Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Meadowbrook Manor - Naperville during CMS and state inspections, most recent first.
The facility failed to test multiple residents with new respiratory symptoms for COVID-19 and other respiratory pathogens as required by its process and CDC guidance. Residents with cough, sore throat, raspy voice, and other respiratory symptoms were placed on isolation, but records did not show rapid COVID-19 tests, COVID-19 PCR tests, respiratory quad panels, or RSV testing for several residents; one resident was tested for flu, RSV, and rapid COVID only, with no PCR documentation. The facility also failed to follow its Legionella water management plan because required real-time documentation of hot water temperatures, distal site temperatures, mixing valve temperatures, and pump checks was not available, and the maintenance director said he was unsure how parts of the plan applied.
Dining practices did not preserve resident dignity when staff seated residents who could feed themselves with residents who needed feeding assistance but did not serve everyone at each table at the same time. Several residents waited while tablemates ate, and one resident grabbed a tablemate's tray before staff intervened. In another incident, an 88-year-old resident repeatedly refused a clothing protector, stating it made him feel like a baby, but the CM still fastened it around his neck despite his protest.
Inaccurate controlled medication counts were found for multiple residents when narcotic logs did not match the actual remaining quantities of Lorazepam, Alprazolam, Hydrocodone-Acetaminophen, Pregabalin, and Oxycodone-Acetaminophen on medication carts and in memory care. The DON stated nurses are expected to count narcotics at shift change and document each removal for administration, and the facility policy requires reconciliation upon receipt, administration, disposition, and at the end of the shift.
Failure to Offer Updated COVID-19 Vaccine to Residents: The facility did not offer the 2025-2026 COVID-19 vaccine to 5 reviewed residents, and EMR review showed no documentation that the vaccine was received or offered. The ADON/IP confirmed the residents were not offered the vaccine, and the DON stated residents are considered up to date only when they receive the 2025-2026 COVID-19 immunization.
Failure to keep a resident free from chemical restraint. A resident with dementia, psychotic disturbances, MDD, and anxiety was receiving Aripiprazole and Mirtazapine, and the record showed moderately impaired cognition and psychotropic use on the MDS. When asked for evidence of a GDR, the DON provided a pharmacy consult noting the resident had been on Aripiprazole for MDD since the prior year and requesting a gradual dose reduction, but it had not been addressed by psychiatry.
Failure to provide nail care assistance for residents needing help with personal hygiene. Three residents with diagnoses including CVA-related hemiplegia, dementia, aphasia, and Parkinson's disease were observed with long, jagged, or dirty nails with blackish substance underneath. Each resident required substantial assistance or was dependent for personal hygiene per MDS/care plan, and one resident stated staff had not cleaned the nails despite repeated requests. The DON stated CNAs were responsible for cutting and cleaning nails, mostly on shower days and as needed.
Multiple residents experienced significant delays in receiving incontinence care, assistance with call lights, and other essential services due to insufficient nursing staff. Observations included residents left in soiled briefs for hours, unaddressed medical needs, and staff unable to complete scheduled care tasks. Staffing schedules confirmed frequent understaffing compared to facility requirements, and there was no formal staffing policy in place.
A resident developed a pressure ulcer and UTI after admission, reporting long waits for incontinence care and needing to contact a family member for assistance. Staff observed dried feces and skin redness, and confirmed that incontinence care and repositioning were not provided as required. Facility policy mandates timely care to prevent skin breakdown, but this was not followed, resulting in the resident's condition.
A diabetic resident with multiple comorbidities developed a necrotic ulcer on the left heel after staff failed to perform and document routine foot and skin checks as required by facility policy. Despite being at high risk for skin breakdown and having a care plan that included regular monitoring, no skin alterations were recorded prior to the discovery of the advanced wound, which ultimately required vascular consultation.
A resident with a history of falls, cognitive impairment, and mobility issues was left unsupervised in their room, leading to an unwitnessed fall while attempting to self-transfer from a wheelchair. Despite a care plan calling for increased supervision and visual monitoring, the resident experienced multiple unwitnessed falls, culminating in a serious head injury and seizure that required hospitalization.
A resident with cognitive impairment alleged that a family member stole money from their bank account and revoked the family member's power of attorney. Although the allegation was communicated to the DON and Social Services, the abuse coordinator did not investigate or report the incident, believing it was a misunderstanding. No documentation of an investigation or state report was found, despite facility policy requiring such actions.
A resident with multiple pressure wounds was found on a non-functioning air-loss mattress, which was disconnected from the pump and emitting a beeping alarm that staff did not address. The resident was also lying on bunched-up pads and a sheet, and subsequently developed a new deep tissue injury despite care plans and orders requiring regular monitoring and use of a pressure-reducing mattress. Staff interviews revealed a lack of specific policy for air-loss mattresses and failure to respond to equipment alarms.
A resident with cognitive and physical decline requested assistance to revoke a POA and pursue a divorce, but staff did not make a referral to the Ombudsman or provide needed legal aid support, leaving the resident without necessary social services.
A resident with diabetes was administered fast-acting insulin despite refusing meals, contrary to medication instructions requiring insulin to be given with food. Staff failed to follow hypoglycemic protocols and did not ensure an emergency glucagon order was in place. The resident was later found unresponsive with severe hypoglycemia and required emergency intervention and hospitalization.
A CNA transferred a high fall risk resident with severe cognitive impairment without a gait belt and without a second staff member, contrary to the resident's care plan and facility policy. The resident, who had a recent history of multiple falls and was wearing only socks, was left unattended during the process. The correct transfer procedure was only followed after another CNA joined and a gait belt was applied.
