Average — CMS composite of the measures below.
The next survey window likely opens around November 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 Pearl Of Naperville, The during CMS and state inspections, most recent first.
Staff failed to respond timely to residents’ call lights and requests for assistance or pain medication. A resident with paraplegia waited nearly an hour for toileting help, and other cognitively intact residents reported similar delays, including waiting about an hour for pain meds or call light response, especially on nights and when agency CNA staff were working. Resident council minutes also documented ongoing concerns about unanswered call lights and needs not being met.
A resident who had long occupied the same room became upset when maintenance staff began packing her belongings and moving her to a different room without prior explanation or written notice, prompting a grievance questioning the reason for the move. Interviews revealed that the move was driven by planned remodeling, that the Admissions Director and SWD only obtained verbal consent from the resident’s family member and then from the resident during the move, and that they were unaware of any policy requiring written notification of room changes or notification of new roommates. This practice, applied to multiple residents reviewed for rights, resulted in room changes occurring without the required written notice to residents or their representatives.
The facility failed to ensure the QAPI committee met quarterly and included required members. Attendance records showed missing signatures or no indication of presence for the DON, Administrator, and Medical Director/designee at multiple meetings, with no records provided for several months after the facility reduced QAPI meetings from monthly to quarterly. V1 stated the committee was led by V1, expected to include department managers, the IP, and vendor partners, but staff nurses and CNAs were not included, despite the facility policy listing the Administrator and DON as chairs and including Unit Nurses/CNAs as members.
Repeated PCV20 Vaccination Given Despite Completed Pneumococcal Series: The facility gave a second PCV20 dose to five residents who had already received PCV20, based on the IP nurse’s practice of offering the vaccine annually. The RN consultant stated CDC guidance indicates residents who received PCV20 do not need another dose, and the facility policy says residents should be offered pneumococcal immunization unless already immunized.
Failure to Issue NOMNC at End of Medicare Coverage: The facility did not provide NOMNCs to 3 residents when their Medicare Part A skilled coverage ended. Record review showed each resident had a covered skilled episode with a last covered day, but there was no documentation that the resident or POA was notified. The SS Director stated she did not issue the NOMNCs and did not know she was supposed to.
Two residents had new mental health diagnoses documented in the EMR and MDS, including psychosis and bipolar disorder, after prior PASARR Level I screens had found no mental health condition. The DON, MDS Coordinator, and Social Services Director stated the residents’ information had not been resubmitted to PASARR after the new diagnoses were identified.
A resident’s chart lacked sufficient documentation to support a new psychosis diagnosis. The EMR and psychiatry notes later listed psychosis/atypical psychosis, but the admission MDS and PASARR did not show a psychotic disorder, and behavior monitoring did not show psychosis or depression. The DON said the diagnosis was added because pharmacy wanted an allowable indication for risperidone, while the resident’s family and DON reported no significant mental change after brain surgery.
The facility failed to ensure a clean, safe, and homelike environment, with strong urine odors, dirty and cluttered hallways, and resident rooms containing debris, food waste, and overflowing trash. Multiple residents with cognitive and physical impairments were found in unclean conditions, and staff confirmed that deep cleaning was not performed as required by facility policy, with no documentation of cleaning schedules or audits.
A resident with multiple diagnoses did not receive prescribed medications due to unavailability, as documented in the EMAR. The resident expressed frustration about the facility running out of medications, despite providing some from home. A medication cart audit confirmed missing medications, and the LPN acknowledged non-administration due to unavailability, contrary to the facility's policy.
The facility failed to ensure call lights were within reach for several residents, including those at risk of falls and with cognitive impairments. Observations showed that residents did not have access to their call lights, relying on staff rounds for assistance. Staff acknowledged the issue, and the facility's policy requires call lights to be accessible, but compliance was not ensured.
The facility failed to provide adequate ADL assistance, including incontinence care and bathing, for four residents. A resident with multiple health issues was found with a saturated brief and missed a scheduled shower. Another resident with ALS reported not receiving showers as scheduled, and documentation showed significant gaps. A third resident with acute kidney failure received only one shower in a month. The Resident Council President reported delays in incontinence care and missed showers, with documentation confirming a lack of recorded showers. The facility's policy requires regular showers for residents unable to perform ADLs independently, which were not consistently provided.
