Inspection Reports for Three Oaks Assisted Living and Memory Care
1055 Silver Lake Rd, Cary, IL 60013, United States, IL, 60013
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 30, 2025, found deficiencies related to service plans not being signed by a registered nurse or resident representative, not being revised as resident needs changed, and lacking details on health-related services. Earlier inspections also noted issues with service plan updates, including failure to address fall interventions and toileting care, as well as involvement of residents and nurses in plan development. A substantiated complaint investigation in September 2025 identified a failure to prevent the elopement of a memory care resident due to inadequate safety policies and staff checks. Enforcement actions such as fines or license suspensions were not listed in the available reports. The pattern of deficiencies primarily involves service plan documentation and resident safety, with no clear improvement trend over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
3.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Sep 30, 2025
Visit Reason
Annual Licensure Survey conducted on 9/30/2025 to assess compliance with service plan requirements for residents.
Findings
The establishment failed to ensure that service plans were signed by a registered nurse and the resident or resident representative, were revised as the resident's service needs changed, and addressed the amount, type, and frequency of health-related services. These deficiencies affected 7 of 8 residents reviewed.
Deficiencies (1)
Service plans were not signed by a registered nurse and the resident or resident representative, were not revised as resident needs changed, and did not address the amount, type, and frequency of health-related services.
Report Facts
Residents reviewed: 8
Residents with deficiencies: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing, LPN | Interviewed regarding therapy services and nursing licenses; noted not to be a registered nurse |
| E3 | Director of Resident Care, LPN | Signed service plans without being a registered nurse; noted not to be a registered nurse |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 28, 2025
Visit Reason
The inspection was conducted as an original investigation following a complaint regarding the facility's failure to prevent the elopement of a memory care resident.
Complaint Details
The visit was complaint-related due to an elopement incident involving resident R1. The complaint was substantiated based on observation, record review, and interviews confirming the elopement and failure of staff to perform required safety checks.
Findings
The facility failed to prevent the elopement of one memory care resident due to a courtyard gate that became unalarmed during a scheduled system switch, allowing the resident to exit undetected. Staff failed to perform required checks at the time of the gate transition, creating a substantial probability of harm.
Deficiencies (1)
Failure to develop and implement policies and procedures ensuring the continued safety of residents who may wander, resulting in elopement of a memory care resident.
Report Facts
Distance of elopement: 450
Date of elopement incident: Aug 19, 2025
Time of elopement incident: 1800
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Observed resident outside facility and escorted resident back to Memory Care unit; identified as E1 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 18, 2025
Visit Reason
The inspection was conducted as a complaint investigation following facility-reported incidents dated 6/22/25 and related complaint numbers regarding service plan deficiencies.
Complaint Details
Complaint investigation triggered by facility-reported incidents dated 6/22/25 and related complaint numbers IL195361, IL193774, and IL193823. The investigation found the service plan regulation was not met for two residents.
Findings
The facility failed to ensure that service plans were reviewed and revised to address fall interventions and toileting/incontinence care for residents. Specifically, two residents (R1 and R2) had multiple falls or incontinence issues that were not properly reflected or updated in their service plans.
Deficiencies (2)
Failure to review and revise service plan fall interventions for resident R1 despite multiple falls.
Failure to update service plan for resident R2 who requires assistance with toileting/incontinence care after catheter removal.
Report Facts
Resident sample size: 4
Residents with service plan deficiencies: 2
Resident age: 94
Date of incident: Jun 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Clinical Services | E2 acknowledged the need to review and revise R1's service plan and confirmed R2's care plan was not updated | |
| Resident Assistant | E5 stated she was not aware of R2's incontinence and had not checked on her wetness | |
| Licensed Practical Nurse | E7 noted R2's declining condition and need for assistance with toileting but had not checked on her yet |
Inspection Report
Deficiencies: 0
Date: Feb 19, 2025
Visit Reason
Investigation IL00184255, IL00185435, IL00185472, & IL00185942 conducted on 2/19/2025.
Findings
For this survey, the establishment is 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
Annual Inspection
Deficiencies: 3
Date: Oct 1, 2024
Visit Reason
Annual survey conducted on 10/01/2024 to assess compliance with service plan regulations at Three Oaks Assisted Living.
Findings
The facility failed to update service plans with the amount, type, and frequency of health-related services needed by residents, did not include a registered nurse in the development of service plans, and failed to involve residents or their representatives in the development of service plans for 7 of 7 residents reviewed.
Deficiencies (3)
Failed to update service plans with amount, type, and frequency of health-related services needed by the resident.
Failed to include a registered nurse in the development of service plans.
Failed to involve residents or resident representatives in the development of service plans.
Report Facts
Residents reviewed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Director of Nursing | Interviewed regarding unsigned service plans and resident therapy start dates |
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