Inspection Report
Plan of Correction
Deficiencies: 0
Oct 30, 2025
Visit Reason
Investigation of facility reported incidents on 9/5/25 and 10/19/25, including follow-up on a previously investigated incident with a cited violation and a subsequent incident with no violations.
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. One prior incident had a violation cited, while the later incident had no violations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 21, 2025
Visit Reason
Complaint investigation conducted for case number 2579737/IL197907 to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living regulations and administrative codes during this complaint investigation.
Complaint Details
Complaint investigation case number 2579737/IL197907; the establishment was found compliant.
Inspection Report
Complaint Investigation
Deficiencies: 4
Sep 26, 2025
Visit Reason
Complaint investigation survey conducted due to concerns about resident safety, supervision, and care related to elopement and fall incidents.
Findings
The facility failed to follow and implement service plans for residents at risk of elopement and falls, resulting in a resident (R4) eloping from a locked memory care unit and another resident (R2) sustaining multiple unwitnessed falls. The facility also failed to provide adequate supervision, sufficient staffing, and did not report or investigate the elopement incident as required.
Complaint Details
Complaint investigation survey #2578539/IL#197393 focused on allegations of neglect related to resident elopement and fall incidents. The investigation confirmed failures in supervision, safety interventions, staffing, and reporting requirements.
Severity Breakdown
Type 2 Violation: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to follow and implement R4's service plan to provide supervision and conduct visual checks, resulting in elopement from a locked memory care unit. | Type 2 Violation |
| Failure to conduct personalized fall risk assessment, develop fall prevention plan, and implement monitoring for R2, resulting in multiple unwitnessed falls and decline in mobility. | Type 2 Violation |
| Failure to provide adequate supervision and monitoring to R4, provide secure environment, and sufficient staffing to prevent elopement. | Type 2 Violation |
| Failure to submit a written report and conduct investigation of R4's elopement incident within required timeframes. | Type 2 Violation |
Report Facts
Unwitnessed falls: 10
Unwitnessed falls: 3
Resident census: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Confirmed R4's elopement risk and lack of reporting; provided statements about incident |
| E2 | Area Resident Care Director/RN | Confirmed R4's elopement risk and lack of reporting; provided statements about incident and resident conditions |
| E4 | Sales Director | Found R4 in parking lot after elopement and returned resident to unit |
| E5 | Concierge | Reported not being at desk during elopement incident and unaware resident was missing |
| E8 | Lead Care Manager - second shift | Reported staffing shortages and lack of monitoring contributing to elopement |
| E9 | LPN | Reported staffing shortages and lack of awareness of resident elopement |
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 29, 2024
Visit Reason
Annual Licensure survey conducted to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable Illinois Assisted Living and Shared Housing regulations during the annual licensure survey.
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