The facility failed to provide adequate pressure ulcer care for two residents, resulting in delayed healing. One resident was not repositioned regularly and received inadequate incontinence care, while both residents missed scheduled wound care treatments. Staff interviews revealed a lack of awareness and oversight, and facility policies were not followed.
The facility failed to provide timely incontinence care, showers, oral care, and shaving assistance for several residents. One resident, dependent on staff for ADLs, was not receiving scheduled showers or oral care, with his spouse performing these tasks instead. Another resident had not received oral care, and others expressed a desire for shaving assistance. The Director of Nursing acknowledged the deficiency, noting that residents should receive showers twice a week.
A resident was transferred to the hospital due to acute medical issues, but the facility failed to notify the resident's spouse or other emergency contacts. The LPN called the wrong area code and did not attempt further contact, leaving the spouse unaware until the hospital reached out the next day. This oversight violated the facility's policy on immediate notification of changes in a resident's condition.
The facility failed to maintain sanitary practices during dishwashing and storage of dish rags, affecting 199 residents. Observations revealed improper handling of clean dishes by dietary aides without changing gloves or washing hands, and inadequate storage of dish rags. The Director of Dining Services confirmed the lack of a policy for these procedures, contributing to the deficiency.
The facility failed to assist seven residents with personal hygiene and grooming, despite their care plans indicating the need for substantial assistance. Residents with various medical conditions were observed with unkempt appearances, including overgrown facial hair and dirty fingernails. Staff acknowledged the need for care but did not provide the necessary assistance, contrary to facility policies on ADLs and nail care.
The facility failed to label and date opened medications, leading to expired insulins being stored in medication carts. Additionally, a narcotic medication was improperly handled with a torn package. These issues affected ten residents, with the Director of Nursing acknowledging the need for proper labeling and disposal procedures.
A resident with severe cognitive impairment and multiple diagnoses developed pressure wounds that worsened due to the facility's failure to provide ordered wound treatment. The resident's right buttock wound, initially a stage 2, became unstageable due to lack of dressing and exposure to contaminants. The facility did not document the prescribed treatment, and the resident was not repositioned as required, leading to the deficiency.
A resident with Parkinson's disease and upper extremity impairment was not consistently provided with a prescribed resting hand splint to prevent contractures. Despite care plans and physician orders, the splint was often not applied, as confirmed by observations and staff interviews. The splint was found in a dresser drawer, and staff reported inconsistencies in its application, leading to a deficiency in care.
A resident with Alzheimer's and dementia, under hospice care, was transferred by a single CNA using a mechanical lift, despite care plan instructions requiring two staff members. The Restorative Director confirmed the need for two staff during transfers for safety.
Two residents with significant weight loss received substitute meals that did not meet the facility's policy for equivalent nutritive value. The main meal provided 3 oz of protein, while the substitute egg salad sandwich contained only 2 oz. The Director of Dining Services acknowledged the discrepancy.
Two residents in a LTC facility experienced medication administration errors, resulting in a 15.63% error rate. A nurse administered a lower dosage of Vitamin D3 and omitted other medications for one resident. Another nurse gave three puffs of Albuterol without the required interval and omitted a nasal spray for a second resident. The DON highlighted the need to follow physician's orders and the five rights of medication administration.
The facility failed to follow infection control practices, including improper gown removal and inadequate hand hygiene. A nurse did not remove her isolation gown after administering medication to a resident on Enhanced Barrier Precaution, and a CNA carried soiled linens without a plastic bag. Another CNA did not perform hand hygiene after assisting a resident, violating the facility's policies.
A resident was found with bruising around her eye and indicated she was punched by a man. Despite this, the incident was not reported to the appropriate authorities. An LPN reported the injury to a nurse practitioner but did not escalate it further. The DON and Assistant DON were not informed, and the administrator was unaware of the incident. The facility's policy requires such injuries to be reported, but this was not followed.
A resident with a known surgical wound was readmitted to the facility without proper assessment or treatment orders. Despite being informed of the wound, the facility staff did not assess the wound or obtain necessary treatment orders until several days later, contrary to the facility's policies on skin assessment and care.
Facility staff failed to report an allegation of mistreatment and potential sexual abuse involving a resident. Despite the resident's report of rough handling and pain during incontinence care, the staff did not inform the administrator as required by the facility's abuse policy.
