Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arista Healthcare during CMS and state inspections, most recent first.
Failure to Provide Grooming and Hygiene Assistance: Several residents who required ADL help were observed with poor grooming and hygiene, including long or dirty fingernails and overgrown facial hair. Residents with dementia, MS, weakness, and other impairments were dependent on staff or needed assistance for personal hygiene, showering, bathing, and grooming, yet CNAs did not ensure nails were clean and trimmed or facial hair was shaved as needed or requested.
Failure to monitor meal intake before rapid-acting insulin administration. A resident with type II DM and other chronic conditions received 17 units of insulin lispro before breakfast even though staff later found the meal tray largely untouched and the resident was not eating normally. The resident became shaky, diaphoretic, and confused, with a blood sugar of 43 mg/dL, requiring glucagon and later oral intake to improve her glucose level. Staff and the attending MD noted the resident eats slowly and that oral intake should be present before giving rapid-acting insulin.
Two residents with hemiplegia and limited ROM were observed without their ordered or recommended upper extremity devices. One resident had a right wrist-hand-finger orthosis ordered for daily use, but staff and restorative personnel did not apply it despite repeated observations showing the device absent. Another resident had OT-recommended left hand palm mitt use overnight, yet the resident was repeatedly seen without the device, and staff stated they had no such order or device in place.
Inadequate peri-care, missed barrier cream application, and unsecured catheter tubing were observed for three residents. A CNA did not fully cleanse a female resident’s perineal area, two CNAs failed to apply ordered moisture barrier cream after incontinence care for a resident with dry fecal matter and red skin, and a resident with an indwelling catheter reported the tubing had been loose for days and was dangling during care, causing pain and discomfort.
Hand hygiene and PPE failures occurred during resident care. A nurse cared for a resident with a g-tube, removed gloves, touched other surfaces, put on new gloves without hand hygiene, and then checked blood glucose. A CNA entered the room of a resident on EBP wearing gloves only instead of full PPE, performed care tasks, and left without hand hygiene. In another event, a CNA handled a urinal with bare hands, emptied it, left without hand hygiene, and then touched a meal tray cart that another resident later accessed.
Facility staff failed to follow infection control protocols, including hand hygiene and PPE use, for residents under Enhanced Barrier Precautions. Multiple staff members entered rooms without washing hands or wearing appropriate PPE, and visitors were not educated on contact precautions. This affected residents with increased infection risk due to medical devices and conditions.
The facility failed to maintain proper food safety and hygiene standards in their kitchen, affecting all residents receiving oral nutrition. Observations revealed improperly labeled or expired food items, a dirty bin with a dead fly in the walk-in cooler, and a cook with an inadequately worn hair net. The Dietary Manager confirmed these lapses, acknowledging that expired food should be discarded, the cooler cleaned twice daily, and scoops stored separately to prevent contamination.
The facility failed to maintain resident dignity and privacy during care. An ADON stood over a resident while feeding, and CNAs left residents exposed during incontinence and catheter care without closing curtains or doors. Residents expressed discomfort, and staff acknowledged the importance of privacy, which aligns with facility policies.
The facility failed to provide written notice of transfer reasons to residents, their representatives, and the Ombudsman before hospital transfers. This deficiency was identified in three residents, including one with multiple diagnoses and frequent hospitalizations. Interviews revealed a lack of awareness among staff about the notification requirements.
The facility failed to provide written bed hold policy information to residents and/or their representatives before hospital transfers, as required by federal regulations. This deficiency was identified in the cases of three residents transferred for various medical reasons. Interviews with staff revealed a lack of awareness and adherence to the policy, despite the facility's own guidelines mandating such information be provided.
A resident with multiple diagnoses experienced severe itching and discomfort due to skin impairment, which was not properly assessed or treated by the facility. Despite CNAs documenting the issue and notifying the LPN, the nurse did not follow up with an assessment or notify the physician, contrary to facility policy.
A facility failed to provide restorative therapy services as care planned for a resident with hemiplegia and muscle weakness. The resident's care plan required participation in Bed Mobility and AROM/AAROM Restorative Nursing Programs, but staff documented participation only nine times in 30 days. Interviews revealed the resident had not received services for weeks, and the restorative nurse confirmed the programs were not conducted as required. The DON acknowledged the care plan was not followed, leading to a deficiency.
The facility failed to provide proper urinary catheter care and hand hygiene, leading to potential risks of UTIs for two residents. CNAs were observed cleaning catheter tubing incorrectly and not following hand hygiene protocols. The DON confirmed the correct procedures, which were not adhered to, as per the facility's policies.
