Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alden Estates Of Naperville during CMS and state inspections, most recent first.
Medications and biologicals were found improperly stored in nurses’ station drawers on a dementia unit, including IV dextrose bags labeled for a deceased resident, an expired multivitamin, and resident-labeled lidocaine patches, ointment, and dressings. Record review and staff interviews confirmed that some items belonged to deceased residents and should have been discarded, while the DON stated medications should be kept in the medication room, medication cart, or wound treatment cart and stored separately.
Respiratory equipment was not maintained or documented properly for two residents. A resident using CPaP was found with the nose piece on the floor and tubing dated months earlier, and the DON stated the nose piece should be kept in the bag when not in use and tubing changed monthly; the record also lacked a physician order for CPaP even though the care plan referenced its use. Another resident receiving O2 via nasal cannula had no date label on the cannula, despite the order and facility policy requiring monthly changes, and the BIPAP policy required tubing changes every 3 months and use only with a physician order.
A resident with GERD and a physician order for a GI consult was not transported to the specialist in a timely manner. The resident reported being told about the GI appointment but never getting to see the doctor. The appointment and transportation scheduler described repeated problems with the contracted transportation company, including late arrival that led to a canceled visit and a subsequent missed visit when the driver went to the wrong facility, with no backup transportation options in place. A new appointment was scheduled for a later date, and the NP, who was unaware of the missed visits, stated the consult was for abdominal pain and acid reflux and still expected timely transport.
A resident with stroke-related right-sided weakness, apraxia, aphasia, seizures, and severe dry skin was allowed to shave using a personal electric razor that family later observed to have a damaged head with a gouge in the metal and raised edges. Staff routinely handed the razor to the resident for self-shaving and then put it away, but did not identify or report the damage before use. A family member reported that the razor had been dropped and cracked, that the resident’s face was cut and scratched from shaving with it, and that staff did not initially assess the resident’s face, only stating the razor would be replaced. Nursing documentation noted scratches to the resident’s chin and neck from shaving, and the DON acknowledged staff should check razors for damage before use, but neither staff nor management could explain how the razor became broken, and no razor safety policy was produced when requested.
A resident with multiple stage 2 pressure injuries was not provided with a low air loss mattress as ordered by the wound physician and outlined in the care plan. Despite facility policy and active orders, the resident was found on a regular mattress after a room change, and wound deterioration was observed by the wound care nurse.
The facility did not ensure that the QAPI committee met quarterly with all required members present. Attendance records for meetings were incomplete, missing signatures from key members such as the Infection Preventionist, Medical Director, and Director of Nursing. The Administrator confirmed the absence of the Medical Director from meetings since the previous year and noted the lack of Pharmacy and Laboratory representatives, only receiving quarterly reports.
The facility failed to provide properly prepared pureed and mechanically altered meals for residents requiring specific dietary consistencies. Pureed meals contained lumps unsuitable for residents, and mechanical soft diets included whole meatballs and raw vegetables, contrary to dietary guidelines. Staff acknowledged the discrepancies, confirming the meals did not meet the required standards.
A resident's personal refrigerator contained unlabeled and undated food items stored over spills and debris, without a thermometer, violating the facility's food safety policy. The resident, with multiple health conditions, orders food from outside due to dissatisfaction with the facility's meals. An LPN confirmed the lack of compliance with labeling and temperature monitoring requirements.
A resident with severe cognitive impairment was found exposed in a hallway due to a lack of necessary incontinence supplies, which were not provided by the family. Staff did not address the situation until prompted by a surveyor, highlighting a failure to maintain the resident's dignity and privacy.
A resident with multiple health conditions reported missing personal items, but the facility failed to follow its grievance policy. The grievance was not documented or communicated to the Administrator, and the resident was not informed of any investigation results. Staff members did not adhere to the facility's procedures, leading to unresolved concerns.
The facility failed to assess and provide appropriate splints and therapy services for three residents with range of motion limitations. One resident with arthritis had contractures in the right hand without a splint, another with hemiplegia was unable to move the right upper extremity, and a third with polyarthritis had deformed fingers without any device. Occupational therapy evaluations recommended specific splints and therapy services for each resident to prevent further deformities and maintain motion.
A facility failed to follow proper procedures for g-tube medication administration for a resident with dysphagia. The LPN did not check g-tube placement by aspirating for gastric content and administered medications by pushing them through the tube instead of using the gravity method. The facility's policy required a 30 ml water flush before and after each medication, which was not followed.