Failure to Test Residents With New Respiratory Symptoms and Follow Water Management Plan
Penalty
Summary
The facility failed to perform laboratory testing for residents who developed new respiratory illness symptoms. R164 was observed in a room with R209 under contact and droplet isolation, but the sign outside the room did not indicate that an N95 mask was required to enter. R164’s record showed admission with diagnoses including hypertensive heart disease, epilepsy, nasal congestion, and cough, and a nurse progress note documented coughing, sore throat, and a raspy voice with oseltamivir in use. By the time of review, there was no documentation of a rapid COVID-19 test, COVID-19 PCR test, or respiratory quad panel for R164. R209’s record showed admission with chronic respiratory failure and Alzheimer’s disease/dementia. A nurse progress note documented respiratory symptoms, notification of the nurse practitioner, and orders for a stat CBC with differential/CMP and chest x-ray, with family notified. There was no documentation that a rapid COVID-19 test, COVID-19 PCR test, or respiratory quad panel had been performed. R142, who had COPD with acute exacerbation, asthma, CHF, and supplemental oxygen dependence, was also placed on contact and droplet isolation, but the sign outside the room did not show that an N95 mask was required. A progress note described a possible upper respiratory infection with occasional cough, and there was no documentation of a rapid COVID-19 test, COVID-19 PCR test, or RSV test. R85, who had CHF, Alzheimer’s disease, dementia, and a personal history of COVID-19, was noted to be coughing and placed on isolation for coughing, with the POA notified, but there was no documentation of a rapid COVID-19 test, COVID-19 PCR test, or respiratory quad panel. R188, who had Alzheimer’s disease, dementia, and COPD, had a cough and was tested for flu, RSV, and a rapid COVID test, but there was no documentation of a rapid COVID-19 PCR test. The IP nurse stated the facility was in an influenza A and RSV outbreak so residents with respiratory illness symptoms were no longer being tested for acute respiratory illness, while the DON stated residents with respiratory symptoms should have a respiratory quad panel and that if a rapid COVID test was negative, a COVID-19 PCR test should have been done. The CDC Viral Respiratory Pathogens Toolkit for Nursing Homes was cited as stating that residents and healthcare providers with new respiratory illness signs or symptoms should be tested, with testing at a minimum including SARS-CoV-2 and influenza, with consideration for RSV. The facility also failed to follow its water management plan. The plan required monitoring of hot water generation and storage temperatures weekly, distal site temperatures quarterly, thermostatic mixing valve temperatures quarterly, and daily pump operation checks, along with documentation of these activities. The maintenance director stated he documented water management monitoring in a computerized building management platform, did not do anything with the hot water return pumps, was unsure what the plan meant when it referred to a pump, and thought a company came annually to inspect a pump. The administrator provided handwritten documentation from the maintenance director, and later stated it was recreated from memory, including water temperature results. The facility did not have documentation showing real-time monitoring of quarterly distal site temperatures, weekly hot water generation and storage temperatures, daily pump operation inspection, hot water return temperature, or quarterly thermostatic mixing valve temperatures.
Dining Practices Did Not Preserve Resident Dignity
Penalty
Summary
The facility failed to provide a dining experience in a manner that promoted dignity for 6 of 16 residents reviewed for dining experience. During lunch in the 3rd floor dining room, residents who could feed themselves were seated at tables with residents who required feeding assistance, but staff did not ensure that everyone at the same table was served at the same time. At one table, R42 and R191 waited while three tablemates were already eating; R42 did not begin eating until after receiving the tray, and R191 had to wait for staff assistance before eating. At another table, R138 waited while other residents at the table ate and finished their meals before R138 received a tray and was fed. R80 was seated alone near the exit door and was served later while watching others eat. R12 also waited while tablemates ate, then grabbed a tablemate's tray before staff intervened; R12 later received a tray but still had to wait for staff to come feed her. On January 14, 2026, R199 was waiting for lunch when the Clinical Manager attempted to place a clothing protector on him. R199 protested and stated he did not want it because he was 88 years old and it made him feel like a baby. Despite his repeated refusal and attempts to block and remove it, the Clinical Manager continued fastening the clothing protector around his neck and then walked away. The facility's policy stated to avoid using bibs or clothing protectors unless requested by the resident, and the DON stated that residents may use a clothing protector if requested and that staff must respect a resident's refusal.
Inaccurate Controlled Medication Counts
Penalty
Summary
The facility failed to document narcotic medications removed from their containers for resident administration, resulting in inaccurate controlled medication counts for 10 of 10 residents reviewed for controlled medication count in a sample of 35. During a narcotic count in the memory care unit, discrepancies were found between the log sheets and the actual counts for multiple residents, including Lorazepam, Alprazolam, Hydrocodone-Acetaminophen, Pregabalin, and Oxycodone-Acetaminophen. Examples included counts that were one or two tablets or capsules lower than the documented remaining amounts for residents such as R55, R126, R145, and R74. Additional discrepancies were observed on two medication carts, where the documented remaining quantities did not match the actual counts for residents including R18, R34, R141, R109, R58, and R2. The DON stated that nurses are supposed to count narcotics during shift change and document and sign the narcotic sheet every time a narcotic medication is removed for administration to ensure accuracy and accountability. The facility policy dated April 2025 states controlled substances are reconciled upon receipt, administration, disposition, and at the end of the shift, and that the administering nurse is responsible for recording the resident receiving the medication, the quantity remaining, and the nurse’s signature.
Failure to Offer Updated COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to offer the updated 2025-2026 COVID-19 vaccine to 5 of 5 residents reviewed for immunizations in a sample of 35: R48, R71, R142, R162, and R164. The EMR immunization reports dated January 14, 2026, did not show that any of these residents had received or been offered the updated vaccine, and the facility had no documentation showing that the vaccine was offered to them. The residents had multiple diagnoses, including sleep apnea and hypertensive heart disease for R48; transient ischemic attack, stroke, and epilepsy for R71; COPD with acute exacerbation, asthma, CHF, and dependence on supplemental oxygen for R142; essential hypertension, venous insufficiency, and a personal history of COVID-19 for R162; and hypertensive heart disease and epilepsy for R164. During interviews, the ADON/IP stated he follows CDC guidelines for COVID-19 vaccinations and confirmed that R48, R71, R142, R162, and R164 were not offered the 2025-2026 COVID-19 vaccine. The DON stated the expectation was for the ADON/IP to follow the facility policy for COVID-19 immunizations and confirmed that residents are considered up to date when they receive the 2025-2026 COVID-19 immunization. The facility policy required eligible residents and staff to be encouraged to receive the most recent seasonally updated COVID-19 vaccine, and the CDC adult immunization schedule dated October 7, 2025, showed adults 65 years or older are recommended to receive two or more doses of the 2025-2026 COVID-19 vaccine.
