Inspection Reports for Auberge at Naperville
1936 Brookdale Rd, Naperville, IL 60563, United States, IL, 60563
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 22, 2025, identified a deficiency related to a medication administration error that caused Vitamin D toxicity and hospitalization. Earlier inspections showed a pattern of issues including inadequate supervision of residents with aggressive behaviors, failure to comply fully with assisted living regulations, and multiple deficiencies involving medication errors, fall and elopement risks, and resident rights violations. Complaint investigations substantiated concerns about medication errors, insufficient fall and elopement interventions, and privacy breaches. No fines or enforcement actions were listed in the available reports. The inspection history indicates ongoing challenges with medication management and resident safety, with no clear improvement trend.
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
Complaint Investigation
Deficiencies: 1
Date: Aug 22, 2025
Visit Reason
The inspection was conducted due to a facility reported incident involving a medication administration error where a resident was given an incorrect dosage of Vitamin D3.
Complaint Details
The complaint investigation was substantiated as the medication error involving resident R1 was confirmed. The resident received 50,000 units daily of Vitamin D3 instead of the prescribed 5,000 units, leading to toxicity and hospitalization.
Findings
The facility failed to prevent an incorrect dosage of medication being administered to a resident, resulting in Vitamin D toxicity and hospitalization. The error was linked to a pharmacy change and inadequate verification by nursing staff. Corrective actions included in-service training and updated medication verification procedures.
Deficiencies (1)
Failure to ensure measures are in place to prevent incorrect dosage of medication being given to a resident, violating resident rights.
Report Facts
Vitamin D3 dosage error: 50000
Vitamin D3 prescribed dosage: 5000
Vitamin D level after incident: 228.8
Vitamin D level prior to incident: 93.4
Days medication error administered: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Confirmed medication error and provided details about pharmacy change and resident condition |
| E2 | Health Services Director | Described corrective actions including nurse training and updated medication verification system |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jan 10, 2025
Visit Reason
Annual Licensure Survey conducted to assess compliance with Alzheimer's and Dementia Programs regulations at the assisted living facility.
Findings
The facility failed to implement adequate interventions to monitor and supervise a resident (R2) exhibiting aggressive behaviors, resulting in another resident (R1) being physically harmed. The service plan for R2 lacked specific interventions for monitoring wandering and aggressive behavior, posing safety risks to residents.
Deficiencies (1)
Failure to implement interventions to monitor/supervise resident R2's aggressive behaviors, leading to injury of resident R1.
Report Facts
Resident age: 91
Resident age: 71
Incident date: Dec 21, 2024
Admission date: Sep 16, 2017
Admission date: Dec 13, 2024
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jan 10, 2025
Visit Reason
The Illinois Department of Public Health conducted an annual licensure survey of the Assisted Living facility to assess compliance with the Assisted Living and Shared Housing Establishment Code.
Findings
The facility did not meet all compliance requirements and was cited with 1 Type 2 Violation. Based on the violation's gravity and compliance history, no fine was imposed. A plan of correction was submitted to address the findings.
Deficiencies (1)
1 Type 2 Violation related to non-compliance with the Assisted Living and Shared Housing Establishment Code
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Edward Pitts | PSA | Attention recipient of the statement of correction and signatory of the letter |
| Linsey Rosland | Executive Director | Author of the plan of correction letter |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Sep 26, 2024
Visit Reason
The inspection was conducted based on multiple complaint investigations and facility reported incidents regarding resident care, medication errors, fall risks, elopement risks, and resident rights violations at the assisted living facility.
Complaint Details
Multiple complaint investigations were partially substantiated or substantiated regarding medication errors, fall risks, elopement risks, and resident rights violations. Specific complaints included failure to report medication errors, inadequate fall and elopement interventions, and privacy breaches.
Findings
The facility failed to report a medication error requiring emergency attention, did not update or implement adequate fall and elopement interventions in residents' service plans, failed to ensure residents received specified services such as dental hygiene, and violated resident privacy by sharing care information inappropriately. These failures resulted in resident harm including hospitalizations, falls, elopement incidents, and death.
Deficiencies (4)
Failed to report a medication error to the Department involving a resident requiring emergency medical attention.
Failed to develop and update individualized service plans with fall interventions for residents at risk, contributing to multiple falls, injuries, hospitalizations, and death.
Failed to implement policies and procedures ensuring safety of residents at high risk for elopement, resulting in residents leaving the building unsupervised.
Failed to ensure residents received services specified in their service plans related to dental hygiene and failed to maintain resident privacy regarding care information.
Report Facts
Residents referenced: 13
Unsigned dental hygiene log days: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Abeba Eshetu | Charge Nurse | Named in medication error finding where she administered discontinued medication. |
| Lisa | Nurse Practitioner | Made aware of resident R5's fall and hospital transfer. |
| Christine | POA | Made aware of resident R11's fall and hospital transfer. |
| E1 | Executive Director | Provided multiple interviews and confirmations regarding incidents, policies, and resident care failures. |
| E4 | LPN | Mentioned in medication error incident involving resident R10. |
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