Aide | Assisted with resident, observed no heartbeat or breathing |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 1, 2025
Visit Reason
The inspection was conducted following a facility report incident investigation related to an incident on 03/09/2025 involving a resident found unresponsive on the floor.
Findings
The facility failed to ensure staff were trained and aware of residents' Individual Service Plans, specifically regarding a resident's Do Not Resuscitate (DNR) status. This failure contributed to improper emergency response during the incident where the resident was found unresponsive and later declared deceased.
Deficiencies (1)
Failure to ensure staff were trained to be aware of residents' Individual Service Plans, including Code status and emergency procedures.
Report Facts
Incident date: Mar 9, 2025
Resident age: 97
Employee chest compressions performed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Residential Aide | Found resident unresponsive and performed CPR |
| E4 | Residential Aide | Assisted with resident and confirmed no heartbeat or breathing |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 4, 2024
Visit Reason
The inspection was conducted as an incident investigation related to a resident's fall on 11.07.24, referenced as IL181158.
Complaint Details
The visit was complaint-related, investigating an incident involving a resident's fall on 11.07.24. The deficiency was substantiated by record review and interview with the Regional Nurse Specialist.
Findings
The facility failed to ensure that the resident's Individual Service Plan was updated in a timely manner following the resident's fall on 11.07.24, which could cause substantial probability of harm. The staff did not follow acceptable standards of care.
Deficiencies (1)
Failure to update the resident's Individual Service Plan with interventions after a fall.
Report Facts
Incident date: Nov 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Regional Nurse Specialist | Interviewed and confirmed the service plan was not updated timely after the resident's fall |
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