Inspection Reports for Brighton Gardens of Wheaton
831 Butterfield Rd, Wheaton, IL 60189, United States, IL, 60189
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Inspection Report
Plan of Correction
Deficiencies: 1
Oct 28, 2025
Visit Reason
The inspection was conducted following a facility-reported incident on 7/30/2025 related to service plan deficiencies for a resident exhibiting hoarding behaviors.
Findings
The facility failed to implement and revise the service plan for a resident (R1) with hoarding behaviors, resulting in a substantial probability of harm. The resident's service plan did not address her hoarding behavior despite multiple documented incidents and staff attempts to manage the situation.
Severity Breakdown
Type 2 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement and revise the service plan for a resident with hoarding behaviors, including lack of updated interventions and failure to address the behavior in the service plan. | Type 2 Violation |
Report Facts
Incident date: Jul 30, 2025
Resident move-in date: Feb 3, 2024
Care conference date: Jan 27, 2025
Psychiatry follow-up date: Jun 24, 2024
Policy revision date: May 15, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Provided information about resident's hoarding behavior and service plan deficiencies |
| E2 | Previous Resident Care Director/Director of Nursing | Discussed resident's hoarding tendencies and need for service plan updates |
| E3 | Resident Care Director/Director of Nursing | Commented on importance of including hoarding behavior in service plan |
| E4 | Assisted Living Coordinator | Described resident's clutter and refusal of care |
| E5 | Lead Care Manager | Reported on resident's hygiene issues and cleaning challenges |
| E6 | Care Manager | Described ongoing issues with resident's hoarding behavior and cleaning efforts |
Inspection Report
Annual Inspection
Deficiencies: 3
May 22, 2025
Visit Reason
Annual Licensure Survey conducted on 5/22/25 to assess compliance with personnel requirements, health care worker background checks, and Alzheimer's and dementia program regulations.
Findings
The facility was found deficient in multiple areas including failure to ensure all nurses had current CPR certification, lack of contingency plans for CPR-certified staff during night shifts, failure to comply with health care worker background check requirements, and inadequate dementia-specific supervised training for memory care staff.
Severity Breakdown
Type 3 Violation: 2
Type 2 Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure all nurses have valid CPR certificates on file and failed to ensure at least one CPR-certified staff is present during night shifts when no nurse is on duty. | Type 3 Violation |
| Failed to comply with Health Care Worker Background Check Act including lack of access to Registry Portal, failure to conduct employment verification, failure to initiate fingerprinting prior to employment, failure to conduct required internet searches, and failure to check eligibility prior to hire for multiple employees. | Type 2 Violation |
| Failed to ensure documented dementia-specific supervised training was completed within the first 16 hours of employment for two memory care employees. | Type 3 Violation |
Report Facts
Number of employees reviewed for personnel requirements: 6
Number of employees without current CPR certificates: 6
Number of memory care employees without documented supervised training: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Mentioned in relation to planning CPR training for Care Managers and organizing employee files for supervised training documentation |
| E2 | Resident Care Assistant | Interviewed about night shift CPR-certified staff contingency |
| E3 | Food Service Supervisor | Reviewed for background check compliance |
| E5 | Care Manager - Memory Care | Lacked documented dementia-specific supervised training and background check compliance |
| E6 | Care Manager - Memory Care | Lacked documented dementia-specific supervised training and background check compliance |
| E7 | Care Manager | Background check not completed, fingerprinting not done, sent home |
| E8 | Care Manager | Background check compliance issues |
| E9 | Care Manager | Background check delayed, eligibility checked late |
| E12 | Licensed Practical Nurse (LPN) | No current CPR certificate |
| E19 | Business Office Manager | Informed about background check status of E7 and E9, confirmed lack of Registry Portal access |
Inspection Report
Annual Inspection
Deficiencies: 3
May 22, 2025
Visit Reason
The Illinois Department of Public Health conducted an annual licensure survey on May 22, 2025, to determine compliance with the Assisted Living and Shared Housing Establishment Code Section 295.
Findings
The facility did not meet compliance requirements related to personnel qualifications and training, health care worker background checks, and Alzheimer's and dementia programs. A $500 fine was imposed, and a plan of correction was submitted addressing CPR certification, background checks, and dementia training.