A facility failed to follow proper infection control practices for a resident in contact isolation due to C-diff. An LPN was observed in the resident's room without a gown and did not wash hands with soap and water after exiting, contrary to the facility's policy. The Regional Nurse Consultant confirmed the necessity of these precautions to protect residents and staff.
The facility failed to administer insulin as ordered, resulting in elevated blood sugars for two residents. One resident reported missing doses due to the facility running out of insulin, and there was no documentation showing that the physician was notified. Another resident also experienced missed doses, with no physician notification. The nurse practitioner confirmed that missing doses significantly impacted the residents' blood sugar levels.
The facility failed to ensure timely medication procurement, causing three residents to miss critical doses of insulin, Vitamin D, and pain relief patches. The EMR documented multiple instances of medications being 'on order,' and the facility did not consistently follow its policy to reorder medications when a two-day supply remained.
The facility failed to ensure nebulizer treatments were completed and documented for two residents with COPD. One resident's family member found the breathing treatment mask on the floor, and another resident reported not always receiving his treatments. The MARs for both residents showed missing documentation for the prescribed treatments.
A resident missed three doses of her seizure medication, Vimpat, due to the facility's failure to reorder it, resulting in a grand mal seizure and hospitalization. Staff interviews and records confirmed the medication was out of stock and not reordered in time, leading to the resident's severe health event.
The facility failed to reorder medications timely, causing residents to miss doses of prescribed medications. Additionally, the facility did not follow proper procedures for handling controlled substances, as only one signature was present for wasted medications and shift-to-shift controlled substance sheets were not signed off by two licensed professionals.
The facility failed to follow infection control measures during incontinence care and COVID-19 isolation. Staff did not change gloves or perform hand hygiene during incontinence care and entered rooms of residents under COVID-19 isolation without proper PPE. The residents involved had severe cognitive impairment and various chronic conditions.
A resident with severe cognitive impairment and multiple medical conditions was not provided adequate assistance for ADLs, resulting in prolonged exposure to moisture and significant skin excoriation. The resident's care plan and facility policies were not followed, leading to the deficiency.
Improper Medication Storage and Labeling
Penalty
Summary
Medications and biologicals were found stored improperly in the medication cart, medication room, and nurses’ station on the second-floor dementia unit. During a tour of the unit’s medication room and nurses’ desk, surveyors found two 1,000 mL bags of 5% dextrose IV solution labeled with a deceased resident’s name, a box of normal saline flushes, an expired bottle of multivitamin dietary supplement, a box of Relevca lidocaine 4% pain relief patches labeled with one resident’s name, a tube of B & C ointment labeled with another resident’s name, silicone-faced foam and border sacrum dressing labeled with a third resident’s name, TheraHoney gel, and miconazole nitrate cream USP 2% antifungal cream in the nurses’ station drawers. The unit census was 28 residents at the time of the observation. Record review showed that one resident had an active order for a 4% lidocaine patch for bilateral knee pain, another resident had died but still had B & C ointment stored in the nurses’ station drawer, a third resident had died but still had two labeled IV dextrose bags stored in the drawer, and a fourth resident had a labeled sacrum dressing stored in the drawer. An LPN stated that the IV bags belonged to a deceased resident and should have been discarded, and the DON stated that medications are stored in the medication rooms and medication carts, not in residents’ rooms or at the nurses’ stations, and that some of the listed medications should have been discarded. Facility policies stated that when a resident is discharged, all medications shall be stored in one designated area and that each resident’s medications are kept separately from others.
Respiratory Equipment Not Maintained or Ordered Properly
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for two residents. R3, whose record documented diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and obstructive sleep apnea, was observed with the nose piece of the CPaP machine on the floor and the green tubing connected to the oxygen concentrator and CPaP machine dated 10/01/2025. The CNA present stated the nose piece should not be on the floor, and the DON stated the nose piece should be kept in the bag when not in use to lower or prevent the risk of infection and that oxygen tubing should be changed monthly. R3’s record reviewed on 05/27/2026 had no physician’s order for the CPaP machine, although the care plan documented use of a CPaP machine and encouragement to use it at bedtime. R1, whose record documented diagnoses including chronic obstructive pulmonary disease, acute on chronic respiratory failure, acute on chronic congestive heart failure, obstructive sleep apnea, and dependence on supplemental oxygen, was observed in bed receiving oxygen via nasal cannula at 2 liters per minute. The RN checked the nasal cannula label and found no label present, and stated it should be labeled with the date it was changed for infection control. The active order summary documented oxygen tubing should be changed monthly and PRN, and the facility policy stated a nasal cannula should be changed monthly and PRN. The BIPAP policy also stated tubing would be changed every 3 months and PRN and that BIPAP therapy would be administered by a respiratory therapist or nurse upon order of a physician.
