Inspection Reports for Ciel of Long Grove

1190 Old McHenry Rd, Long Grove, IL 60047, United States, IL, 60047

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Inspection Report Summary

The most recent inspection on September 26, 2025, identified deficiencies related to the facility’s failure to immediately assess and promptly report a resident fall, which resulted in delayed treatment for a serious injury. Earlier inspections showed mixed results, with prior reports citing issues such as incomplete service plan updates after falls and missing dementia-specific training for staff. The main themes across deficiencies involved resident care following falls and staff qualifications or training. Complaint investigations were substantiated in two instances, including the most recent case, but no fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The inspection history indicates ongoing challenges with fall management and staff training, with no clear improvement trend.

Deficiencies (last 2 years)

Deficiencies (over 2 years) 2 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

43% better than Illinois average
Illinois average: 3.5 deficiencies/year

Deficiencies per year

4 3 2 1 0
2024
2025

Inspection Report

Complaint Investigation
Deficiencies: 2 Date: Sep 26, 2025

Visit Reason
The inspection was conducted as an investigation of a facility-reported incident involving a resident fall on 2025-08-19, where the facility failed to ensure immediate nursing assessment and prompt reporting of the fall incident.

Complaint Details
The investigation was triggered by a facility-reported incident on 2025-08-21 regarding a resident fall on 2025-08-19. The complaint was substantiated as the facility failed to immediately assess the resident and report the fall, resulting in delayed treatment of a subdural hematoma.
Findings
The facility failed to ensure that a resident who fell was immediately assessed by a licensed nurse and that the fall was promptly reported to nursing staff. This failure affected one resident (R1) who was later diagnosed with a subdural hematoma requiring surgical intervention, creating a substantial probability of severe harm.

Deficiencies (2)
Failure to have staff with adequate qualifications and training to meet residents' needs, specifically failing to immediately assess a resident after a fall and promptly report the incident.
Failure to protect a resident's right to be free from neglect by not ensuring prompt reporting and immediate nursing assessment after a fall incident.
Report Facts
Residents reviewed for accidents: 3 Time waited for nurse response: 15 Date of resident fall: Aug 19, 2025 Date of facility incident report: Aug 21, 2025

Employees mentioned
NameTitleContext
E4Physical Therapy AideObserved resident on floor, pressed alarm pendant multiple times, verbally informed caregiver, and assisted resident to get up
E3CaregiverInformed by E4 of fall but did not verify resident identity or report incident to nurse or Health and Wellness Director
E2Health and Wellness DirectorProvided facility protocol for falls and confirmed failures in reporting and assessment
E1Executive DirectorWitnessed interviews regarding the fall incident
Z1PhysicianEvaluated resident via video conference, ordered hospital transfer, and confirmed severity of injury

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Dec 10, 2024

Visit Reason
The inspection was conducted as a complaint investigation and a facility reported incident review.

Complaint Details
Complaint investigation #2477395/#IL178025 was substantiated with no deficiencies written.
Findings
Both the facility reported incident (#IL176703) and the complaint investigation (#2477395/#IL178025) were substantiated with no deficiencies written. The establishment was found to be in compliance with the applicable Illinois Assisted Living and Shared Housing regulations.

Inspection Report

Annual Inspection
Deficiencies: 2 Date: Aug 8, 2024

Visit Reason
Annual Licensure Survey conducted to assess compliance with state regulations for service plans and Alzheimer's/dementia program training requirements.

Findings
The facility failed to update a resident's service plan after fall incidents, including lack of fall root cause analysis and communication between therapy and staff, contributing to additional falls and hospitalization. Additionally, the facility did not ensure dementia-specific training was completed by an employee prior to job responsibilities.

Deficiencies (2)
Failure to update resident's service plan and conduct fall root cause analysis after fall incidents.
Failure to ensure dementia-specific training was completed prior to employee assuming job responsibilities.
Report Facts
Resident sample size: 7 Employee sample size: 9 Resident age: 101 Resident admission date: Dec 30, 2021

Employees mentioned
NameTitleContext
BinduNurse PractitionerProvided post-fall evaluation and treatment for resident R5
E1Executive DirectorAcknowledged training deficiencies and corrective measures
E2Health and Wellness DirectorConfirmed therapy visits and fall root cause analysis issues
E10Business Office ManagerAcknowledged typographical error in training date

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