Failure to Complete or Document GDR for Psychotropic Medication
Penalty
Summary
The facility failed to keep one resident free from chemical restraint. R11 was admitted with diagnoses including dementia with psychotic disturbances, major depressive disorder, and adjustment disorder with anxiety. R11’s MDS dated November 26, 2025, showed moderately impaired cognition and indicated use of an antipsychotic and an antidepressant. The care plan identified psychotropic medication use related to MDD and adjustment disorder with anxiety and included consultation with pharmacy and the MD to consider dosage reduction when clinically appropriate at least quarterly. R11’s January MAR showed Aripiprazole 1 mg daily at 5:00 PM for MDD and Mirtazapine 7.5 mg at bedtime for major depressive disorder, recurrent, mild. On January 13, 2026, the DON was asked to show evidence that a GDR had been completed or attempted for R11. On January 14, 2026, the DON provided a pharmacy consultation report dated May 1, 2025, to May 31, 2025, which stated that R11 had received Aripiprazole every night for MDD since April 2024 in addition to Mirtazapine and requested a gradual dose reduction. The DON stated the consultation report was obtained by calling pharmacy but was not addressed by psychiatry.
Failure to Provide Nail Care Assistance for Residents Needing Help with Personal Hygiene
Penalty
Summary
The facility failed to provide assistance with cleaning and trimming nails for residents who required extensive or dependent assistance with personal hygiene. The deficiency involved 3 of 5 residents reviewed for ADLs in a sample of 35. Facility policy for ADLs stated that appropriate care and services would be provided for residents unable to carry out ADLs independently, including hygiene and nail care, in accordance with the plan of care. One resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, vascular dementia, aphasia, unsteadiness on feet, and cognitive communication deficit. The resident's MDS showed cognitive intactness and substantial maximal assistance needed for personal hygiene. During observation, the resident's left-hand nails were long with blackish substance underneath, and later the right-hand nails were observed long and digging into the palm with blackish substance underneath some nails. The resident stated a desire to have the nails cut and cleaned. The resident's care plan identified an ADL self-care performance deficit and need for substantial assistance with personal hygiene. A second resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, unspecified dementia, Alzheimer's disease, cognitive communication deficit, unsteadiness on feet, and lack of coordination. The admission MDS showed severe cognitive impairment and dependence for personal hygiene. The resident's nails were observed to be very long, jagged, broken, and with blackish substance underneath, and the resident stated a desire to have them clipped. A third resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, cerebral infarction, contracture of the left hand, and Parkinson's disease. The quarterly MDS showed cognitive intactness and substantial maximal assistance for personal hygiene. The resident's nails were short but had extensive blackish substance underneath, and the resident stated they were filthy and that staff had not cleaned them despite repeated requests. The DON stated that CNAs were responsible for cutting and cleaning nails mostly on shower days and as needed.
Failure to Provide Adequate Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide adequate nursing staff to meet the care needs of residents, resulting in multiple instances where residents did not receive timely assistance with incontinence care, prevention of pressure wounds, and response to call lights. One resident, recently admitted with a pressure wound and urinary tract infection, reported waiting hours for incontinence care, sometimes needing to call a family member for help in contacting staff. Upon observation, dried feces and skin redness were noted, and the resident had not received incontinence care or repositioning for several hours during the shift. Staff confirmed that care was delayed and that the wound nurse, not the assigned CNA, provided the necessary care during a dressing change. Another resident was observed repeatedly calling for help, with the call light on and staff walking past without responding. The resident reported nausea and discomfort from knee braces, and stated that requests for medication and assistance were not addressed for several hours. Staff interviews confirmed that the resident's complaints were reported to the nurse multiple times, but the nurse had not administered the ordered medication. Facility policy requires prompt response to call lights, but this was not followed. Additional residents and family members reported similar issues, including long waits for incontinence care, missed showers, and insufficient staff to meet scheduled care needs. Staff interviews revealed that CNAs were assigned to care for up to 20 residents at a time, making it difficult to complete all required tasks. The facility's staffing schedules showed that, on at least 22 shifts, the number of nurses or CNAs was below the facility's own requirements. The administrator confirmed there was no formal staffing policy in place.
Failure to Provide Timely Incontinence Care and Repositioning for Resident with Pressure Ulcer
Penalty
Summary
A resident who was recently admitted to the facility developed a pressure wound on her buttocks and a urinary tract infection (UTI) after arrival. The resident reported that the facility was short staffed and that she had experienced significant delays in receiving incontinence care, sometimes waiting for hours after calling for assistance. On at least one occasion, she contacted a family member to call the nursing station on her behalf due to the prolonged wait for care. During an observation, a CNA and a physical therapist found the resident's undergarment dry but with large streaks of dried feces, and dried, caked feces were present between the gluteal fold. The resident's labia and gluteal fold were reddened, and there was a small open area on her coccyx. The CNA confirmed that she had not provided incontinence care or repositioned the resident during her shift until the time of the observation, and that the wound nurse had provided care during a dressing change. The resident is obese, incontinent of bowel and bladder, and unable to reposition herself without assistance from two staff members. Interviews with staff and review of records indicated that there was no documentation of a pressure wound or UTI at the time of admission, and the wound was first documented two days after admission. Facility policy requires that all residents receive appropriate care to decrease the risk of skin breakdown, including cleaning skin at the time of soiling and at routine intervals, and providing incontinence care to keep residents dry and comfortable. The failure to provide timely incontinence care and repositioning contributed to the resident's skin breakdown and development of a pressure wound.