Failure to Ensure Timely Transportation for GI Specialist Appointment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely transportation to a scheduled GI (gastroenterology) consultation as ordered. The resident had a diagnosis of GERD (Gastroesophageal Reflux Disease) and a physician order entered on 10/27/25 for a GI consult. On 1/20/26, the resident reported that he had been told he was supposed to go to an appointment with a GI doctor but had not yet been able to see one. The Nurse Practitioner stated the resident was to see the GI specialist for previous abdominal pain and acid reflux and was not aware that the resident had missed his GI appointments, while also stating that even though the appointments were considered non-urgent, she would still expect the resident to be transported on time. The Appointment and Transportation Scheduler reported ongoing issues with the transportation company used by the facility, including problems getting residents to appointments on time and the lack of any backup transportation options. She confirmed that she had been trying to get the resident to the GI appointment and described two missed appointments: on 12/23/25, the transportation company called to report they would be late, and the physician’s office could not accommodate a late arrival, resulting in rescheduling; on 1/12/25, the transportation company went to the wrong facility, causing the resident to miss the appointment again. The scheduler stated that a new GI appointment was made for 3/18/26. The facility’s Transportation policy dated 9/2020 states that the facility will assist residents in obtaining transportation to their appointments as needed, but the resident was not successfully transported to the ordered GI consult in a timely manner.
Failure to Prevent Resident Injury From Use of Damaged Electric Razor
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision related to a resident’s use of a personal electric razor. The resident had a history of stroke with right-sided weakness, apraxia, aphasia, epileptic seizures, and severe dry skin, and required staff to hand him his razor because he could not use his right arm. According to the resident’s POA and a family member, the razor was in good condition several days before the incident, but when the family visited, they observed the resident’s face scratched with scabbed blood and noted that the razor head was damaged with a large gouge in the metal part. The POA reported that the damaged area of the razor had metal edges sticking up that would scratch skin if touched lightly, and stated that staff should not have given the resident a broken razor. On the date of the incident, a family member completed a concern form stating that the resident’s razor had been dropped, the head of the blades was cracked, and the razor was not working the same, resulting in the resident’s face being cut. The family member reported that staff did not look at the resident’s face and only told him they would replace the razor. Nursing documentation from that day described dry spot scratches to the resident’s left chin and neck due to shaving, and indicated that the nurse practitioner was notified and treatment orders were obtained. The family also reported finding another razor in the resident’s room that did not belong to him and believed the facility was trying to cover up that the resident’s razor had been damaged. Staff interviews showed that CNAs and the RN regularly assigned to the resident stated that the resident shaved himself and staff would set him up by handing him the razor and putting it away afterward. The CNA recalled the family member being very upset and yelling about the broken razor and the resident’s face being cut, but did not recall the appearance of the resident’s face that day. The RN confirmed there was a day when the resident was cut by the razor and that she documented a progress note, but she did not know how the razor became broken. The DON stated that staff were expected to check the razor for damage before handing it to the resident and acknowledged that a damaged razor head would increase the risk of cutting the resident’s face, but she did not personally examine the razor. The facility’s investigation was unable to determine how the razor was broken, and a requested policy related to razor safety was not provided.
Failure to Provide Ordered Pressure Redistribution Mattress for Resident with Pressure Injuries
Penalty
Summary
The facility failed to implement ordered wound care interventions for a resident with multiple pressure injuries. Upon observation, the resident was found in bed on a regular mattress, despite an active physician order and care plan intervention for a low air loss mattress to aid in pressure redistribution. The wound care nurse and technician confirmed that the resident had stage 2 pressure injuries on both buttocks, which were present on admission and required daily dressing changes. The nurse expressed concern about wound deterioration, noting an increase in wound size and peri-wound irritation with minor bleeding. The nurse also stated uncertainty regarding why the resident was not provided with the specialized mattress after a recent room change. Record review showed that the resident's wounds had been measured and documented by the wound physician, with a consistent order for a low air loss mattress since admission. The care plan identified the resident as being at risk for further skin breakdown and included interventions for pressure redistribution. Facility policy required implementation of individualized care plans and provision of low air loss mattresses for residents assessed as needing them. Despite these orders and policies, the resident was not provided with the required mattress, and wound deterioration was observed.
