Inspection Reports for Grace Point Place Memory Care
5701 W 101st St, Oak Lawn, IL 60453, United States, IL, 60453
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 12, 2025, found deficiencies related to the facility’s failure to update a resident’s service plan to prevent further falls, which resulted in severe harm. Earlier inspections identified issues with updating service plans, resident safety including fall and elopement prevention, emergency preparedness such as fire and tornado drills, and compliance with hospice and Alzheimer’s program requirements. Complaint investigations included both substantiated and unsubstantiated findings, with the most notable substantiated case involving harm from inadequate fall prevention interventions. Enforcement actions such as fines or license suspensions were not listed in the available reports. The inspection history shows ongoing challenges with service plan updates and resident safety, with no clear pattern of improvement over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
114% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation survey related to failure to update a resident's service plan and add interventions to prevent further falls.
Complaint Details
The complaint investigation found that the facility did not revise the service plan immediately after significant changes in the resident's condition, despite multiple falls including one resulting in a hip fracture. The failure was substantiated as causing severe harm.
Findings
The facility failed to update the service plan for one resident (R1) who had multiple falls, including a fall resulting in a left hip fracture. The service plan was last reviewed before the falls and did not include interventions to prevent further falls, causing severe harm to the resident.
Deficiencies (1)
Failure to update a resident's service plan and add interventions to prevent further falls.
Report Facts
Number of falls: 3
Date of last service plan review: May 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | E3 stated that service plans should be updated after each fall and described the resident's fall circumstances. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 19, 2025
Visit Reason
Annual Licensure Survey conducted including a complaint investigation which was unsubstantiated.
Complaint Details
Complaint investigation IL00191511/2593873 was unsubstantiated.
Findings
The facility failed to meet residency requirements for four residents admitted to hospice services, failed to orient six residents to emergency and evacuation plans within 10 days of admission, failed to conduct required fire and tornado drills, and failed to adequately address hospice services in the service plans for three residents.
Deficiencies (3)
Failed to ensure residents were adequately assessed for residency requirements for 4 residents admitted to hospice services.
Failed to ensure residents were oriented to emergency and evacuation plans within 10 days of admission for six residents and failed to ensure fire and tornado drills were conducted as required.
Failed to address hospice services adequately in the service plans for three residents, lacking interventions and responsible staff identification.
Report Facts
Residents not adequately assessed for residency requirements: 4
Residents not oriented to emergency and evacuation plans within 10 days: 6
Residents with hospice services not adequately addressed in service plans: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Management (E3) | Not aware that resident did not meet residency requirements; stated service plans are updated with changes including hospice care. | |
| Executive Director (E1) | Stated no resident orientation is done because this is memory care; stated fire and tornado drills are done monthly but failed to provide documentation. | |
| Maintenance Management (E14) | Provided state binder with fire and tornado drill records. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: May 19, 2025
Visit Reason
The visit was conducted as an Annual Licensure Survey combined with a Complaint Investigation to assess compliance with Assisted Living and Shared Housing Establishment Code requirements.
Complaint Details
The inspection included a complaint investigation as indicated by the report title and content, but substantiation status is not explicitly stated.
Findings
The facility failed to meet residency requirements for four residents admitted to hospice services, did not ensure residents were oriented to emergency and evacuation plans within 10 days, and failed to update service plans for hospice services for three residents. Three violations were identified and a Plan of Correction was provided.
Deficiencies (3)
Failed to ensure residents were adequately assessed for Residency requirements for 4 residents admitted to hospice services.
Failed to ensure residents were oriented to the emergency and evacuation plan within 10 days of moving into the establishment for six residents and failed to ensure Fire and Tornado drills were conducted as required.
Failed to address in the service plan hospice services for three residents; deficient practices involved all residents reviewed for service plan.
Report Facts
Number of violations identified: 3
Residents affected - residency requirements: 4
Residents affected - emergency orientation: 6
Residents affected - service plan: 3
Plan of Correction completion date: Jul 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie McGregor | Executive Director | Signed Plan of Correction letter. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 16, 2025
Visit Reason
The inspection was conducted as a complaint investigation survey related to multiple complaint investigations and facility reported incidents, including substantiated and not substantiated complaints.
Complaint Details
Complaint Investigation Survey included IL179945/2498781 and IL180105/2498900 which were not substantiated. Facility Reported Incidents IL180065, IL183003, IL183159, and IL183651 were substantiated.
Findings
The facility was found deficient in updating and individualizing fall interventions for a resident (R5), failure to follow safety measures to prevent elopement resulting in a resident exiting a secured area, and failure to maintain a means of unlocking a bathroom door to provide immediate assistance to a resident who fell inside the bathroom.
Deficiencies (3)
Failed to ensure fall interventions are updated and individualized for one resident (R5) reviewed for fall.
Failed to follow safety measures to prevent elopement, resulting in one resident (R5) exiting a secured area.
Failed to maintain a means of unlocking all doors, specifically no key to unlock bathroom door to provide immediate assistance for one resident (R2) who had a fall inside the bathroom.
Report Facts
Resident age: 79
Resident age: 101
Incident dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clinical Services Director | E2 interviewed regarding fall interventions and elopement incident | |
| Receptionist | E4 involved in elopement incident and interviewed about door monitoring | |
| Receptionist | E6 showed camera feeds and described door monitoring procedures | |
| E5 opened bathroom door with key during inspection |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Oct 23, 2024
Visit Reason
Annual licensure survey conducted to assess compliance with Illinois Department of Public Health regulations for assisted living facilities.
Findings
The facility failed to conduct required fire and tornado drills including resident participation, failed to adequately supervise and monitor residents at high risk for falls and elopement, failed to ensure physician assessments were completed timely and by a physician, and failed to develop and update service plans appropriately including elopement prevention and behavior interventions. The facility also failed to comply with Alzheimer's and Dementia program requirements including preventing elopement from a locked facility.
Deficiencies (5)
Failed to conduct required fire and tornado drills including resident participation.
Failed to have sufficient personnel to supervise and monitor residents at high risk for falls and elopement.
Failed to ensure physician assessments were completed 120 days prior to admission and by a physician for some residents.
Failed to develop and update service plans including interventions for falls, elopement, and behavior concerns; service plans not signed and dated by all involved.
Failed to comply with Alzheimer's and Dementia program requirements including preventing elopement from a locked facility and ensuring adequate staffing and training.
Report Facts
Fire drills conducted: 6
Tornado drills conducted: 4
Fall Risk Assessment Score: 21
Elopement Risk Assessment Score: 11
Elopement Risk Assessment Score: 9
Elopement Risk Assessment Score: 12
Elopement Risk Assessment Score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Provided information on fire and tornado drill frequency and staff involved in elopement incidents |
| E34 | Community Relations Director | Observed resident elopement and provided statements about resident supervision |
| E22 | Assistant Clinical Service Director | Provided list of staff during elopement incidents and information on service plan updates |
| E23 | Caregiver | Observed resident in male resident's room and redirected resident |
| E24 | Licensed Practical Nurse | Documented resident aggressive behavior |
| E27 | Caregiver | Reported resident wandering into other resident's rooms |
| E29 | Caregiver | Reported resident wandering and inappropriate sexual behavior |
| E32 | Licensed Practical Nurse | Reported resident wandering into other resident's rooms |
| E15 | Caregiver | Reported resident wandering during night and entering other resident's rooms |
Viewing
Loading inspection reports...