The facility failed to provide sufficient staffing to meet residents' needs, particularly during evening and night shifts. Several residents reported not receiving necessary care, such as showers and incontinence care, due to staff shortages. The facility's policy on ADL support was not followed, and staff expressed concerns about the workload and difficulty in providing quality care.
Two residents reported a lack of dignified care and timely assistance in an LTC facility. One resident, with ALS, was not assisted to use his wheelchair despite being capable, and was left soiled by CNAs. Another resident, the Resident Council President, was left without incontinence care for hours and not provided a shower for over a week. These incidents highlight a failure to adhere to the facility's policy on maintaining residents' dignity.
A resident with multiple diagnoses, including chronic kidney disease, experienced medication administration errors at a rate of 11.11%, exceeding the acceptable threshold. An RN failed to administer the correct doses of spironolactone and vitamin D3 and incorrectly applied a lidocaine patch, contrary to physician orders and facility policy.
A resident, who is cognitively intact, reported that a former employee exposed himself to her in her room. The employee, part of a community program for individuals with mild cognitive deficits, was terminated after video footage confirmed his presence in the room. The incident was reported immediately by the resident, who was in shock and fear, and corroborated by staff who witnessed her distress.
A resident reported that a CNA was rude and refused to assist with oral care. The complaint was made to the ADON and manager on duty, but no investigation was conducted, and the allegation was not reported to the abuse task coordinator, violating the facility's policy.
The facility failed to provide timely incontinence care to two residents with severe cognitive impairments, leaving them in heavily saturated briefs for extended periods. Despite the facility's policy requiring regular incontinence care, staff did not adhere to these guidelines, resulting in neglect of the residents' toileting and hygiene needs.
A resident with ALS and a history of significant weight loss did not receive a prescribed nutritional supplement for several days due to staff absence and ordering delays. The resident was intolerant to the regular High Calorie drink, necessitating a switch to a clear supplement, which was not ordered in time, leading to missed doses.
Two residents in the facility did not receive their prescribed medications as ordered by physicians, leading to significant medication errors. A resident with ALS missed eight doses of Riluzole, while another resident with diabetic neuropathy did not receive their scheduled morning dose of Gabapentin. These lapses were confirmed through EMAR reviews and staff interviews.
The facility failed to maintain kitchen cleanliness and proper food storage, affecting 85 residents. Observations revealed a soiled dish machine, wet-stacked buckets and pans, unlabeled food items, and improper storage of staff lunches. Facility policies on cleanliness, air drying, labeling, and staff food storage were not followed, leading to unsanitary conditions.
The facility failed to implement its water management plan for Legionella, affecting all 87 residents. The Maintenance Director did not perform required weekly checks of water temperatures and chlorine testing, nor did he properly maintain eye wash stations. The Administrator confirmed the lack of documentation for monitoring activities, and the facility had only recently received chlorine testing kits. The facility's policy required systematic water flushing and regular testing, but no documentation was available to show compliance.
The facility did not develop a comprehensive COVID-19 immunization policy, affecting all 87 residents. The policy lacked procedures for offering vaccines, educating on benefits and risks, and documenting vaccination status. Additionally, staff without health insurance were unable to receive the vaccine at the facility, as confirmed by the Assistant Director of Nursing and a CNA.
The facility failed to conduct timely PASARR re-screenings for residents with serious mental illness, as required by the Level I PASARR process. A resident with schizoaffective disorder was not re-screened until seven months after admission, despite a 30-day authorization. Another resident with depression and schizoaffective disorder was not re-screened after a 60-day approval. Two additional residents with mental health diagnoses also missed timely re-screenings. The Admissions Director admitted to missing alerts for re-screening, leading to non-compliance with the facility's policy.