QAPI Committee Meeting Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met quarterly and included the required members. The facility's records showed attendance for meetings on December 7, 2023, March 14, 2024, and an undated meeting, but these records were incomplete. Specifically, the Infection Preventionist and the Medical Director did not sign the attendance records for the December and March meetings. Additionally, the undated record lacked signatures from the Director of Nursing, the Medical Director, and the Infection Preventionist. The facility's Administrator acknowledged that the Medical Director had not attended a QAPI meeting since the previous year and that there were no representatives from the Pharmacy and Laboratory present, only quarterly reports submitted for review. This indicates that the facility did not comply with the requirement for quarterly QAPI meetings with all necessary members present.
Inadequate Preparation of Pureed and Mechanical Soft Diets
Penalty
Summary
The facility failed to provide appropriately prepared pureed and mechanically altered meals for residents requiring specific dietary consistencies. During an observation, a cook was seen preparing pureed ground meat with spaghetti sauce, which contained small lumps of fat and meat particles that were not suitable for residents on a pureed diet. The dietary supervisor confirmed that the food needed further processing to meet the required consistency. The facility's policy specifies that pureed foods should have a pudding-like consistency, excluding any foods that require chewing. The facility's diet type report indicated that several residents were on pureed diets, yet the food provided did not meet these standards. Additionally, the facility did not adhere to the mechanical soft diet requirements for residents who have difficulty chewing. During a lunch meal service, residents on a mechanical soft diet were served whole meatballs instead of ground meat as specified in the menu spreadsheet. One resident also received a regular consistency salad and mixed vegetables, including corn, which they were unable to chew. The dietary supervisor acknowledged that the resident should have received shredded lettuce or mechanically altered coleslaw instead. The facility's policy for mechanical soft diets states that hard-to-chew foods should be replaced with easily swallowable alternatives, and raw vegetables should be avoided. The diet type report confirmed that several residents were on mechanical soft diets, yet the meals served did not comply with these guidelines.
Improper Storage of Resident's Food in Personal Refrigerator
Penalty
Summary
The facility failed to store a resident's food in a safe and sanitary manner, as observed in the personal refrigerator of a resident diagnosed with malignant neoplasm of the head of the pancreas, type 2 diabetes mellitus without complications, alcohol dependence with unspecified alcohol-induced disorder, and adult failure to thrive. The resident, who is cognitively intact, reported ordering Indian food from outside the facility due to dissatisfaction with the facility's food. Upon inspection, the refrigerator contained five clear plastic containers of cooked food and another item wrapped in silver foil, all placed over excessive spills, food debris, and miscellaneous brownish-black particles. These food items were not labeled or dated, and there was no thermometer found in the refrigerator, although a temperature monitoring log was present. A Licensed Practical Nurse (LPN) confirmed that the resident orders food from an outside source and that the food items should be labeled and dated, with a thermometer present in the refrigerator. The LPN also mentioned that the night shift nursing staff is responsible for checking the refrigerator and logging the temperatures. The facility's policy requires food to be stored at 41 degrees Fahrenheit or below and mandates that resident food be in a tight container labeled with the name, food item, and date it was prepared. The failure to adhere to these policies resulted in the deficiency noted during the survey.
Failure to Provide Necessary Supplies for Resident Dignity
Penalty
Summary
The facility failed to provide necessary supplies to preserve a resident's dignity and privacy, as observed in the case of a resident with multiple diagnoses including chronic diastolic heart failure, chronic obstructive pulmonary disease, peripheral vascular disease, and unspecified dementia. The resident, who was severely cognitively impaired and required assistance with activities of daily living, was found sitting in the hallway without pants, exposing his genitals. This incident occurred while staff were present nearby, but they did not respond until the issue was pointed out by a surveyor. Further investigation revealed that the resident did not have access to the incontinence products he required, specifically pull-up briefs, because the family had not provided more supplies. A CNA confirmed the absence of these products in the resident's room and subsequently retrieved them from the facility's supply room. Another observation noted the resident sitting in his room without pants, with the door open, and putting on a brief himself, with minimal assistance from a CNA. The facility's policy on resident dignity, as provided by the administrator, emphasizes the importance of maintaining residents' privacy and satisfaction.
