Inspection Reports for Lincolnshire Place – Decatur
1215 W Arbor Drive, Decatur, IL, 62526
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 2, 2025, identified deficiencies related to the facility’s failure to develop and implement an elopement prevention policy for a memory care resident. Earlier inspections showed issues with residency requirements and timely updates to service plans, particularly concerning residents’ assistance needs and treatment of pressure ulcers. Complaint investigations conducted in 2025 were unsubstantiated with no violations cited. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s inspection history shows some recurring challenges with care planning and resident safety policies, with no clear pattern of improvement or worsening over time.
Deficiencies (last 1 years)
Deficiencies (over 1 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Original Licensing
Deficiencies: 1
Date: Nov 2, 2025
Visit Reason
Original investigation of facility FRI IL 198260 focusing on compliance with Alzheimer's and Dementia program regulations, specifically regarding elopement prevention policies.
Findings
The facility failed to have and implement an elopement prevention policy to prevent a memory care resident (R1) from eloping. R1 was found outside the facility after leaving through an unsecured window, resulting in a Type 1 violation with the probability of causing significant harm.
Deficiencies (1)
Failure to develop and implement an elopement prevention policy for residents who may wander, resulting in a resident eloping from the facility.
Report Facts
Date of resident admission: Oct 16, 2025
Date of elopement incident: Oct 24, 2025
Time resident last seen: 645
Time resident found: 850
Time police notified: 805
Time police arrived: 833
Time administrator notified: 729
Time staff arrived to review footage: 745
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing | Provided statement about the elopement incident and security footage review |
| E1 | Executive Director | Provided statement about lack of Elopement Risk Assessment and elopement policy |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to complaint number 2563282/IL190183.
Complaint Details
Complaint 2563282/IL190183 was investigated and found to be unsubstantiated with no violations cited.
Findings
The complaint could not be substantiated and no violations were cited. The facility was found to be in compliance with the applicable Illinois Assisted Living and Shared Housing regulations.
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Feb 27, 2025
Visit Reason
The inspection was conducted as an Annual Licensure Survey and included complaint investigations for complaints 2561065/IL186054 and 2561068/IL186057, both of which were found to be unsubstantiated with no violations cited.
Complaint Details
Complaints 2561065/IL186054 and 2561068/IL186057 were investigated and found to be unsubstantiated with no violations cited.
Findings
The facility failed to ensure residents met residency requirements, specifically regarding total assistance needs and treatment of stage 3 pressure ulcers. Additionally, the facility failed to revise service plans immediately after significant changes in residents' conditions and did not ensure service plans addressed the amount, type, and frequency of health-related services or included all support services provided.
Deficiencies (4)
Failed to ensure residents meet residency requirements, including total assistance needs and treatment of stage 3 or 4 decubitus ulcers.
Failed to revise service plans immediately after significant changes in residents' physical, cognitive, or functional condition.
Failed to ensure service plans address the amount, type, and frequency of health-related services needed by residents.
Failed to ensure service plans include all support services provided or arranged for residents.
Report Facts
Complaint numbers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E4 | Licensed Practical Nurse | Observed changing R3's bilateral heel dressings and provided statements about wound status |
| E3 | Care Plan Coordinator/Registered Nurse | Stated intention to revise R1's care plan with hospice staff and family |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Feb 27, 2025
Visit Reason
This document is a Statement of Correction submitted in response to violations cited during the Annual Licensure Survey conducted on 2/27/2025.
Findings
The facility identified deficiencies related to residency requirements and service plan reviews, including issues with prescreening criteria for admissions and timely updates to service plans after significant changes in residents' conditions.
Deficiencies (2)
Residency requirements not met for certain residents, including issues with total assistance needs and wound care management.
Service plans not reviewed and revised immediately after significant changes in residents' conditions.
Report Facts
Date of Completion: Mar 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Janice Lawson | Executive Director | Signed the Statement of Correction letter |
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