Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
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 Hearthwood Snf Senior Living during CMS and state inspections, most recent first.
The facility failed to implement its own water management plan by not conducting the required annual Legionella distal site testing of its water system, despite having a written policy and a contract with a water management service. The Administrator and Maintenance Director both acknowledged that Legionella testing had never been performed, even though testing supplies had been delivered and the plan, based on ASHRAE Standard 188, called for annual monitoring and documentation. This failure to carry out the specified control validation measures affected all residents in the facility.
The facility failed to ensure proper PPE use for residents on isolation, affecting three residents and potentially all 54 residents. A nurse allowed a visitor to enter a Covid-19 isolation room with only a surgical mask, and another visitor was seen without PPE in a Herpes Simplex isolation room. The facility also neglected to test its water for Legionella, as required by its water management plan.
The facility failed to provide the mandatory 12 hours of annual training to CNAs, affecting the care of 54 residents. The deficiency was due to a missed skills fair in 2024 and a lack of documentation for training hours. The HR Director confirmed the absence of required training, and a review of CNA files showed none had completed the necessary hours.
Surveyors found unsecured medications in the rooms of six residents, including over-the-counter and prescription drugs, without proper physician orders for storage. The facility's policy requires medications to be stored in locked compartments, but medications like Advil, DayQuil, Nystatin, and nasal sprays were found on dressers and bedside tables. Some residents had cognitive impairments, and the Director of Nursing confirmed that medications should not be stored in rooms without orders.
The facility failed to provide adequate assistance with ADLs for three residents who required help with personal hygiene. One resident was observed with long, jagged fingernails despite needing staff assistance due to severe cognitive impairment. Another resident had facial hair and unclean fingernails, although his care plan required substantial assistance. A third resident expressed a desire for help with facial hair removal, but her care plan for partial assistance was not followed. The DON stated that CNAs are responsible for these tasks, but there was no scheduled time for ADLs.
The facility failed to provide meaningful activities to three residents, as observed during a survey. One resident expressed dissatisfaction with the lack of activities brought to her room, despite her care plan indicating preferences for socializing and puzzles. Another resident reported that staff did not bring activities or engage with her, and documentation showed sporadic activity provision. A third resident's caregiver stated that the facility did not provide activities or engage with her, despite her care plan indicating enjoyment in leisure activities. The facility's policy emphasizes providing activities based on assessments and preferences, yet the survey findings indicate a failure to adhere to these guidelines.
The facility failed to ensure that a resident's signed POLST form and physician's order were consistent, reflecting the resident's treatment wishes in the event of a medical emergency. The resident's POLST indicated No CPR, while the physician's order indicated Full Code - CPR. This inconsistency was acknowledged by staff but not corrected, leading to conflicting information in the resident's records.
A resident with multiple diagnoses, including respiratory failure and congestive heart failure, did not receive the prescribed 5 liters per minute of oxygen. Instead, the oxygen concentrator was set to 3.5 liters per minute, as confirmed by multiple staff members. This discrepancy was observed despite the facility's policy requiring verification and proper adjustment of oxygen delivery.
A facility failed to ensure narcotic medications were not shared between residents. A nurse gave a hydrocodone/acetaminophen tablet from one resident to another who had an order but no prescription yet. The facility's policy prohibits this practice, requiring a valid prescription for narcotic administration.
The facility failed to identify and monitor behaviors and provide a diagnosis targeted for a prescribed antipsychotic medication for a resident. The resident was calm and had a flat affect, with no documented psychotic illness necessitating the use of Quetiapine. The facility did not adhere to its policy on psychotropic medication use, as there was no evidence of required conditions being met.
Failure to Implement Required Legionella Testing Under Water Management Plan
Penalty
Summary
The deficiency involves the facility’s failure to follow its own water management plan by not conducting required Legionella testing of the building’s water system. The Administrator stated that the facility had never tested its water for Legionella, despite having a written Water Management Plan that specifies Legionella distal site testing with an annual monitoring frequency. The facility entered into a contract with a new water management service on 03/01/2025, after the prior survey, and received Legionella testing supplies dated 05/06/2025, but no testing was performed. The Administrator reported being unaware of why the testing was not done, even though the facility was expected to follow its policy and water management plan. The Maintenance Director confirmed that the facility had not been tested for Legionella and physically presented the unused testing supplies provided by the water management service. The facility’s Water Management Plan, dated 03/17/2025, outlines a risk management strategy based on ASHRAE Standard 188, including identifying building water systems, conducting hazard analysis, establishing control locations and measures, and implementing verification and validation procedures. The plan specifically requires annual Legionella distal site testing as part of control validation and mandates written documentation of monitoring, compliance with control limits, corrective actions, and validation, to be maintained for at least three years. Despite these written requirements, the facility did not carry out the annual Legionella testing or generate the associated documentation, affecting all 55 residents residing in the facility.