Failure to Follow Grievance Policy for Missing Items
Penalty
Summary
The facility failed to adhere to its grievance policy by not informing the Administrator or designee upon receipt of a grievance and not informing the resident of the investigation results. This deficiency was identified in the case of a resident with multiple diagnoses, including end-stage renal disease, diabetes mellitus type 2, and vascular dementia, who reported a missing wallet and pants. Despite the resident's moderate cognitive impairment and need for assistance with activities of daily living, the facility did not document or address the grievance in a timely manner. The resident reported the missing items to a staff member, but there was no record of the grievance being filed or investigated. The Administrator was unaware of the grievance until several days later, and the staff members involved did not follow the facility's policy for handling grievances. The facility's grievance forms for the month did not include the resident's complaint, and the staff failed to communicate the issue to the appropriate personnel, resulting in a lack of resolution and communication with the resident.
Failure to Provide Appropriate ROM Care and Splints
Penalty
Summary
The facility failed to assess and provide appropriate splints and therapy services to maintain or prevent further progression of deformities or reduction in range of motion for three residents. One resident with multiple diagnoses, including rheumatoid arthritis and osteoarthritis, was observed with contractures in the right hand without a splinting device. The resident expressed willingness to be evaluated for therapy, and an occupational therapist later recommended specific splints and occupational therapy to address the deformities and improve hand function. Another resident, who had hemiplegia and hemiparesis following a cerebral infarction, was found to have right-sided paralysis and was unable to move the right upper extremity. Despite being alert, the resident communicated nonverbally and demonstrated weakness in the right arm and hand. An occupational therapist evaluated the resident and recommended a resting hand splint to prevent contracture, along with occupational therapy services. The third resident, diagnosed with hemiplegia and polyarthritis, was observed with deformed and hyperextended fingers on both hands without any splint or device. The resident was confused but verbally responsive. An occupational therapist assessed the resident and recommended specific splints for both hands to prevent further deformity and maintain current motion. The therapist also suggested occupational therapy services to support the resident's condition.
Improper G-Tube Medication Administration
Penalty
Summary
The facility failed to ensure proper procedures were followed for the administration of medications and flushes through a gastric tube (g-tube) for a resident, identified as R147. The resident, who was admitted with multiple diagnoses including dysphagia and pneumonitis due to inhalation of food/vomit, required tube feeding and stoma site care. The care plan for R147 specified that the placement and patency of the feeding tube should be checked prior to administering medications, feedings, and flushes. However, during an observation, it was noted that the Licensed Practical Nurse (LPN) did not check the g-tube placement by aspirating for gastric content before administering medications. Instead, the LPN palpated the abdomen and asked the resident about pain, which was not in accordance with the facility's policy. Additionally, the LPN administered the medications and flushes by pushing them through the tube rather than using the gravity method as recommended by the facility's policy. The policy required a 30 ml water flush before and after each medication administration, but the LPN used only 15 ml of water for each medication and did not follow the proper technique. The Regional Nurse Consultant confirmed that the correct procedure was not followed, highlighting the facility's failure to adhere to its own medication pass guidelines.
Infection Control Breach in C-diff Isolation
Penalty
Summary
The facility failed to adhere to proper infection control practices for a resident in contact isolation due to Clostridium Difficile (C-diff). The resident, who was cognitively intact, was admitted with multiple diagnoses including C-diff. The care plan indicated that the resident was in a single room under contact isolation, and staff were to be educated on isolation precautions. However, an LPN was observed in the resident's room without wearing a gown, despite the presence of a contact isolation sign and a PPE cart outside the room. The LPN exited the room wearing the same gloves, disposed of them at the nurses' station, and did not wash hands with soap and water as required. The facility's policy, dated 2020, mandates the use of contact precautions for residents with C-diff, including wearing appropriate PPE and washing hands with soap and water, as alcohol-based hand sanitizers are ineffective against C-diff spores. The Regional Nurse Consultant confirmed that these precautions are necessary to protect both residents and staff. The failure to follow these procedures was observed and confirmed through interviews, highlighting a deficiency in the facility's infection prevention and control program.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to administer insulin as ordered by the physician, resulting in elevated blood sugars and lab values for two residents. One resident reported missing their morning dose of insulin on a specific date due to the facility running out of the medication. This resident's EMR showed multiple instances where insulin was not administered as ordered, and there was no documentation indicating that the physician was notified of the missed doses. The resident's blood sugar levels were significantly elevated on these occasions, and their HBA1C levels indicated poor glycemic control over several months. Another resident also experienced missed doses of insulin, as documented in their EMR. The facility's policy on medication administration requires that medications be administered as prescribed and that the physician be notified if an order cannot be followed. However, the facility did not adhere to this policy, as there was no documentation showing that the physician was informed of the missed doses for either resident. The nurse practitioner confirmed that the first resident is a brittle diabetic and that missing even one dose of insulin significantly impacts their blood sugar levels. The facility's failure to ensure the availability of insulin and to notify the physician of missed doses directly contributed to the residents' elevated blood sugar levels and poor diabetes management.