Failure to Monitor and Document Diabetic Foot Care
Penalty
Summary
A diabetic resident with multiple comorbidities, including hemiplegia, vascular disease, and immobility, was admitted to the facility and identified as being at high risk for skin breakdown. The resident's care plan included regular skin and foot inspections as per facility protocol, and the podiatrist provided recommendations for daily foot care and monitoring. Despite these interventions, documentation and interviews revealed that routine skin checks, particularly of the feet, were either not performed adequately or not documented accurately by nursing staff and CNAs. Over the course of a month, no skin alterations were recorded, even though the resident was dependent on staff for mobility and hygiene and at high risk for ulcers. On assessment, the resident was found to have developed a necrotic diabetic ulcer on the left heel, which was not identified until it had progressed to a significant size with 100% hard eschar. The wound required a vascular consultation for possible surgical intervention. Staff interviews confirmed that the wound should have been detected earlier, and the facility's own policies required daily skin assessments and prompt reporting of changes, especially for residents with diabetes and vascular disease. The failure to monitor and document the resident's foot condition in accordance with professional standards and facility policy led to the development and progression of the necrotic ulcer.
Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Fall and Hospitalization
Penalty
Summary
A resident with a significant history of falls, traumatic brain injury, hydrocephalus, vascular dementia, severe cognitive impairment, and mobility issues was not adequately supervised, resulting in an unwitnessed fall in their room. The resident's care plan identified them as high risk for falls and included interventions such as increased supervision, conducting rounds, and placing the resident in common areas for visual monitoring. Despite these interventions, the resident experienced multiple unwitnessed falls in their room, with the most recent incident occurring when the resident attempted to self-transfer from their wheelchair without assistance. At the time of the fall, the assigned CNA was assisting in the dining room, and the assigned nurse was at the nurse's station, leaving the resident unsupervised. Following the unwitnessed fall, the resident was initially assessed and found to have no apparent injury or change in condition, but later developed a bump on the head and subsequently experienced a massive seizure while being transported to the hospital. Hospital records indicated the resident suffered a significant head trauma, acute encephalopathy, and seizures, leading to hospice care. The facility's policy required staff to implement and adjust individualized fall prevention interventions based on ongoing risk and incident review, but the repeated unwitnessed falls and lack of supervision in the resident's room demonstrated a failure to provide adequate supervision and prevent accident hazards as required.
Failure to Investigate and Report Alleged Financial Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of financial abuse involving a resident and a family member. The resident, who was noted to have cognitive impairment and physical decline, reported that a family member had stolen money from his bank account and subsequently revoked the family member's access and power of attorney. The allegation was communicated to the Director of Nursing by another family member, who then informed Social Services. Social Services followed up with the resident, who verbally revoked the financial power of attorney from the accused family member. Despite being aware of the allegation, the facility's abuse coordinator did not initiate an investigation or report the incident, believing it to be a misunderstanding. The resident's care plan identified a risk for abuse and included interventions to report potential abuse or neglect per policy. However, there was no documentation of an abuse allegation investigation or a report to the state health department regarding the financial abuse claim, contrary to the facility's abuse prevention policy, which requires all allegations to be investigated and reported.
Failure to Ensure Functionality of Pressure-Relieving Mattress for Resident with Pressure Wounds
Penalty
Summary
A resident with multiple pressure wounds was observed lying on an air-loss mattress that was not functioning due to being disconnected from the pump, as indicated by a continuous beeping alarm and lack of mattress inflation. Despite the alarm, staff, including a Certified Nurse Assistant and a Wound Care Nurse, did not address the malfunction during wound care. The resident was also found lying on two overlapping cloth pads and a sheet that were bunched up, which could further compromise pressure relief. The Wound Care Nurse believed the mattress was working properly, even though it was not. The resident had a recent history of readmission with multiple pressure wounds and was identified as being at risk for further skin breakdown, with care plans and physician orders specifying the use and regular monitoring of a pressure-reducing mattress. Documentation showed the development of a new deep tissue injury to the left buttock while under these interventions. Staff interviews confirmed that expectations included responding to and troubleshooting medical equipment alarms, but there was no specific facility policy regarding air-loss mattresses. The facility's general policy required the provision of support devices and assistance as needed for pressure injury prevention.
Failure to Assist Resident with Social Service Needs for POA and Legal Aid
Penalty
Summary
A resident with a history of cognitive impairment and recent physical decline expressed a desire to revoke an existing Power of Attorney (POA) and pursue a divorce, as communicated by a family member to the facility. The Director of Nursing was informed of the resident's request for legal aid, and the matter was relayed to the Social Services staff. The Social Services staff followed up with the resident, who verbally confirmed his wish to revoke the POA and proceed with the divorce, indicating another family member as the preferred new POA. The Social Services staff believed the new POA documents were with the out-of-state family member and informed the resident that he would need to obtain these documents and manage the divorce process independently. Despite the resident's ongoing requests and his declining cognitive and physical abilities, there was no evidence that the facility made a referral to the Ombudsman or provided assistance in securing legal aid, as required by facility policy. The Ombudsman confirmed that no referral had been received for the resident. The facility's policy mandates making referrals to social service agencies as necessary, but this was not done, resulting in a failure to assist the resident with his social service needs.
Failure to Follow Insulin Administration Protocols Leads to Hypoglycemic Emergency
Penalty
Summary
A diabetic resident experienced a significant medication error when nursing staff failed to follow insulin administration instructions. On the day in question, the resident refused both breakfast and lunch, but was still administered scheduled doses of fast-acting insulins (Humalog and Fiasp) as documented in the Medication Administration Record. The instructions for Humalog specifically required administration with meals. The Certified Nurse Assistant documented the meal refusals and informed the nurse on duty, but the insulin was administered regardless. Later that day, the resident was found unresponsive with abnormal breathing, and emergency paramedics determined the resident's blood sugar was critically low at 22. Emergency interventions, including intravenous fluids and glucagon, were required, and the resident was transferred to the hospital for further evaluation. Interviews with staff revealed a lack of awareness and adherence to the facility's hypoglycemic protocol. One nurse stated she was not aware of the protocol, and another believed an active order for emergency glucagon was required for diabetic residents. The resident's care plan included monitoring and reporting signs and symptoms of hypoglycemia, but there was no active order for glucagon in the resident's records. Facility policies required verification of insulin orders and administration instructions, but these were not followed, resulting in the resident's hypoglycemic episode.
