Inspection Report Summary
The most recent inspection on October 22, 2025, identified deficiencies related to failure to follow a resident’s service plan requiring escort and monitoring device use for elopement risk. Earlier inspections also noted issues with ensuring residents remained appropriate for assisted living placement after cognitive decline, failure to implement effective interventions to prevent elopement, and incomplete adherence to service plans. Prior reports cited deficiencies in incident reporting, fall risk assessment, and service plan updates, with some repeat violations in these areas. Complaint investigations included substantiated findings related to elopement and service plan noncompliance, while other complaints were substantiated without deficiencies cited. The inspection history shows ongoing challenges with resident safety and service plan compliance, with recent efforts including resident transitions and staff training to address these concerns.
Deficiencies (last 1 years)
Deficiencies (over 1 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
214% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 22, 2025
Visit Reason
The inspection was conducted as an investigation of a facility-reported incident involving a resident at risk for elopement, specifically related to failure to follow the resident's service plan and ensure monitoring device use.
Complaint Details
Investigation of Facility Reported Incident of 10/8/25/IL198048-substantiated.
Findings
The facility failed to follow the service plan for one resident (R1) who required escort and monitoring due to elopement risk. The resident was found outside unsupervised without his monitoring device on two occasions, creating a substantial probability of harm. Staff failed to report and properly supervise the resident as required.
Deficiencies (1)
Failure to follow a resident's service plan requiring escort and monitoring device use for elopement risk.
Report Facts
Incident dates: 2
Time of incident: 1500
Time of incident: 634
Time of staff notification: 630
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Transporter | E7 escorted resident back to facility after elopement | |
| Care Associate | E5 escorted resident and admitted to letting resident walk unsupervised | |
| Wellness Director | E2 provided information about resident's wanderguard and supervision needs | |
| V2 stated resident did not have wanderguard on during elopement incidents |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 25, 2025
Visit Reason
The inspection was conducted as an entity reported incident survey related to a complaint identified as IL197053.
Complaint Details
Complaint IL197053 was substantiated, but no deficiencies were cited.
Findings
The complaint was substantiated, but no deficiencies were cited. The establishment 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.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 13, 2025
Visit Reason
The inspection was conducted following complaints and incident investigations related to resident safety and care at Carrington at Lincolnwood, specifically concerning elopement and failure to follow service plans.
Complaint Details
The complaint investigation was triggered by incidents involving resident R1 eloping from the facility and being found by police, and resident R2 not being assisted to bed as per her service plan. The investigation included interviews, record reviews, and observations confirming these issues.
Findings
The facility failed to ensure that a resident (R1) remained appropriate for placement in the assisted living unit after a significant decline in cognition and behaviors, resulting in elopement incidents. Additionally, the facility failed to provide care in accordance with another resident's (R2) service plan, including failure to assist with bedtime routines. These failures posed substantial risks to resident safety and care.
Deficiencies (3)
Failure to ensure a resident remained appropriate for placement in assisted living after cognitive decline, leading to elopement and safety risks.
Failure to have effective interventions to prevent a resident from leaving the facility unsupervised despite assessed supervision needs.
Failure to provide care in accordance with a resident's service plan, including assistance with bedtime routines.
Report Facts
Incident date: Jul 1, 2025
Incident date: Jun 8, 2025
Resident age: 74
Resident age: 92
Morse Fall Scale score: 80
Elopement risk screening date: Aug 28, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Confirmed resident R1 needs to be transitioned to memory care unit |
| E2 | Health & Wellness Director | Provided information on resident R1's elopement and care plan |
| E3 | Nurse Manager | Reported on incident involving resident R2 not being assisted to bed and staff disciplinary actions |
| E4 | Physician | Recommended resident R1 transition to memory care due to cognitive decline and elopement risk |
| E5 | LPN | Confirmed resident R1's elopement risks and monitoring bracelet limitations |
| E6 | CNA | Described care needs of resident R2 |
| E7 | LPN | Confirmed staff adherence to resident R2's care plan and routine |
| E10 | CNA | Monitored resident R1 and described safety concerns |
| E11 | CNA | Reported on monitoring needs and behaviors of resident R1 |
| E12 | Concierge | Described elopement binder and door access procedures |
| E13 | CNA | Failed to provide care to resident R2 as assigned, resulting in termination |
| E14 | LPN | Involved in incident with resident R2 and terminated |
| E15 | CNA Supervisor/Scheduler | Reported on staffing and incident involving resident R2 |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jul 13, 2025
Visit Reason
The document is a Statement of Violation and Plan of Correction following an Illinois Department of Public Health Incident Investigation Survey conducted on July 13, 2025, related to residency requirements and service plan violations at The Carrington at Lincolnwood.