Severity Breakdown
Type 3 Violation: 2
Type 2 Violation: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure all nurses have current CPR certification and to have at least one CPR certified staff present during the night shift. | Type 3 Violation |
| Failure to comply with Health Care Worker Background Check requirements, including fingerprinting, employment verification, and internet searches. | Type 2 Violation |
| Failure to ensure direct care staff received 16 hours of supervised dementia-specific training within the first 16 hours of employment. | Type 3 Violation |
Report Facts
Fine amount: 500
Date of survey: May 22, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Executive Director | Signed the Plan of Correction and mentioned as retraining coordinator for CPR certification and health care worker registry. |
| E2 | Staff nurse without current CPR certification; mentioned in findings. | |
| E3 | Food Service Supervisor | Employee file reviewed; failed to meet background check requirements. |
| E5 | Care Manager | Employee file reviewed; failed to meet background check and dementia training requirements. |
| E6 | Care Manager | Employee file reviewed; failed to meet background check and dementia training requirements. |
| E7 | Care Manager | Employee file reviewed; failed to meet background check requirements. |
| E8 | Care Manager | Employee file reviewed; failed to meet background check requirements. |
| E9 | Care Manager | Employee file reviewed; failed to meet background check requirements. |
| E19 | Business Office Manager | Informed about staff eligibility and background check issues. |
| E1 | Executive Director | Mentioned as organizing employee files and responding to surveyor requests. |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 9, 2025
Visit Reason
The inspection was conducted as a complaint investigation survey to determine compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living regulations and administrative codes during this complaint investigation survey.
Complaint Details
Complaint Investigation Survey IL191870; establishment found in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 3
Feb 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of verbal abuse from an employee towards a resident.
Findings
The establishment failed to report the verbal abuse allegation within the required timeframe, failed to send the final written report within 14 days, and did not follow their Abuse Policy regarding physician and POA notification. The internal investigation found the allegation unsubstantiated due to the resident's cognitive deficit, but the establishment did not fully comply with required procedures and training.
Complaint Details
The complaint investigation was substantiated in part; the allegation of verbal abuse was not substantiated, but the establishment failed to timely report the allegation and failed to comply with required policies and procedures.
Severity Breakdown
Type 3 Violation: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to report an allegation of verbal abuse from an employee towards a resident within the required timeframe and failed to send the final written report within 14 days after the initial report. | Type 3 Violation |
| Failed to follow Abuse Policy regarding physician and POA notification about the abuse allegation incident. | Type 3 Violation |
| Failed to follow performance improvement plan for the employee involved in the alleged abuse, including lack of documented in-service/re-education. | Type 3 Violation |
Report Facts
Days late for initial report: 2
Days late for final report: 32
Resident age: 89
Date of resident admission: Jun 21, 2024
Date of in-service training: Jan 25, 2025
Date of performance improvement plan: Feb 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E4 | Care Manager | Employee alleged to have verbally abused resident and subject of performance improvement plan. |
| E3 | Care Manager | Employee who reported witnessing the alleged verbal abuse. |
| E1 | Executive Director | Provided information regarding the investigation and acknowledged failures in reporting and training. |
| E2 | REM/MC Coordinator | Provided explanation for delayed reporting and confirmed plans for employee training. |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 18, 2025
Visit Reason
This document is a plan of correction submitted in response to a regulatory inspection related to abuse, neglect, and financial exploitation prevention and reporting at Brighton Gardens of Wheaton.
Findings
The plan of correction addresses concerns related to abuse, neglect, and financial exploitation, including the termination of an employee involved, retraining of staff on abuse prevention policies, and implementation of ongoing monitoring and audits to ensure compliance.
Deficiencies (1)
| Description |
|---|
| Abuse, neglect, and financial exploitation prevention and reporting deficiencies |
Report Facts
Inspection date: Feb 18, 2025
Plan of correction target dates: Apr 11, 2025
Plan of correction target dates: Apr 23, 2025
Plan of correction target dates: Apr 30, 2025
Audit period: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Karlinski | Executive Director | Named as legal entity representative signing the plan of correction and responsible for reporting compliance |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation following an allegation of verbal abuse by a care manager (E3) towards a resident (R1) on November 15, 2024.
Findings
The investigation confirmed that the care manager verbally abused the resident, causing emotional distress. The care manager's employment was terminated as a result of the findings.
Complaint Details
The complaint was substantiated based on resident and staff interviews and internal investigation. The care manager was found verbally abusive and was terminated.
Deficiencies (1)
| Description |
|---|
| Failed to prevent verbal abuse of one resident by a care manager. |
Report Facts
Date of incident: Nov 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Caregiver/Care Manager | Named in verbal abuse finding and subsequent termination |
| E2 | Resident Care Director R.N. | Confirmed investigation findings and termination of E3 |
| E4 | Nurse | Responded to resident after incident |
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