Failure to Follow Two-Person Transfer and Gait Belt Protocol for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident with a history of multiple falls and severe cognitive impairment from a wheelchair to the toilet without the required use of a gait belt and without a second staff member present, as specified in the resident's care plan and the facility's policies. The CNA used the resident's waistband and incontinence brief to lift her, which resulted in the brief tearing and the resident being unable to bear full weight during the transfer. The resident, identified as a high fall risk by a yellow wristband, was wearing only socks at the time, and the CNA was unaware that shoes were available for her. The CNA left the resident unattended in the bathroom to seek assistance, and only upon return with another CNA was a gait belt used and the transfer completed according to protocol. The resident's electronic medical record (EMR) and care plan clearly indicated the need for a two-person assist and the use of a gait belt for all transfers, due to her multiple diagnoses including dementia, Alzheimer's disease, and a recent history of falls. The facility's policies also required staff to verify transfer techniques and use gait belts unless contraindicated or refused. Despite these documented requirements, the CNA failed to follow established procedures, resulting in an unsafe transfer process for the resident.
Failure in Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for residents, resulting in delayed healing of pressure ulcers for two residents. One resident, who was admitted with multiple diagnoses including a Stage 4 pressure ulcer, was not repositioned at regular intervals as ordered by the physician. Observations showed the resident lying in the same position for extended periods without repositioning or the use of positioning aids. Additionally, the resident was found with soiled incontinence briefs and inadequate incontinence care, which contributed to the deterioration of the pressure ulcer. The facility also failed to document and administer wound care treatments as ordered by the physician for both residents. The electronic medical records showed multiple instances where the scheduled wound care treatments were not documented, indicating that the treatments may not have been provided. This lack of documentation and potential omission of care was noted over several months, despite the residents' high risk for developing new or worsening wounds due to their medical conditions. Interviews with facility staff, including the Wound Care Nurse Practitioner and the Director of Nursing, revealed a lack of awareness and oversight regarding the missed treatments and inadequate repositioning. The facility's policies on pressure injury prevention and wound care were not followed, as evidenced by the failure to reposition residents every two hours and to provide timely wound care. The interdisciplinary team responsible for wound care management had not been meeting regularly, contributing to the oversight and deficiencies in care.
Failure to Provide Timely ADL Assistance
Penalty
Summary
The facility failed to provide timely incontinence care, showers, oral care, and assistance with shaving for five out of six residents reviewed for assistance with Activities of Daily Living (ADLs). This deficiency was observed through various instances where residents were not receiving the necessary care as per their care plans. For instance, one resident, who is cognitively intact and dependent on staff for transfers and substantial assistance with ADLs, was found with facial hair stubble and visible debris on his teeth. His spouse reported that she had to perform his shaving and oral care because the facility staff did not do it. Additionally, the resident expressed a preference for showers, which he was not receiving, contrary to the facility's schedule. Another resident was found with teeth caked with black debris and reported not receiving oral care from the facility staff. This resident, who is also cognitively intact, requires supervision with oral hygiene and substantial assistance with other ADLs. The facility lacked documentation to show that this resident received oral care, highlighting a failure to adhere to the care plan. Further observations included residents with long facial hair who expressed a desire for assistance with shaving, which was not provided. The Director of Nursing acknowledged that residents should receive showers twice a week and that there was no reason for any resident not to get their showers. The facility's policy states that residents unable to carry out ADLs independently should receive necessary services to maintain good grooming and hygiene, which was not consistently followed, as evidenced by the lack of documentation and resident reports.
Failure to Notify Resident's Family of Hospital Transfer
Penalty
Summary
The facility failed to adhere to its policy of immediately notifying a resident's representative when there was a significant change in the resident's condition requiring hospital transfer. This deficiency was identified in the case of a resident who was sent to the hospital due to acute medical issues, including vomiting, clamminess, and an elevated heart rate. The LPN documented that the resident's doctor and family were notified, but it was later revealed that the nurse called the wrong area code and did not reach the resident's spouse or any other emergency contacts. The resident's spouse was not informed of the hospital transfer and only learned of the situation when contacted by the hospital the following day. This lack of communication was distressing for the spouse, who was unaware of the resident's critical condition and subsequent surgery. The facility's Director of Nursing acknowledged the error, noting that the nurse should have continued attempts to contact the spouse or other family members listed in the resident's chart. The facility's policy clearly states that changes in a resident's condition must be immediately communicated to the resident's representative, which was not followed in this instance.
Sanitary Practices Deficiency in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary practices during dishwashing procedures and storage of dish rags, affecting 199 residents who receive food from the facility kitchen. During an inspection, multiple dry and wet/dirty rags were observed on free-standing carts in the kitchen. Additionally, a dietary aide, while wearing gloves, was seen washing and rinsing dirty dishes and then handling clean dishes without changing gloves or washing hands. Another dietary aide entered the kitchen from outside, handled clean dishes without washing hands or wearing gloves, and later admitted to not washing hands after returning from upstairs where he had collected used tableware. The Director of Dining Services acknowledged the need to rewash the dishes touched by the aides and confirmed that the facility lacked a policy for dishwashing procedures to prevent cross-contamination. Furthermore, the director noted that clean dish rags should have been stored in a designated bucket with sanitizing solution, while dirty rags should have been placed in a separate container for dirty linen. The absence of a policy for these procedures contributed to the observed deficiencies.
