Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 14, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to medication reminders, supervision of self-medication, medication administration, and storage.
Findings
The facility failed to ensure a resident's medications were administered according to physician's orders, affecting 1 of 3 residents reviewed. Specific issues included missed doses, unavailable eye drops, and improper medication administration practices.
Complaint Details
Complaint Investigation 2579692/IL00197886 regarding medication reminders, supervision of self-medication, medication administration, and storage. The complaint was substantiated with findings of medication administration failures.
Severity Breakdown
Type 2 violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a resident's medications were administered according to physician's orders, including missed doses and unavailable medications. | Type 2 violation |
Report Facts
Residents reviewed for medication administration: 3
Resident affected: 1
Medications scheduled for R3: 7
Medication administration times: Scheduled times from 05:00 AM - 10:59 AM, 11:00 AM - 03:59 PM, and 04:00 PM - 07:59 PM
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | E3 prepared and administered medications to resident R3 | |
| Director of Healthcare | E2 provided information about medication delivery and inventory processes |
Inspection Report
Annual Inspection
Deficiencies: 6
Jul 23, 2025
Visit Reason
Annual Licensure Survey and complaint investigation #2575836 / IL195367 were conducted to assess compliance with state regulations for the assisted living facility.
Findings
The facility was found deficient in multiple areas including failure to conduct tornado drills on each shift in February, inadequate CPR certification among direct care staff, incomplete and unsigned service plans lacking resident/representative involvement, insufficient dementia training for management, and failure to disclose a meal delivery charge in the contract.
Complaint Details
Complaint investigation #2575836 / IL195367 was initiated based on concerns including failure to involve resident representatives in service plan development and undisclosed meal delivery charges.
Severity Breakdown
Type 3 Violation: 1
Type 2 Violation: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to conduct tornado drills on each shift during February and failure to document resident assistance during evacuation. | — |
| Failure to ensure at least one direct care staff person on duty at all times with current CPR certification including demonstration of ability. | — |
| Service plans were not developed with resident/representative involvement, were unsigned, not reviewed or updated after falls, and did not address level of assist, medication needs, or special accommodations. | — |
| Failure to ensure manager and direct care staff completed required annual dementia/Alzheimer's training. | Type 3 Violation |
| Failure to ensure resident rights including involvement of resident/representative in service plan development and provision of 30-day notice for fee changes. | Type 2 Violation |
| Failure to disclose five-dollar meal delivery charge in the assisted living contract and failure to provide written notice to residents/families. | — |
Report Facts
Employees without current CPR certification: 5
Residents reviewed for service plans: 7
Residents lacking representative involvement in service plan: 6
Meal delivery charge: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Verified lack of current CPR certification for staff and confirmed meal delivery charge policy. |
| E10 | Regional Director of Health Services | Acknowledged service plans were unsigned and resident representatives were not involved. |
| E2 | Director of Health Services | Agreed on resident rights regarding service plan development and signature. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 27, 2025
Visit Reason
The inspection was conducted as a complaint investigation survey related to a facility reported incident and a complaint investigation survey with one substantiated and one unsubstantiated complaint.
Findings
The facility failed to ensure timely reporting of an injury of unknown origin for one resident (R2), which had the potential to affect all residents. The injury was a bruise on the resident's forehead likely caused by hitting the shower head while seating, and night staff failed to report the incident promptly to nursing staff.
Complaint Details
Facility reported Incident Survey IL00179482 was substantiated. Complaint Investigation Survey IL00181244/2479507 was unsubstantiated.
Severity Breakdown
Level 2 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure employee report injury of unknown origin in a timely manner to the Nurse on Duty, Director of Healthcare, and/or Executive Director for one resident. | Level 2 Violation |
Report Facts
Resident age: 84
Resident move-in date: Sep 25, 2023
Incident date: Sep 25, 2024
Incident report date: Sep 25, 2024
Interview date: Feb 26, 2025
Interview date: Feb 27, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Reported on 2/26/2025 about the incident and staff reporting failure |
| E4 | Lead Caregiver | Interviewed on 2/27/2025 about reporting of resident R2's bruise |
| E5 | Nurse | Received immediate report of resident R2's bruise from Lead Caregiver |
Inspection Report
Plan of Correction
Deficiencies: 1
Feb 27, 2025
Visit Reason
The document is a Plan of Correction submitted by The Whitley of Aurora in response to a Complaint survey conducted by the Illinois Department of Public Health on 2/27/2025.
Findings
The Plan of Correction addresses alleged deficiencies related to personnel requirements, qualifications, and training, specifically regarding failure to ensure timely reporting of an employee injury of unknown origin. The complaint investigation was found to be unsubstantiated, but a Facility Reported Incident was substantiated with a Level 2 violation.
Complaint Details
Complaint Investigation Survey #181244 was unsubstantiated. Facility Reported Incident IL00179482 was substantiated with 1 Type 2 Violation.
Severity Breakdown
Level 2 Violation: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure employee report injury of unknown origin in a timely manner to the Nurse on Duty, Director of Healthcare, and Executive Director, affecting all residents. | Level 2 Violation |
Report Facts
Fine amount: 500
Date of survey: Feb 27, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Burbridge | Executive Director | Named in Plan of Correction and employee identity key. |
| Edward Pitts | RN-BSN, PSA, Assisted Living | Author of complaint investigation letter and contact person. |
| Tenison Williams | Director of Healthcare | Named in employee identity key and referenced in deficiency description. |
| Rosemary Williams | Lead Caregiver | Named in employee identity key. |
| Tandara Moore | Caregiver | Named in employee identity key. |
| Cynthia Lawton | Nurse | Named in employee identity key. |
| Ophelia Goanue | Caregiver | Named in employee identity key. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 8, 2024
Visit Reason
Complaint Investigation Survey #178501 was conducted following a complaint intake #170222.
Findings
The complaint investigation was substantiated but no deficiencies were written.
Complaint Details
Complaint Investigation Survey #178501 was substantiated with no deficiencies written; related to intake #170222 exited 9/20/24.
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