The facility failed to assist residents with personal hygiene and grooming, as observed in four residents with significant medical conditions. One resident with Alzheimer's had unclean fingernails while eating, another with ALS requested nail trimming but was ignored, a third with dementia had long, dirty nails, and a fourth had debris on her clothing, indicating a lack of assistance with dressing. These deficiencies highlight the facility's failure to adhere to its policy of providing necessary ADL support.
A resident with multiple diagnoses, including atrial fibrillation, did not receive prescribed anticoagulant medication due to a need for prior authorization. The facility failed to notify a provider about this issue, as required by their policy. A nurse practitioner discovered the oversight during a chart review, and staff confirmed that the provider should have been notified and documentation should have been made.
The facility failed to issue correct Beneficiary Protection Notification forms to two residents receiving Medicare Part A services. One resident was not given a Notice of Medicare Non-Coverage when their coverage ended, and another resident's family was not informed about the transition to private pay. The Social Services Director was unaware of the requirement due to being new to the facility.
A resident with multiple diagnoses, including atrial fibrillation, did not receive prescribed anticoagulant medication due to a lack of prior authorization and communication failures. The facility did not administer Rivaroxaban or bridging therapy with Enoxaparin as ordered, and a warfarin dose was missed despite subtherapeutic lab results. The facility's policy required physician notification with lab results, but this was not documented.
The facility failed to provide adequate personal care to dependent residents, with six out of seven residents reviewed experiencing unmet needs. Observations revealed residents with soaked incontinent briefs and delays in care, attributed to staff shortages. The facility's policy requires regular incontinent care, which was not consistently provided.
The facility failed to provide adequate staffing, resulting in delayed care for residents. On the day of the survey, only four nurses and four CNAs were available for 80 residents, leading to several residents not receiving timely assistance with activities of daily living. Multiple residents were found in soiled conditions, and staff acknowledged the delay in care due to being shorthanded. The DON and Administrator recognized the staffing issues and mentioned efforts to contract with staffing agencies.
A resident with multiple health issues was found to have two Scopolamine patches applied simultaneously, contrary to the prescribed order. The incident was discovered by the resident's daughter and later addressed by an LPN, but there was a lack of communication and documentation among the staff. The facility's medication error report confirmed the error, and both the Nurse Practitioner and Pharmacist emphasized the importance of removing the old patch before applying a new one to prevent overdose.
A resident with end-stage renal disease and CHF received a one-time IV fluid administration, but the facility failed to remove the IV catheter afterward. The catheter remained in place without proper maintenance or documentation, despite the facility's policy requiring regular flushing and monitoring. The oversight was discovered when the resident's daughter reported it to hospice, leading to the catheter's eventual removal.
The facility failed to provide timely incontinent care to three residents, resulting in prolonged exposure to urine-soaked briefs. One resident with severely impaired cognition was found with a urine-soaked brief and discoloration from prolonged wetness. Another resident with moderate cognitive impairment reported being wet despite being changed the previous night, and a third resident with intact cognition had not been changed since the previous night. The facility's policy of providing incontinent care every two hours was not followed.
The facility failed to investigate and revise fall care plans for two residents according to their fall policy. One resident with moderate cognitive impairment experienced multiple falls without subsequent care plan updates. Another resident with severely impaired cognition also had falls without revisions to their care plan. The Director of Nursing confirmed the lack of required investigations and updates.
A resident with multiple diagnoses reported abuse by a CNA to another CNA, who informed an RN. The RN assessed the resident and administered anxiety medication but did not immediately report the abuse to the administrator or state agency, leading to a delay in compliance with the facility's policy and state regulations.