Failure to Assist Residents with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene and grooming for seven residents who were identified as needing such assistance. These residents, who had various medical conditions including dementia, hemiplegia, and metabolic encephalopathy, were observed with unkempt appearances, including overgrown facial hair, long and dirty fingernails, and uncombed hair. Despite their care plans indicating the need for substantial or maximum assistance with activities of daily living (ADLs), the staff did not adequately address these needs. For instance, one resident with dementia was observed with facial hair that needed shaving, and another resident with metabolic encephalopathy had long, jagged fingernails with black substances underneath. Both residents expressed the need for assistance, and staff acknowledged the necessity but failed to provide the required care. Similarly, other residents with cognitive impairments and physical limitations were found with unkempt facial hair and dirty fingernails, despite their care plans specifying the need for grooming assistance. The facility's policies on ADLs and nail care emphasize the importance of maintaining residents' hygiene and grooming, yet these were not adhered to. The Director of Nursing and other staff members acknowledged the deficiencies in providing grooming and hygiene care, which are essential for the residents' well-being. The lack of adherence to care plans and facility policies resulted in the observed deficiencies in personal hygiene and grooming for the affected residents.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to properly label and date medications after they were opened, which is necessary to determine their expiration dates. This deficiency was observed during an inspection of multiple medication carts, where several instances of insulin medications, such as Insulin Glargine and Insulin Lispro, were found to be opened but not dated. Additionally, some medications were found to be expired but still present in the medication carts. This issue affected ten residents, including those with insulin medications that had been opened for more than the recommended 28 days without being discarded. Furthermore, the facility did not adhere to proper procedures for handling narcotic medications. A container of Alprazolam was found to be torn open and taped over, which is against the facility's policy that requires such medications to be discarded in the presence of a nurse and a witness. The Director of Nursing confirmed that opened insulins should be labeled and dated, and narcotic medications with damaged packaging should be wasted with a second nurse as a witness to prevent diversion.
Failure to Provide Ordered Wound Treatment
Penalty
Summary
The facility failed to provide wound treatment as ordered for a resident, resulting in the worsening of a pressure ulcer from stage 2 to an unstageable wound. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, developed pressure wounds on the sacrum and right buttock. The wound on the right buttock was initially identified as a stage 2 wound but worsened to an unstageable wound due to lack of proper dressing and exposure to urine and fecal contamination. The treatment administration record showed no documentation of the prescribed treatment being administered on the specified dates. Observations revealed that the resident remained seated in a wheelchair for extended periods without repositioning, contrary to the care plan's intervention to turn and reposition at regular intervals. The facility's policy required that new wounds be reported, assessed, and treated according to physician orders, but this protocol was not followed. The CNA assigned to the resident did not report the missing dressing, and the nurse did not replace it as required. The facility's Director of Nursing stated that residents should be repositioned every two hours, but there was no specific intervention for repositioning the resident while seated in the wheelchair.
Failure to Apply Resting Hand Splint for Resident
Penalty
Summary
The facility failed to apply a resting hand splint for a resident, identified as R155, to prevent contractures. R155, who has diagnoses including Parkinson's disease and upper extremity impairment, was observed without the prescribed hand splint on multiple occasions. The care plan and physician orders specified that the splint should be applied in the morning and removed after lunch, with checks every shift. However, during an observation, the splint was not on the resident's hand, and it was found in a dresser drawer after a search. The resident's spouse confirmed that the splint was only applied twice a week by the restorative aide during exercise sessions. Interviews with staff revealed inconsistencies in the application of the splint. The restorative aide claimed to apply the splint regularly, but a certified nursing assistant reported that the resident was not wearing the splint during a shower. The occupational therapist had previously recommended the splint to prevent further contractures, and the facility's policy emphasized the importance of such devices in preventing joint contractures. Despite these guidelines, the splint was not consistently applied, leading to a deficiency in the resident's care.
Inadequate Staff Assistance During Resident Transfer
Penalty
Summary
The facility failed to ensure safe transfer procedures for a resident requiring two staff members for assistance. The resident, who is under hospice care and has multiple medical diagnoses including Alzheimer's disease and dementia, was transferred by a single hospice CNA using a mechanical lift, contrary to the care plan instructions. The resident's care profile and care plan both specify the need for a full lift with the assistance of two staff members due to the resident's cognitive impairment and limited mobility. This incident was confirmed by the Restorative Director, who stated that two staff members should always be present during such transfers for safety reasons.