Inadequate PPE Use and Water Testing in Facility
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) for residents on isolation status, affecting three residents and potentially all 54 residents in the facility. Observations revealed that a registered nurse allowed a visitor to enter a resident's room with only a surgical mask, despite the resident being on contact and droplet isolation for Covid-19. Another visitor was seen in a resident's room without any PPE, even though the resident was on contact isolation for Herpes Simplex. The facility's Infection Preventionist confirmed that visitors are expected to follow the facility's policy on PPE, which includes wearing gowns, gloves, masks, and eye protection as necessary. However, staff failed to educate visitors on these requirements. Additionally, the facility did not adhere to its water management plan, as it had never tested the water for Legionella or other opportunistic waterborne pathogens. The plan, dated 2017, required water samples to be collected and tested four times yearly, especially in buildings occupied by high-risk individuals such as seniors in nursing homes. This oversight in testing could potentially affect the health and safety of all residents in the facility.
Failure to Provide Mandatory CNA Training
Penalty
Summary
The facility failed to provide the mandatory 12 hours of annual training to their Certified Nursing Assistants (CNAs), which is required for all staff to ensure they have the necessary skills to care for residents, including training in dementia care and abuse prevention. This deficiency was identified during a review of the facility's training records and interviews with staff members. The facility has a current census of 54 residents, and the lack of training affects all CNAs responsible for their care. The CNA Supervisor and the Director of Nursing both acknowledged the absence of the required training, attributing it to a missed skills fair in 2024 due to a transition in management and human resources. The Human Resources Director, who assumed the role in November 2024, confirmed the absence of documentation for the 12 hours of training for the CNAs. Although a skills fair was conducted in 2023, it did not specify the number of hours for each topic, and there was no skills fair in 2024. A review of five CNA files revealed that none had completed the required training hours. The facility's policy mandates a minimum of 16 hours of initial training in various areas before CNAs have direct contact with residents, but the annual requirement of 12 hours was not met, leading to this deficiency.
Unsecured Medications Found in Resident Rooms
Penalty
Summary
The facility failed to ensure that resident medications were safely secured, as observed during a survey. Medications were found unsecured in the rooms of six residents, including over-the-counter drugs and prescription medications. For instance, bottles of Advil, DayQuil, and Loperamide were found on a resident's dresser, with no physician orders for these medications to be stored in the room. Another resident had Nystatin powder on their bedside table, which was not ordered to be stored at the bedside. Similar findings were noted for other residents, with medications such as saline nasal spray, Fluticasone Propionate nasal spray, and various creams found unsecured in their rooms. The residents involved had varying levels of cognitive impairment, with some being severely impaired and others having intact cognition. Despite this, the facility's policy required all medications to be stored in locked compartments, and any medications brought from home needed a physician's order to be used. The Director of Nursing confirmed that medications should not be stored in residents' rooms without proper orders. The facility's failure to adhere to these policies resulted in unsecured medications being accessible in residents' rooms, posing potential risks to resident safety.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) for three residents who required help with personal hygiene. Resident R32 was observed with long and jagged fingernails, despite having a care plan that indicated she needed staff assistance for personal hygiene due to severe cognitive impairment and physical limitations. Similarly, Resident R10 was found with facial hair and long, unclean fingernails, although his care plan required substantial assistance for personal hygiene. He could not recall the last time he received nail care or was shaved. Resident R33 also exhibited signs of neglect in personal hygiene, with jagged fingernails and facial hair that she expressed a desire to have removed. Her care plan indicated a need for partial assistance with personal hygiene due to moderate cognitive impairment. The Director of Nursing acknowledged that CNAs are responsible for these tasks, but there was no scheduled time for ADLs, which are performed as needed. The facility's policy mandates that residents unable to perform ADLs independently should receive necessary services to maintain grooming and hygiene, which was not adhered to in these cases.
Failure to Provide Meaningful Activities to Residents
Penalty
Summary
The facility failed to provide meaningful activities to three residents, R25, R32, and R33, as observed during a survey. R25, who is alert and oriented, expressed dissatisfaction with the lack of activities brought to her room, despite her care plan indicating a preference for socializing, watching TV game shows, and doing word search puzzles. The documentation showed that R25 only received activities on a few occasions in January and February 2025, with no records of her refusing to participate in activities. R33, with intact cognition, also reported that staff did not bring activities to her room or engage with her. Her care plan highlighted her preference for informal room activities such as reading novels and watching TV. The documentation revealed that R33 received activities sporadically in January and February 2025, and there were no notes indicating her refusal to participate. Additionally, R32 was observed with her private caregiver, who stated that the facility did not provide activities or engage with R32, despite her care plan indicating enjoyment in independent leisure activities and occasional participation in facility activities. The facility's Activity Program policy, dated June 2018, outlines that activities should support residents' well-being and be based on comprehensive assessments and preferences. The policy emphasizes the importance of providing activities seven days a week, yet the survey findings indicate a failure to adhere to these guidelines, as evidenced by the lack of consistent activity engagement for the residents involved.