Delayed Call Light Response and Unmet Resident Requests
Penalty
Summary
The facility failed to ensure staff responded timely to residents’ requests for care assistance and pain medication in accordance with its policy. Surveyors found that on April 29, 2026, R1, a cognitively intact resident with paraplegia, neurogenic bowel and bladder, and substantial assistance needs for toileting and transfers, had a call light unanswered for an extended period. A written statement from an LPN documented that the call light display board showed 59 minutes had elapsed since R1 activated the call light, and the resident had complained to management that he had been waiting 45 minutes for help to go to the bathroom. The Staffing Coordinator reported receiving calls from both an agency CNA and the LPN about the incident, and another LPN confirmed that management informed staff that R1 had been waiting 45 minutes for assistance. The concern was not limited to one resident. R2, a cognitively intact resident who served as Resident Council President and required varying levels of assistance with ADLs, stated she had waited about an hour for pain medication after activating her call light and the staff did not bring it. R2 also reported that call light response was a concern on overnight shifts and weekends when more agency staff were present. R3, who was cognitively intact and required extensive assistance with mobility and self-care tasks, stated that when he used his call light it was not always answered in a reasonable timeframe and his needs were not always met, especially when agency staff were assigned. R4, also cognitively intact and requiring assistance with multiple ADLs, was identified in Resident Council minutes as having raised concerns about call light response times on night shift. R4 stated that on one occasion during night shift, he waited about an hour for someone to answer his call light. The DON stated staff were expected to answer call lights as they passed by rooms and seek help if unable to meet the resident’s need, and said waiting 45 minutes was excessive. The facility’s policy stated it aimed to meet residents’ needs as timely as possible, and its resident rights policy stated staff interactions must focus on assisting residents while respecting individuality and honoring their input.
Failure to Provide Required Written Notice Prior to Resident Room Changes
Penalty
Summary
The deficiency involves the facility’s failure to provide residents or their representatives with written notice prior to room changes, affecting five residents reviewed for resident rights. One cognitively intact resident, admitted since 2021 and long residing in the same room, reported that on 1/28/2026 maintenance staff entered her room and began packing her belongings without prior explanation or notification of a room change. She became upset and questioned the reason for the move, later filing a grievance the same day stating she was not informed of the reason for the room change. The resident stated that management told her that her daughter had been notified, but she emphasized that she made her own decisions and remained unsure why she was moved. Interviews and record review showed that the Admissions Director was instructed to assist with the room move due to planned remodeling on the resident’s unit and acknowledged not knowing the facility’s process for notifying residents or representatives about room changes. The Maintenance Director confirmed he was told to assist with the move and stopped when the resident became upset, then notified the Social Worker Director (SWD) and Admissions Director. The SWD documented contacting the resident’s daughter to obtain consent and reported that the daughter agreed as long as the resident approved the move; the SWD and Admissions Director then explained the reason for the move to the resident, who verbally agreed but remained upset. The SWD stated she was unaware of the facility’s policy requiring written notice of room changes, relied only on verbal consents, and did not notify new roommates of room changes, despite acknowledging that residents have the right to be informed of room changes and the reasons for them.
QAPI Committee Lacked Required Members and Quarterly Meetings
Penalty
Summary
The facility failed to ensure QAPI meetings were held quarterly and that the required members were in attendance. Review of QAPI attendance records from November 2024 through December 9, 2025 showed missing signatures or no indication of presence for required participants at multiple meetings, including the DON at the November 11, 2024 meeting, the Administrator at the December 10, 2024 meeting, and the Medical Director or designee at the July 8, 2025 meeting. There were no attendance records provided for January 2025 through June 2025, and the November 11, 2025 QAPI meeting did not have the signature of either the Medical Director or the Administrator and did not indicate their presence. During interview on December 17, 2025, V1 stated the facility reduced QAPI meetings from monthly to quarterly at the beginning of January 2025 and said there was supposed to be a meeting on April 8, 2025, but there was no attendance record to validate that it occurred or show who was present. V1 stated the QAPI committee is led by V1 and is expected to include the Medical Director, managers of all departments, the Infection Preventionist, and vendor partners such as dialysis, pharmacy, laboratory, and dietary services. V1 also stated staff nurses and CNAs were not included in the QAPI process, while the facility policy stated the QAPI committee should be chaired by the Administrator and DON and include Unit Nurses/CNAs among its members.