Failure to Obtain Medications in a Timely Manner
Penalty
Summary
The facility failed to ensure medications were obtained from the pharmacy in a timely manner, resulting in residents missing medication doses as ordered by their physicians. This deficiency affected three residents who experienced delays in receiving critical medications, including insulin, Vitamin D, and depression medication. For instance, one resident reported missing a morning dose of insulin and experiencing inconsistent blood sugar levels due to the facility running out of the medication. The resident also missed doses of Vitamin D and depression medication. The EMR documented multiple instances where medications were marked as 'on order,' indicating they were not available when needed. Another resident, who was cognitively intact and required supervision with ADLs, also experienced delays in receiving insulin and pain relief patches. The EMR showed several instances where these medications were documented as 'on order,' leading to lapses in therapy. The pharmacy confirmed that the facility requested refills but did not follow the proper process to ensure timely delivery. The facility's policy requires nursing staff to reorder medications when a two-day supply remains, but this procedure was not consistently followed. A third resident, with multiple diagnoses including end-stage renal disease and diabetes, also faced delays in receiving pain relief patches. The pharmacy records indicated that the facility requested refills but did not adhere to the policy of reordering medications in advance. Interviews with the pharmacy staff and the DON revealed that the facility staff did not consistently request medication refills in a timely manner, leading to lapses in therapy for the residents. The facility's policy on reordering medications was not effectively implemented, contributing to the deficiency.
Failure to Administer and Document Nebulizer Treatments
Penalty
Summary
The facility failed to ensure nebulizer treatments were completed and documented on the medication administration record (MAR) for two residents diagnosed with chronic obstructive pulmonary disease (COPD). On 4/8/24, a family member of one resident (R1) reported finding the resident's breathing treatment mask on the floor and the nebulizer machine turned off. The MAR for March 2024 indicated that R1 was supposed to receive a treatment of Ipratropium-Albuterol via nebulizer on 3/28/24 at 6:00 AM, but there were no recorded nurse initials to confirm the medication was administered. Another resident (R10) reported on 4/9/24 that staff did not always ensure he received his prescribed nebulizer treatments twice per day. The MAR for March 2024 showed that R10 was also supposed to receive a treatment of Ipratropium-Albuterol via nebulizer on 3/28/24 at 6:00 AM, but again, there were no recorded nurse initials to indicate the medication was provided. The Director of Nursing confirmed that both residents should have received their treatments as ordered and that the administration should have been documented on the MAR.
Failure to Reorder Seizure Medication Leads to Resident Hospitalization
Penalty
Summary
The facility failed to reorder a resident's seizure medication, Vimpat, resulting in the resident missing three doses. This led to the resident experiencing a grand mal seizure and subsequent hospitalization. Interviews with various staff members, including LPNs and RNs, revealed that the medication was out of stock and not reordered in a timely manner. The resident's family member and neurology specialist confirmed that the missed doses likely caused the seizure. The facility's progress notes and Medication Administration Review (MAR) documented the missed doses and the out-of-stock status of the medication. The resident, who had a history of epilepsy and other medical conditions, required Vimpat twice daily to manage her seizures. The failure to administer the medication as prescribed resulted in the resident having multiple seizures, requiring emergency medical intervention and hospitalization. The facility's policy on medication administration was not followed, leading to a significant medication error that compromised the resident's health and safety.