The facility failed to follow proper hand hygiene practices, affecting two residents. A nurse fed a resident and handled a dirty plate without cleaning her hands. Two CNAs provided care to a resident without changing gloves or cleaning hands between tasks. The DON confirmed the expectation for staff to clean hands after glove removal and before donning new gloves.
Failure to Provide Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to provide grooming and hygiene assistance for residents who required help with activities of daily living. R39, who had unspecified dementia, cognitive communication deficit, generalized muscle weakness, and arthritis, was observed with long fingernails on both hands with brown-black substances under the nails while sitting in a wheelchair in the dining room. The next day, R39 was observed eating in the dining room and used his hands and a fork to open a carton of milk, touching the inside of the milk container with his hands while attempting to open it. His MDS showed moderate cognitive impairment and a need for moderate assistance from staff for personal hygiene, shower, and bath, and the care plan directed CNAs to assist with hygiene tasks as needed. R52, who had active primary progressive multiple sclerosis, cognitive communication deficit, musculoskeletal symptoms, and fatigue, was observed in the dining room with brown-black substances under the fingernails of both hands. His MDS showed moderate cognitive impairment and dependence on staff for personal hygiene and shower or bath. R89, who had vascular dementia, muscle disorder, and seizures, was observed in a wheelchair at the nursing station with black substances under his fingernails; the ADON stated CNAs are responsible for cleaning residents’ nails during showers, baths, and as needed. R3, who had generalized muscle weakness, lack of coordination, and legal blindness, was observed in bed with thick, overgrown facial hair on the upper lip and chin, and stated she wanted it shaved but needed someone to help. The DON stated hygiene and grooming include oral, nail, and hair care, facial hair shaving for both men and women as needed or requested, as well as showering, bathing, and dressing.
Failure to Monitor Meal Intake Before Rapid-Acting Insulin Administration
Penalty
Summary
The facility failed to assess and monitor a resident’s nutritional intake before administering rapid-acting insulin. The resident had multiple diagnoses including type II diabetes, obesity, peripheral vascular disease, hypothyroidism, anxiety disorder, and bilateral above-the-knee amputations. The resident’s MDS showed she was cognitively intact and needed setup/clean-up assistance with eating and oral hygiene. On the morning of the event, the resident was in bed with her breakfast tray on the over-bed table when staff later found her shaking, diaphoretic, flushed, and unable to answer questions appropriately. At 9:55 AM, the resident’s blood sugar was 43 mg/dL. She was given glucagon at 9:58 AM, and at 10:00 AM staff found her breakfast tray largely untouched, including scrambled eggs with cheese, toast, oatmeal, milk, and yogurt. A nutritional supplement was given at 10:04 AM, and yogurt was fed to her at 10:06 AM. Her blood sugar remained low at 51 mg/dL at 10:06 AM and improved to 71 mg/dL by 10:13 AM. The resident’s breakfast intake records showed very limited intake over the prior month, with meals documented as 0 to 25% except one meal at 26 to 50%. The resident had orders for blood sugar checks before meals and at bedtime, 13 units of insulin lispro with meals/15 minutes prior to meals, and additional lispro per sliding scale. Her blood sugar at 7:00 AM was 163 mg/dL, and she received a total of 17 units of lispro at about 8:36 AM. Staff stated the resident eats slowly, sometimes not finishing breakfast until 11:00 AM, and one CNA stated the resident was sleeping when the breakfast tray was placed in the room at 8:00 AM. The attending physician stated insulin should not be given if the resident does not eat or if blood sugar is below 150 mg/dL, and the pharmacist stated rapid-acting insulin should be given 15 minutes before eating and that the combination of not eating and insulin administration contributed to the hypoglycemic event.
Failure to Apply Ordered Upper Extremity Devices
Penalty
Summary
The facility failed to follow orders and therapy recommendations for upper extremity devices for two residents with functional limitations on one side. One resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, wrist drop, paraplegia, and lack of coordination. The quarterly MDS showed cognitive intactness and functional limitation in ROM due to impairment on one side, and the POS ordered a right wrist-hand-finger orthosis to be applied before breakfast and removed after lunch for 4-6 hours daily as tolerated. However, the resident was observed on multiple occasions over two days with the right arm flaccid and no device on the arm, and the resident stated staff had not been putting the device on recently. Staff interviews showed CNA staff did not apply the device, restorative staff were responsible for it, and restorative staff could not explain why it had not been applied. The second resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, muscle disorder, cognitive communication deficit, vascular dementia, and lack of coordination. The quarterly MDS showed moderate cognitive impairment and functional limitation in ROM due to impairment on one side. Although OT had discharged the resident from skilled services, the therapist stated she had recommended a left upper extremity palm mitt overnight to prevent contractures and had sent the recommendation to nursing/restorative follow-up. The resident was observed seated in a wheelchair with the left arm immobile and flaccid and no device on the left hand on two separate days, while restorative nursing and restorative aide staff stated they did not have or apply any such device and that restorative staff performed ROM exercises instead.