Repeated PCV20 Vaccination Given Despite Completed Pneumococcal Series
Penalty
Summary
The facility failed to follow CDC guidelines for pneumococcal vaccination for 5 of 5 residents reviewed for immunizations in a sample of 20. The EMR and MARs showed that R8, R12, R21, R39, and R50 each received the PCV20 vaccine in the facility on October 25, 2023, and again on October 10, 2025. Their Immunization Reports, dated December 17, 2025, documented both PCV20 administrations for each resident. The records showed these residents had already received PCV20 and were later given a second PCV20 dose in the facility. On December 17, 2025, the Infection Preventionist Nurse stated she was responsible for resident vaccinations and said she thought residents should receive a pneumococcal vaccine every eight years. She said the five residents were offered a second PCV20 vaccine because she offers the vaccine every year even if residents already received PCV20. The Regional Nurse Consultant stated the facility follows CDC guidelines and that, per CDC guidance, residents who received PCV20 should not receive a second PCV20 dose because their pneumococcal vaccination is complete after the first dose. The CDC Pneumococcal Vaccine Timing for Adults, dated March 2025, showed adults 65 years old and older should receive one PCV20 vaccine, and the facility policy stated residents should be offered pneumococcal immunization unless medically contraindicated or already immunized.
Failure to Issue NOMNC at End of Medicare Coverage
Penalty
Summary
The facility failed to follow its policy and issue a Notice of Medicare Non-Coverage (NOMNC) to residents at the end of their Medicare Part A coverage. This deficiency applied to 3 of 3 residents reviewed for beneficiary notification in the sample of 20: R34, R48, and R51. Record review showed each resident had a Medicare Part A skilled episode with a documented last covered day of service, but the facility had no documentation showing that a NOMNC was provided before the end of the Medicare Part A stay. R34’s Medicare Part A skilled episode began on April 1, 2025, with a last covered day of May 20, 2025. R48’s episode began on August 22, 2025, with a last covered day of October 4, 2025. R51’s episode began on October 1, 2025, with a last covered day of November 26, 2025. On December 16, 2025, the Social Services Director stated she did not issue NOMNCs to R34, R48, or R51, did not know she was supposed to issue them at the end of Medicare Part A stay, and had never issued one to a resident. The facility’s Medicare and Insurance Payment Policy stated that when the end of Medicare benefits is determined, the resident or POA will be notified with a Notice of Medicare Non-Coverage.
Failure to Resubmit PASARR After New Mental Health Diagnoses
Penalty
Summary
The facility failed to notify the PASARR program when two residents had newly diagnosed mental disorders. One resident was admitted with multiple diagnoses including anxiety and conversion disorder with seizures or convulsions, and the EMR later showed a diagnosis of unspecified psychosis not due to a substance or known physiological condition. The resident’s admission MDS showed anxiety disorder, while a later quarterly MDS added psychotic disorder. The resident’s PASARR Level I screen outcome stated there was no known or suspected mental health diagnosis and that a new screen must be submitted if changes occurred or new information refuted the findings. The DON stated the resident received a new diagnosis of psychosis in March 2025 and that documentation existed in a psychiatric note, but the facility had no documentation showing a new PASARR screening was completed after the diagnosis. A second resident was admitted with diagnoses including depression, PTSD, stroke, and convulsions, and the EMR later showed a diagnosis of bipolar disorder. The admission MDS listed depression and PTSD, while a later quarterly MDS added bipolar disorder. The resident’s PASARR Level I screen outcome stated there was no known or suspected mental health diagnosis and no mental health medications, and that a new screen must be submitted if changes occurred or new information refuted the findings. The MDS Coordinator stated the hospital documentation showed bipolar disorder when the resident was readmitted from the hospital, and the Social Services Director stated she was responsible for submitting resident information to PASARR when reevaluation was needed, but the resident’s information had not been resubmitted after the new mental health diagnosis.