Findings
The facility failed to meet residency requirements for a resident who eloped and was no longer safe in the assisted living unit, and failed to have an effective service plan to prevent elopement and ensure resident safety. The resident was transitioned to a Memory Care setting with appropriate support. The facility implemented interventions including elopement inservice training, hourly safety checks, and use of a wanderguard bracelet.
Deficiencies (2)
Failure to ensure a resident remained appropriate for placement in the assisted living unit after a significant change in condition leading to cognitive decline and unsafe behaviors, resulting in elopement.
Failure to develop and implement an effective service plan based on physician assessment and resident evaluation, including failure to prevent resident elopement and ensure supervision.
Report Facts
Incident date: Jul 1, 2025
Target date for correction: Sep 30, 2025
Resident age: 74
Resident age: 92
Number of residents reviewed: 3
Number of residents reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Health & Wellness | Director of Health & Wellness | Responsible party for statement of correction and involved in findings |
| Executive Director | Executive Director | Responsible party for statement of correction and involved in findings |
| CNA Supervisor | CNA Supervisor | Involved in resident care and findings related to elopement |
| Nurse On Duty | Nurse On Duty | Involved in resident supervision and reporting during elopement incident |
| Daughter | Resident's daughter involved in care decisions and communication | |
| POA | Power of Attorney for resident involved in care decisions |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 23, 2025
Visit Reason
Annual Licensure Survey conducted to assess compliance with Illinois Department of Public Health regulations for assisted living facilities.
Findings
The facility was found to have repeat violations related to incident and accident reporting and service plan development. Specifically, the facility failed to provide documentation of reporting a serious fall incident to the Illinois Department of Public Health, did not complete required post-fall assessments or implement measurable fall interventions, and failed to update the resident's service plan to address significant weight loss and nutritional concerns.
Deficiencies (3)
Failed to provide documentation showing fall accident/incident of 2/4/25 was forwarded to the Illinois Department of Public Health as required.
Failed to develop and implement fall interventions based on fall risk assessment factors and investigation to mitigate the risk of a fall with injury.
Failed to update service plan for continued significant weight loss and obtain signature from resident's Power of Attorney for the current service plan.
Report Facts
Weight loss: 18.2
Fall incidents reviewed: 3
Fall assessment score: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing | Named in relation to failure to confirm reportable incident documentation and service plan updates. |
| E3 | Licensed Practical Nurse | Provided information about resident R1's condition and fall risk. |
| Z1 | Attending Physician | Provided clinical notes regarding resident R1's weight. |
| Z2 | Nurse Practitioner | Documented health concerns related to resident R1's appetite. |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Apr 23, 2025
Visit Reason
The document is an Annual Licensure Survey for The Carrington of Lincolnwood, conducted by the Illinois Department of Public Health on 04/23/25, to assess compliance with state regulations including incident and accident reporting and service plan requirements.
Findings
The facility was found to have repeat violations related to incident and accident reporting and service plan development. Specifically, the facility failed to provide documentation of a fall incident on 2/4/25 to the Illinois Department of Public Health and did not fully comply with fall risk assessment and service plan update requirements for a resident who had a fall and significant weight loss.
Deficiencies (2)
Failed to provide documentation showing fall accident/incident of 2/4/25 was forwarded to Illinois Department of Public Health as required for 1 resident out of 3 reviewed.
Failed to develop and implement fall interventions based on fall risk assessment and investigation to mitigate risk of fall with injury; incomplete fall assessments and missing components of fall assessment documentation.
Report Facts
Fine amount: 1000
Residents reviewed: 3
Resident weight loss: 18.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Renvi Carreon | Director of Health & Wellness | Named in letter disputing deficiency and responsible party for corrective actions |
| E2 | Director of Nursing | Named in findings related to incident reporting and fall assessments |
| E3 | Licensed Practical Nurse | Provided observations related to resident R1's cognitive and physical status |
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