Inadequate Peri-Care, Barrier Cream Use, and Catheter Securing
Penalty
Summary
Appropriate peri-care was not provided for a resident with hemiplegia and hemiparesis following cerebral infarction, chronic kidney disease, and other diagnoses when a CNA rendered incontinence care while the resident was saturated with urine. The CNA used wet towels to wipe the resident’s groins and outer labia but did not open and clean the inner labial folds or the urethra, and then completed the care without ensuring the entire perineum was completely cleaned. The facility policy for perineal/incontinence care required cleansing the perineal area with an approved no-rinse product and, for female residents, separating the labia and cleansing side to side and then the center toward the rectal area. Appropriate care was also not provided for a resident with a physician order for moisture barrier cream to the buttocks and groins as needed when two CNAs provided incontinence care after the resident had been sitting on feces for about an hour. The resident’s fecal matter was dry and pasty and the skin was flushed/red, but barrier cream was not applied before the resident was transferred back to the wheelchair. In addition, a resident with an indwelling urinary catheter reported that the catheter tubing had been loose for several days and moved a lot inside the ureter during transfers and care, causing pain and discomfort. During care, the urinary tube was dangling and moving loosely while the resident was being transferred, repositioned, and cleaned, and the DON stated the catheter tube must always be secured to prevent pulling, tension, and trauma.
Hand Hygiene and PPE Failures During Resident Care
Penalty
Summary
The facility failed to perform hand hygiene between tasks during provision of care and failed to wear complete PPE when providing care to a resident on Enhance Barrier Precautions (EBP). For one resident with multiple diagnoses including diabetes mellitus and a gastrostomy tube, a nurse checked g-tube placement and administered medications via the g-tube, then removed gloves, touched other surfaces, donned a new pair of gloves without hand hygiene, and proceeded to check the resident’s blood glucose level. The facility’s hand hygiene policy states gloves do not replace hand hygiene and hand hygiene is the final step after removing PPE, and the DON stated staff must perform hand hygiene before care, between dirty and clean tasks, and before donning new gloves. The facility also failed to follow EBP and hand hygiene practices for a resident with multiple diagnoses including type 2 diabetes mellitus with a foot ulcer and ESRD who received dialysis and had a dialysis access port. The resident’s care plan identified high infection risk related to dialysis and a left foot wound and included PPE use during high-contact care activities. During observation, a CNA entered the room wearing gloves only, without a gown, turned the resident to check for incontinence, removed the mechanical lift sling, straightened the bedding, and left without hand hygiene. In a separate event, a CNA brought soup to another resident, placed the food on a bedside table next to a urinal containing urine, handled the urinal with bare hands, emptied it into the toilet, left the room without hand hygiene, then touched a meal tray cart in the hallway; another resident subsequently accessed the same tray cart and handled the same tray.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility staff failed to adhere to infection prevention and control protocols, specifically in performing hand hygiene and using Personal Protective Equipment (PPE) while providing care to residents under Enhanced Barrier Precautions (EBP) and Transmission-Based Precautions (TBP). This deficiency was observed in the care of seven residents, all of whom were at increased risk of infection due to various medical conditions and the presence of indwelling medical devices. The staff's non-compliance with established protocols was evident in multiple instances, such as entering rooms without washing hands, not wearing gowns or gloves during high-contact activities, and failing to educate visitors about necessary precautions. One resident, identified as R2, was at a higher risk for infection due to a feeding tube and indwelling Foley catheter. Despite having a care plan that required EBP, a registered nurse (RN) entered R2's room and repositioned the resident without donning a gown. Similarly, another resident, R3, who had a tracheostomy and feeding tube, was not provided care in accordance with EBP protocols. A speech-language pathologist and an RN both failed to wear appropriate PPE while providing direct care, and a certified nursing assistant (CNA) did not change gloves or perform hand hygiene between caring for different residents. Additionally, the facility staff did not educate visitors about contact precautions for a resident with a C. difficile infection. Visitors were observed in the resident's room without wearing gloves or gowns, and there was no evidence that they had been informed about the necessary precautions. Interviews with the Assistant Director of Nursing (ADON) and an Infection Prevention (IP) nurse revealed a lack of clarity regarding the implementation and discontinuation of TBP, further highlighting the facility's failure to maintain effective infection control practices.