Inspection Reports for Summit of Uptown

10 N Summit Ave, Park Ridge, IL 60068, United States, IL, 60068

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Inspection Report Summary

The most recent inspection on October 16, 2025, identified deficiencies related to inadequate supervision of a resident with dementia who was at high risk for falls, which resulted in a fall causing a subdural hematoma and subsequent death. Prior inspections showed issues with timely incident reporting and updating service plans after resident condition changes, including a failure to report a serious fall injury within 24 hours and to implement fall prevention interventions. The main themes across these inspections involved resident supervision, fall prevention, and communication with families and authorities. There were no fines, immediate jeopardy findings, or license actions listed in the available reports. The inspection history indicates ongoing challenges with fall risk management and supervision, with recent findings reflecting similar concerns as earlier reports.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

14% worse than Illinois average
Illinois average: 3.5 deficiencies/year

Deficiencies per year

4 3 2 1 0
2025

Inspection Report

Complaint Investigation
Deficiencies: 2 Date: 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.

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.
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.

Deficiencies (2)
Failed to ensure a resident had one-to-one supervision to prevent falls and injury.
Failed to ensure a resident with dementia was safe by providing supervision to prevent falls.
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
NameTitleContext
E3Licensed Practical Nurse (LPN)Found resident on floor bleeding and applied pressure, called 911
E4Certified Nursing Assistant (CNA)Walked with resident and sat her in chair before fall
E5Certified Nursing Assistant (CNA)Reported resident's walking behavior and fall risk
E6Resident AssistantReported resident's walking behavior and fall risk
E7PhysicianSpoke with family about resident's care needs and higher level of care
E8Nurse PractitionerProvided progress notes recommending increased skilled nursing care
E2Resident Care DirectorDiscussed resident's supervision needs and family communication
E1Executive DirectorReviewed fall incident and family communication

Inspection Report

Plan of Correction
Deficiencies: 2 Date: 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.

Deficiencies (2)
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.
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.
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
NameTitleContext
Mark ConleyMedical DoctorNotified via fax about resident's hospital transfer after fall.
Leo FoleyFamily member notified of resident's fall and condition.
E8Licensed Practical Nurse (LPN)Assessed resident after fall and sent resident to hospital.
E11Memory Care Program Director/RNResponsible for incident investigation and implementing interventions.

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