Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 28, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse, neglect, and financial exploitation at the facility.
Findings
The facility failed to submit the final written abuse allegation investigation report to the department within 14 days of the initial report, affecting one resident. The initial report was sent on 2025-07-24, but the final report was not submitted as of 2025-08-26.
Complaint Details
The complaint investigation was substantiated for one incident (IL00188725) with no deficiency cited, and unsubstantiated for another (IL00196925) with a citation under 295.6010. The deficiency involved failure to timely submit the abuse investigation report.
Deficiencies (1)
| Description |
|---|
| Failure to submit the final written abuse allegation investigation report to the department within 14 days of the initial report. |
Report Facts
Days to submit final report: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Stated on 2025-08-26 that the investigation was completed but the final report was not sent to the department. |
Inspection Report
Annual Inspection
Deficiencies: 4
Jul 15, 2025
Visit Reason
Annual Survey conducted from 7/9/25 to 7/15/25 to assess compliance with state regulations for assisted living and memory care units.
Findings
The facility was found deficient in multiple areas including disaster preparedness orientation for residents, service plan development and updates, dementia-specific staff training, and medication storage and administration practices. Several residents' service plans lacked required updates and signatures, staff failed to complete mandatory dementia training, and medication errors were identified involving unattended medications and failure to administer as ordered.
Deficiencies (4)
| Description |
|---|
| Failed to ensure that 4 residents and their responsible parties received orientation on emergency evacuation with signed documentation. |
| Failed to revise service plans to address unwitnessed falls, include physical therapy details, and ensure plans were signed and dated by residents or POA. |
| Failed to ensure five newly hired direct care employees and one non-direct employee completed required dementia-specific orientation training prior to assuming job responsibilities. |
| Failed to ensure oral medications were stored in a locked medication cart inaccessible to residents and failed to administer medications as ordered for 2 residents. |
Report Facts
Residents reviewed for falls: 4
Newly hired employees reviewed: 8
Residents reviewed for medication errors: 2
Medication error date: Mar 16, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E10 | Resident Service Director / RN Resident Care Director | Involved in resident orientation and medication error investigation |
| E11 | Maintenance Director | Meets with new residents and families to show fire safety instructions |
| E12 | Licensed Practical Nurse (LPN) | Left medications unattended and failed to administer medications as ordered, resulting in termination |
| E13 | Human Resources Manager | Provided personnel files and could not explain missing dementia training documentation |
Inspection Report
Annual Inspection
Deficiencies: 4
Jul 15, 2025
Visit Reason
The Illinois Department of Public Health conducted an annual survey of Arbor Terrace Naperville on 7/15/2025 to assess compliance with the Assisted Living and Shared Housing Establishment Code Section 295.
Findings
The establishment did not meet all compliance requirements, resulting in multiple general violations related to disaster preparedness, service plans, Alzheimer's and dementia programs, and medication reminders. A total fine of $3,500 was imposed.
Severity Breakdown
General Violation: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to orient each resident to emergency and evacuation plans within 10 days after arrival, including documentation of signatures. | General Violation |
| Failure to revise service plans with interventions addressing unwitnessed falls and to include required signatures and dates. | General Violation |
| Failure to provide required dementia-specific orientation and training for newly hired direct care employees. | General Violation |
| Failure to store medications securely and maintain proper medication administration records; medication errors found. | General Violation |
Report Facts
Fine amount: 3500
Number of residents affected by disaster preparedness deficiency: 4
Number of newly hired employees lacking dementia training: 5
Number of residents reviewed for medication errors: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Cerny | Executive Director | Signed letter regarding survey results and plan of correction |
| E10 | Resident Service Director / RN / Resident Care Director | Involved in resident orientation and medication error investigation |
| E11 | Maintenance Director | Met with new residents and family to show fire safety instructions |
| E12 | Nurse | Left several medications unattended, involved in medication error |
| E13 | Human Resources Manager | Personnel files reviewed for newly hired employees |
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