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene standards in their kitchen, affecting all residents who receive oral nutrition. During a tour of the facility's kitchen, several deficiencies were observed. In the walk-in cooler, a large empty silver bin was found on the top shelf under the fan, containing crusted dirt, dust, and a dead house fly. Additionally, several food items were improperly labeled or expired, including a medium-sized bin labeled 'gravy' and a small bin of leftover fish fillets, both with past expiration dates. Other items, such as cut-up fruit and Spanish rice, were found without any labels or dates. In the kitchen, a bin of powdered mashed potatoes and large buckets of thickener and flour were not dated, and scoops were improperly stored inside the bins, posing a contamination risk. Furthermore, a cook was observed serving lunch with a hair net that did not fully cover her hair, leaving her bangs and the top front of her head exposed. The facility's policies require all food items to be labeled and dated to ensure food safety, and for kitchen staff to wear hair restraints that cover all hair to prevent contamination. The Dietary Manager acknowledged these lapses, stating that expired food should be discarded by the end of the expiration date, and that the walk-in cooler should be cleaned twice daily. The facility's policies also dictate that scoops should not be stored inside food bins to prevent contamination, and that refrigeration units should be routinely cleaned and free from waste.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to provide care with dignity to three residents, as observed during a survey. One incident involved the Assistant Director of Nursing standing over a resident while assisting with feeding, which was acknowledged by the Director of Nursing as inappropriate for maintaining dignity and respect. Another incident involved two Certified Nursing Assistants providing incontinence care and a bed bath to a resident without closing the curtain, leaving the resident exposed to their roommate. The resident expressed discomfort and a preference for privacy, stating that staff often leave the door and curtain open, making them feel cold and uncomfortable. In a separate incident, two CNAs provided catheter and incontinence care to another resident without closing the door or pulling the curtain, exposing the resident to the hallway. One of the CNAs admitted to forgetting to ensure privacy and acknowledged the importance of doing so for dignity and privacy. The facility's policies emphasize the importance of treating residents with dignity and respect, maintaining their privacy, and ensuring their quality of life, which were not adhered to in these instances.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notice of the reason for transfer to the resident, their representative, and the Ombudsman before transferring residents to the hospital. This deficiency was identified in three residents who were reviewed for hospital transfers. Resident 62 was transferred to the hospital with a diagnosis of pneumonia and acute cystitis, but there was no documentation of written notice being provided to the resident, their representative, or the Ombudsman. Similarly, Resident 69 was transferred for gastrostomy and jejunostomy tube evaluation without the required written notifications. Additionally, Resident 37, who had multiple diagnoses including cirrhosis of the liver and type 2 diabetes, was transferred to the hospital on several occasions for various medical conditions, including high ammonia levels. The clinical records for Resident 37 lacked documentation of written notification to the resident or their representative regarding the reason for transfer, and no copy was sent to the Ombudsman. Interviews with the facility's Administrator and Director of Nursing revealed a lack of awareness regarding the requirement to notify the resident, their representative, and the Ombudsman in writing about the reasons for hospital transfers.
Failure to Provide Bed Hold Policy Information Before Hospital Transfers
Penalty
Summary
The facility failed to provide written bed hold policy information to residents and/or their representatives prior to hospital transfers, as required by federal regulations. This deficiency was identified in the cases of three residents. One resident was transferred to the hospital with pneumonia and acute cystitis, another for gastrostomy and jejunostomy tube evaluation, and a third for high ammonia levels. In each case, there was no documentation that the residents or their representatives received the required bed hold policy information before the transfers. Interviews with facility staff revealed a lack of awareness and adherence to the policy. The Administrator confirmed the absence of documentation for bed hold notices, and the Director of Nursing admitted to not knowing the requirement to provide such documentation. The facility's own policy, last revised in July 2024, mandates that residents be informed of the bed hold and reserve bed payment policy upon admission and at the time of transfer. Despite this, the facility did not comply with these requirements, resulting in the deficiency noted in the report.
