Inspection Reports for Summit of Uptown
10 N Summit Ave, Park Ridge, IL 60068, United States, IL, 60068
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Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 16, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to provide appropriate supervision and services to a resident, resulting in a fall and serious injury.
Findings
The facility failed to ensure one-to-one supervision for a resident with dementia who was a high fall risk, leading to a fall that caused a subdural hematoma and subsequent death. Staff and family interviews, nurse notes, and medical records confirmed inadequate supervision and communication issues.
Complaint Details
The complaint investigation found that the facility did not provide adequate supervision to resident R1, who was a high fall risk with dementia. The resident fell on 09/15/2025, sustaining a subdural hematoma and later died on 09/24/2025. The facility lacked sufficient staff presence in the dining room at the time of the fall, and family communication was inadequate.
Severity Breakdown
Type 1 Violation: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident had one-to-one supervision to prevent falls and injury. | Type 1 Violation |
| Failed to ensure a resident with dementia was safe by providing supervision to prevent falls. | Type 1 Violation |
Report Facts
Resident sample size: 3
Staff to resident ratio: 3
Date of fall: Sep 15, 2025
Date of death: Sep 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Licensed Practical Nurse (LPN) | Found resident on floor bleeding and applied pressure, called 911 |
| E4 | Certified Nursing Assistant (CNA) | Walked with resident and sat her in chair before fall |
| E5 | Certified Nursing Assistant (CNA) | Reported resident's walking behavior and fall risk |
| E6 | Resident Assistant | Reported resident's walking behavior and fall risk |
| E7 | Physician | Spoke with family about resident's care needs and higher level of care |
| E8 | Nurse Practitioner | Provided progress notes recommending increased skilled nursing care |
| E2 | Resident Care Director | Discussed resident's supervision needs and family communication |
| E1 | Executive Director | Reviewed fall incident and family communication |
Inspection Report
Plan of Correction
Deficiencies: 2
Sep 21, 2025
Visit Reason
The inspection was conducted following a facility-reported incident involving a resident fall and subsequent injury, to evaluate compliance with incident reporting and service plan requirements.
Findings
The facility failed to report a resident's change in condition within the required 24-hour timeframe, resulting in delayed notification to the Illinois Department of Public Health. Additionally, the facility failed to update and implement new interventions in the resident's service plan to reduce fall risk, contributing to a severe injury (right femur fracture) and subsequent hospice care.
Severity Breakdown
Type 1 Violation: 1
Type 2 Violation: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report a serious incident (resident fall with injury) to the Illinois Department of Public Health within 24 hours as required by Section 295.2050 Incident and Accident Reporting. | Type 2 Violation |
| Failure to update and implement new interventions in the resident's service plan to reduce fall risk after a significant change in condition, as required by Section 295.4010 Service Plan. | Type 1 Violation |
Report Facts
Deficiencies cited: 2
Resident age: 84
Incident date: Aug 2, 2025
Report submission date: Aug 4, 2025
Service plan update date: Aug 11, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Conley | Medical Doctor | Notified via fax about resident's hospital transfer after fall. |
| Leo Foley | Family member notified of resident's fall and condition. | |
| E8 | Licensed Practical Nurse (LPN) | Assessed resident after fall and sent resident to hospital. |
| E11 | Memory Care Program Director/RN | Responsible for incident investigation and implementing interventions. |
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