Failure to Provide Nutritive Equivalent Substitute Meals
Penalty
Summary
The facility failed to provide an alternate meal with similar nutritive value as the main entree for residents with a history of weight loss. This deficiency was observed in two residents, R60 and R152, during a lunch meal service. The main meal consisted of a Turkey Burger Patty Melt with a 3 oz protein portion. However, the substitute meal, an egg salad sandwich, was prepared with only 2 oz of egg salad, which did not meet the facility's policy of providing a substitute with equivalent nutritive value. The facility's scoop guidance indicated that the egg salad sandwiches were prepared with a #16 scoop, equating to 2.07 fluid oz, which was less than the required 3 oz protein serving. Resident R152, who had diagnoses including cerebrovascular disease, type 2 diabetes, and dementia, received the egg salad sandwich with tater tots. R152's weight history showed a significant decline over several months. Similarly, Resident R60, diagnosed with conditions such as hemiplegia, dysphagia, and dementia, also received the egg salad sandwich with tater tots. The dietitian's progress notes indicated that both residents had experienced significant weight loss, and R60 had requested extra portions. The Director of Dining Services acknowledged that the substitute meal should have equaled the main meal's protein content, as per the facility's policy.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to adhere to physician's orders during medication administration, resulting in a medication error rate of 15.63%, which is significantly above the acceptable threshold of 5%. This deficiency was observed in two residents. In the first instance, a nurse administered Vitamin D3 to a resident using a tablet with a lower dosage than prescribed. Additionally, the nurse did not administer other scheduled medications, including Cyanocobalamin and Polyethylene Glycol, to the same resident. In the second instance, another nurse administered three puffs of Albuterol Sulfate HFA inhaler to a resident without the required one-minute interval between doses, contrary to the physician's order of two puffs. The nurse justified this by stating that the resident preferred three puffs. Furthermore, the nurse did not administer the prescribed Fluticasone Propionate nasal spray, as the resident usually refused it. The Director of Nursing emphasized the importance of following physician's orders and the five rights of medication administration, and noted that persistent refusal of medication should be communicated to the physician.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control practices, as observed in the cases of three residents. A nurse, identified as V4, did not remove her isolation gown after administering intravenous medication to a resident on Enhanced Barrier Precaution (EBP). Instead, she left the resident's room wearing the gown, prepared oral medications, and re-entered the room without changing the gown. This action was contrary to the facility's policy, which requires the removal of isolation gowns before leaving the room to prevent the spread of infection. Additionally, a CNA, V34, was seen carrying soiled linens and a gown without using a plastic bag, transporting them down the hallway, and disposing of them in the soiled linen bin while wearing gloves. Another CNA, V36, failed to perform hand hygiene after assisting a resident with repositioning and meal setup, leaving the room without washing hands. These actions violated the facility's hand hygiene policy, which emphasizes hand hygiene as the primary means to prevent infection spread and requires handwashing after glove removal and direct resident contact.
Failure to Report Alleged Abuse of a Resident
Penalty
Summary
The facility failed to report allegations of resident abuse for one resident, identified as R1, who was observed with yellow/green bruising around her left eye orbit and a small purple mark under her left eye. When questioned, R1 indicated through gestures and words that a man had punched her. Despite this, the incident was not reported to the appropriate authorities as required. V5, an LPN, stated that he would report such injuries to a supervisor and the administrator, but V4, another LPN, only reported the incident to the nurse practitioner and did not escalate it further. V8 and V9, R1's family members, confirmed that R1 consistently reported being hit by a man during their visits. The Director of Nursing (V2) and Assistant DON (V3) were not informed of the potential abuse, and V3 did not consider the bruise as related to abuse, thus did not report it to the administrator (V1). V1 stated that he had not been informed of any abuse allegations or injuries of unknown origin since July 2024 and would have initiated an investigation had he been aware. The facility's policy requires injuries of unknown origin to be reported to the abuse coordinator, but this protocol was not followed in R1's case, leading to a failure in addressing a potential abuse situation.
Failure to Assess and Obtain Treatment Orders for Surgical Wound
Penalty
Summary
The facility failed to assess and obtain treatment orders for a resident with a known surgical wound. The resident, who was readmitted with multiple diagnoses including a left gluteal abscess, did not have her wound assessed or treatment orders obtained upon readmission. The wound care nurse was notified of the resident's condition but did not assess the wound until several days later. The wound was initially covered with a dressing that was not removed or evaluated, and the resident's electronic medical record did not show any treatment orders for the wound until several days after readmission. The facility's staff, including the Nursing Unit Manager and the Director of Nursing, acknowledged that the wound was not assessed and treatment orders were not obtained in a timely manner. The facility's policies on skin assessment and pressure injury risk assessment were not followed, as the resident's wound was not documented or addressed according to the established procedures. The lack of timely assessment and treatment orders for the resident's surgical wound represents a deficiency in the quality of care provided by the facility.
Failure to Report Allegation of Mistreatment and Potential Sexual Abuse
Penalty
Summary
The facility staff, including a Registered Nurse (V3) and a Certified Nursing Assistant (V16), failed to report an allegation of mistreatment and potential sexual abuse to the administrator. This incident involved a resident (R1), who was cognitively intact and required moderate to extensive assistance with ADLs. R1 reported to V3 that another aide (V4) was rough during incontinence care and had inserted her finger into R1's vagina, causing pain. Despite documenting the incident in the progress notes, V3 did not report the allegation to the facility administrator. Similarly, V16 did not report R1's complaint about V4's rough handling during incontinence care to anyone, including the administrator. The facility's undated abuse policy mandates that employees report any incident, allegation, or suspicion of potential abuse, neglect, exploitation, or mistreatment to the administrator immediately or to an immediate supervisor who must then report it to the administrator. Both V3 and V16 failed to adhere to this policy, resulting in a deficiency in reporting suspected abuse. The failure to report the incident promptly and appropriately was identified during an interview and record review, highlighting a significant lapse in the facility's internal reporting and identification of allegations process.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,092 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) |
|---|---|---|---|---|
| St Patrick's Residence | 0.1 mi | ★★★★★ | 4 | 1 |
| Tabor Hills Health Care Fac | 1.1 mi | ★★★★★ | 0 | 0 |
| Arista Healthcare | 1.5 mi | ★★★★★ | 0 | 0 |
| Pearl Of Naperville, The | 2.2 mi | ★★★★★ | 10 | 0 |
| Springs At Monarch Landing, The | 2.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.