Failure to Assess and Treat Resident's Skin Impairment
Penalty
Summary
The facility failed to assess and provide necessary treatments and services for a resident experiencing severe itching and discomfort due to skin impairment. The resident, a cognitively moderately intact female with multiple diagnoses including chronic respiratory problems and depression, was observed scratching her arms, which showed redness, scratch marks, dry skin, and scabs. The resident reported that the itching had been ongoing for at least a month and that staff were aware of it. Despite this, there was no evidence that the nurse assessed the resident's skin condition or notified the physician for further evaluation and treatment. Certified Nursing Assistants (CNAs) had documented the resident's skin issues and notified the Licensed Practical Nurse (LPN) on duty, but the nurse failed to follow up with an assessment or notify the physician. The facility's policy required the nurse to review the CNA's completed shower sheet form for skin impairments and ensure follow-up, which was not done. The Director of Nursing and Infection Preventionist confirmed that the nurse should have checked the CNA skin attention form, assessed the resident, and notified the appropriate personnel for evaluation and treatment.
Failure to Provide Restorative Therapy Services as Care Planned
Penalty
Summary
The facility failed to provide restorative therapy services as care planned for a resident with multiple diagnoses, including hemiplegia and hemiparesis following a cerebral infarction, muscle weakness, and difficulty walking. The resident was admitted with a need for assistance with personal care and had a care plan that included participation in Bed Mobility and AROM/AAROM Restorative Nursing Programs. Despite the care plan's requirements, the facility staff documented the resident's participation in these programs only nine times over the past 30 days, with no documentation of resident refusal. Interviews revealed that the resident reported not receiving restorative nursing services for weeks, and the restorative nurse confirmed that the programs were not being conducted as frequently as required. The Director of Nursing acknowledged that the care plan was not being followed and that restorative nursing participation should be documented daily. The facility's policy on restorative nursing emphasizes the importance of maintaining the highest practicable physical, mental, and psychosocial well-being, yet the resident's care plan was not adhered to, leading to a deficiency in providing the necessary restorative services.
Inadequate Catheter Care and Hand Hygiene Practices
Penalty
Summary
The facility failed to provide appropriate urinary catheter care to prevent urinary tract infections (UTIs) for two residents. One resident, admitted with a urinary catheter due to neuromuscular dysfunction and other conditions, was observed with dried debris on the catheter tubing during care. Certified Nurse Assistants (CNAs) were seen wiping the catheter tubing incorrectly, towards the body, and without stabilizing the catheter to prevent pulling. The Director of Nursing (DON) confirmed that catheter tubing should be wiped away from the body to prevent UTIs and that staff should clean the tubing of any debris and inform a nurse for further assessment. Another resident, with a history of UTIs and under hospice care, was observed with a hard brown substance on the catheter tubing near the urethral meatus. A CNA cleaned the tubing incorrectly, towards the urethral meatus, and failed to perform proper hand hygiene between glove changes during care. The facility's catheter care policy requires hand washing before and after touching any part of the urinary catheter drainage system and specifies that encrustations should be removed from the meatus outward. The facility's hand hygiene policy also mandates hand hygiene before applying gloves, after removing gloves, and when moving from a contaminated to a clean body site during resident care.
Inadequate Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to standard infection control practices concerning hand hygiene, affecting two residents. In the first instance, a Restorative Nurse was observed feeding a resident, then moving another resident in a wheelchair, and subsequently returning to feed the first resident without cleaning her hands. The nurse further handled a dirty lunch plate and continued feeding the resident without performing hand hygiene. In another instance, two CNAs were providing incontinence care and a bed bath to a resident. One CNA moved a garbage can with gloved hands and then proceeded to provide care without changing gloves or cleaning hands. The other CNA changed gloves between cleaning different body parts but did not clean her hands in between. Both CNAs completed the care, dressed the resident, and transferred him to a wheelchair without removing gloves, cleaning hands, or donning new gloves. The Director of Nursing confirmed that staff should clean their hands after removing gloves and before putting on new ones, as per the facility's hand hygiene policy.
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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.
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Nursing homes near Naperville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowbrook Manor - Naperville | 1.5 mi | ★★★★★ | 6 | 0 |
| St Patrick's Residence | 1.6 mi | ★★★★★ | 4 | 1 |
| Pearl Of Naperville, The | 1.8 mi | ★★★★★ | 10 | 0 |
| Tabor Hills Health Care Fac | 2 mi | ★★★★★ | 0 | 0 |
| Thrive Of Lisle | 2.4 mi | ★★★★★ | 1 | 0 |
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