Inconsistent POLST and Physician's Order for Resident
Penalty
Summary
The facility failed to ensure that a resident's signed POLST (Practitioner Order for Life-Sustaining Treatment) form and physician's order were consistent, reflecting the resident's treatment wishes in the event of a medical emergency. This deficiency was identified for one resident who had multiple diagnoses, including Parkinsonism, generalized muscle weakness, and stage 3 chronic kidney disease. The resident's quarterly MDS indicated cognitive intactness. The active physician order summary report showed an order for Full Code - CPR, while the POLST form indicated No CPR: Do Not Attempt Resuscitation (DNAR). The POLST form was signed by the resident's legal representative and primary care physician but was not scanned into the resident's electronic records, leading to conflicting information in the resident's physical chart and electronic records. During the survey, a registered nurse and the Social Service Director acknowledged the inconsistency between the POLST form and the physician's order. The Director of Nursing confirmed that the physician's order is part of the resident's plan of care and should be consistent with the signed POLST to prevent confusion during emergency procedures. The facility's policy on advance directives also emphasized that the plan of care should align with the resident's documented treatment preferences. The inconsistency was not addressed when the POLST was signed, resulting in a failure to update the physician's order from Full Code to DNR, as required by the facility's policy.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen to a resident as ordered by the physician. The resident, who had diagnoses including respiratory failure with hypercapnia, congestive heart failure, bradycardia, atrial fibrillation, obstructive sleep apnea, and anxiety disorder, was observed with his oxygen concentrator set to deliver 3.5 liters per minute instead of the prescribed 5 liters per minute. This discrepancy was noted during multiple observations on the same day, and confirmed by a CNA, the Infection Control Nurse, and an LPN. The physician's order for continuous oxygen at 5 liters per minute via nasal cannula was initiated on July 17, 2023, and discontinued on April 22, 2024, at 2:13 PM. Despite the care plan indicating the need for oxygen therapy related to congestive heart failure, the resident's oxygen was not administered at the correct rate. The facility's policy on oxygen administration, revised in October 2023, was not followed, as it requires verification of the physician's order and proper adjustment of the oxygen delivery device to ensure the correct flow rate.
Narcotic Medication Borrowed Between Residents
Penalty
Summary
The facility failed to ensure that a narcotic medication was not borrowed from one resident and given to another resident. This incident involved a resident who had a physician order for hydrocodone/acetaminophen but did not yet have a prescription processed by the pharmacy. A registered nurse admitted to giving this resident a hydrocodone/acetaminophen tablet that belonged to another resident, which resulted in a discrepancy in the narcotic count. The nurse stated that the facility's policy prohibits sharing narcotic medications between residents, but he was unable to obtain the medication from the backup supply due to the lack of a prescription at that time. The resident who received the borrowed medication had a medical history that included syncope, history of falling, pain in the right shoulder, and the presence of a cardiac pacemaker. The pharmacist confirmed that an order is not sufficient for administering narcotics and that a valid prescription is required. The Director of Nursing reiterated that the facility's policy mandates a prescription for narcotic administration and prohibits sharing medications between residents. The facility's policy on administering medications emphasizes verifying the right resident, medication, dose, time, route, and documentation before administration.
Failure to Monitor and Justify Antipsychotic Medication Use
Penalty
Summary
The facility failed to identify and monitor behaviors and provide a diagnosis targeted for a prescribed antipsychotic medication for one resident. The resident, who was admitted with multiple diagnoses including unspecified dementia with behavioral disturbance and anxiety disorder, was observed to be calm and had a flat affect. The resident's physician order sheet included an order for Quetiapine Fumarate for anxiety, but there was no documented psychotic illness that would necessitate the use of an antipsychotic medication. Additionally, the PASRR indicated no severe mental illness, and there was no record of behavior monitoring in the facility record. A progress note from a psychiatric nurse practitioner mentioned a history of screaming and resisting care but did not provide other diagnostic criteria for the use of the antipsychotic medication. The resident's spouse confirmed that the resident was not taking Quetiapine before being hospitalized prior to admission to the facility. The facility's policy on psychotropic medication use states that antipsychotic medications should only be used for specific conditions and diagnoses, and behavioral symptoms must present a danger to the resident or others. The facility did not adhere to its policy, as there was no documented evidence of the required conditions being met for the use of Quetiapine in this case.
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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 Bartlett
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bella Terra Streamwood | 2.1 mi | ★★★★★ | 2 | 0 |
| Ignite Medical Hanover Park | 2.6 mi | ★★★★★ | 2 | 0 |
| Aperion Care Fox River | 4.7 mi | ★★★★★ | 0 | 0 |
| Alden Poplar Creek Rehab & Hcc | 4.9 mi | ★★★★★ | 9 | 0 |
| Crescent Care Of Elgin | 5.3 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.