Medication Reordering and Controlled Substance Handling Deficiencies
Penalty
Summary
The facility failed to reorder medications in a timely manner, resulting in residents missing doses of their prescribed medications. One resident missed three doses of Vimpat due to the medication being out of stock, as documented in the facility's progress notes. Another resident did not receive her scheduled morphine doses because the prescription had ended, and the staff failed to reorder it in time. Both residents had significant medical conditions that required consistent medication management, and the lapses in medication administration were noted in their Medication Administration Records (MAR) and Electronic Medical Records (EMR). Additionally, the facility did not adhere to proper procedures for handling controlled substances. The Controlled Drug Receipt/Record/Disposition Forms for two residents showed that only one signature was present for wasted medications, instead of the required two signatures. This was confirmed during a review of the medication cart and interviews with staff members. The facility's policy mandates that two licensed professionals must sign off on wasted controlled substances to prevent drug diversion and ensure safe disposal. The facility also failed to have two licensed professionals sign off on the shift-to-shift controlled substance sheet. Multiple days were identified where the controlled substances were not verified and signed off by two nurses, as required by the facility's policy. This lapse was confirmed by the Consultant Pharmacist and the Director of Nursing, who both acknowledged the necessity of having two signatures for verification and handoff of narcotics. The facility's policies on reordering medications and controlled drug documentation were not followed, leading to these deficiencies.
Infection Control Deficiencies During Incontinence Care and COVID-19 Isolation
Penalty
Summary
The facility failed to follow infection control measures for several residents during incontinence care and COVID-19 isolation. Specifically, a CNA provided incontinence care for a resident without changing gloves or performing hand hygiene after removing a dirty brief and before handling clean items and applying barrier cream. This resident had severe cognitive impairment and required total dependence on staff for toileting hygiene and other activities of daily living. Additionally, multiple staff members entered rooms of residents under COVID-19 isolation without wearing the required personal protective equipment (PPE). For instance, a CNA entered a resident's room with only a surgical mask, and an LPN entered another resident's room without a gown, glasses, or an N-95 mask. A social work intern also entered a room with two residents under COVID-19 isolation without wearing an N-95 mask and eye protection. The residents involved had various medical conditions, including severe cognitive impairment, hemiplegia, hemiparesis, metabolic encephalopathy, pressure ulcers, and other chronic conditions. The Director of Nursing acknowledged that staff should wear a gown, gloves, N-95 mask, and face shields before entering rooms under COVID-19 isolation precautions. However, the Director was unable to specify when gloves should be changed and hand hygiene performed during incontinence care. The facility's policies on Universal PPE for Staff and Perineal Care were not followed, leading to these deficiencies in infection control practices.
Failure to Provide Adequate Assistance for ADLs
Penalty
Summary
The facility failed to provide adequate assistance to a resident (R11) for activities of daily living (ADLs). On the morning of 12/21/23, a family member expressed concerns to an LPN about R11 not being checked on frequently enough and needing to be cleaned up. R11, who had severe cognitive impairment and multiple medical conditions including pneumonia and COVID-19, was found by a CNA to have urine and stool in his incontinence brief, with excoriated and red skin around his perineal area, buttocks, and sacrum. The resident was in visible pain during the cleaning process. Despite these observations, the CNA did not report the skin breakdown to the LPN. Later, a wound LPN and wound tech confirmed the skin damage was due to prolonged moisture exposure and noted that R11's lunch tray was untouched, indicating a lack of assistance with eating as well. The Director of Nursing (DON) confirmed that staff are required to check on residents every two hours and provide incontinence care as needed, and that excoriated skin can result from prolonged moisture. The DON also stated that staff should check meal trays within an hour to monitor residents' food intake. R11's care plan required turning and repositioning every two hours, pericare after every incontinent episode, and monitoring for skin excoriation. However, these care plan interventions were not followed, leading to the resident's condition. The facility's policies on feeding and perineal care were also not adhered to, contributing to the deficiency.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,185 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Naperville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pearl Of Naperville, The | 2 mi | ★★★★★ | 10 | 0 |
| Arista Healthcare | 3.5 mi | ★★★★★ | 0 | 0 |
| Brookdale Plaza Lisle Snf | 3.7 mi | ★★★★★ | 11 | 0 |
| Thrive Of Lisle | 3.7 mi | ★★★★★ | 1 | 0 |
| Meadowbrook Manor - Naperville | 4.1 mi | ★★★★★ | 8 | 0 |
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