Insufficient Documentation for New Psychosis Diagnosis
Penalty
Summary
The nursing facility failed to have sufficient documentation to support a new mental health diagnosis for one resident. The resident was admitted with multiple medical and psychiatric diagnoses, including anxiety and conversion disorder with seizures or convulsions. The EMR later showed a diagnosis of unspecified psychosis not due to a substance or known physiological condition, and the Quarterly MDS reflected psychiatric diagnoses of anxiety disorder and psychotic disorder, while the admission MDS and PASARR did not show a psychotic disorder or a known or suspected mental health diagnosis. The DON stated the psychosis diagnosis was added because pharmacy recommended a diagnosis to support risperidone use, and a psychiatric nurse practitioner signed a recommendation to add atypical psychosis. The psychiatric notes documented confusion, weakness, vision impairment, anxiety, depression, and irritability, but they continued to list conversion disorder with seizures or convulsions, unspecified anxiety disorder, and unspecified malignant neoplasm of brain, with psychosis added later. The resident’s behavior monitoring from February through April 2025 did not show behaviors of psychosis or depression. The resident’s family member said the resident had been minimally responsive since brain surgery in November 2024 and had not had a change since then, and the DON said the resident had not had any significant mental change since surgery. The facility did not have documentation showing any change in symptoms or behaviors at the time the new psychosis diagnosis was entered.
Failure to Maintain Clean and Homelike Environment and Adhere to Deep Cleaning Policy
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for all 79 residents, as evidenced by persistent urine odors, dirty hallways, and debris in both resident rooms and common areas. Upon entrance and throughout the survey, strong urine odors were noted in the hallways, and multiple areas were observed to have dirty floors with black and brown marks, smudges, and food debris. Trash and soiled linen receptacles were full, and old meal trays were left on top of trash bins. Housekeeping staff were not observed cleaning the hallways during these times, and the facility was unable to provide documentation of regular or deep cleaning as required by their own policy. Several residents with significant cognitive and physical impairments were found in unclean environments. One resident, who is always incontinent and requires assistance with most activities of daily living, was found in a room with broken furniture pieces, plexiglass from a lighting fixture, and food and paper debris scattered on the floor. Another resident, with severe cognitive impairment and frequent incontinence, had a room and hallway cluttered with food debris, trash, and wheelchair parts, and reported that cleaning was only done when she left her room. Additional observations included overflowing garbage cans, medication cups and food wrappers on the floors, and residents having to step over debris to enter their rooms. One resident, who is dependent on staff for mobility and transfers, had a care plan specifically requiring clutter-free and clean environments, yet her room and hallway were not maintained accordingly. Interviews with staff revealed that the facility was not following its own policy for quarterly deep cleaning of resident rooms. The Housekeeping Director and Administrator confirmed that only one room was deep cleaned per week, resulting in each room being deep cleaned only once per year, rather than quarterly. There was no documentation of monthly cleaning schedules or audits to ensure compliance. Staffing shortages and changes were also noted, with key housekeeping staff absent or on leave, further impacting the cleanliness of the facility. Residents and staff both reported a decline in cleanliness and housekeeping services.
Medication Administration Deficiency Due to Unavailability
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered according to its policy, affecting one of the three residents reviewed for medication administration. The resident, identified as R3, was admitted with multiple diagnoses, including interstitial pulmonary disease, pulmonary fibrosis, and essential hypertension, and was cognitively intact. The resident's electronic medical record (EMR) and electronic medication administration record (EMAR) revealed that several medications, including Pantoprazole sodium and Dorzolamide HCL ophthalmic solution, were not documented as administered on specific dates due to unavailability. Additionally, Mycophenolate mofetil was also unavailable and not administered as prescribed. R3 expressed frustration about not receiving medications as prescribed and reported that the facility often ran out of her medications, despite her providing some from her home supply. During a medication cart audit, it was confirmed that two of R3's ordered medications were missing, and the Licensed Practical Nurse (LPN) acknowledged that the medications were not administered due to their unavailability. The facility's medication administration policy requires documentation of medication preparation and reasons for non-administration, as well as contacting the pharmacy if medications are not present, which was not adhered to in this case.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for five out of eight residents reviewed, leading to a deficiency in accommodating the needs and preferences of residents. Observations revealed that several residents, including those with fall risks and cognitive impairments, did not have access to their call lights. For instance, one resident reported not having a call light for months, relying on staff rounds for assistance, while another resident's call light was found on the floor, out of reach. These residents were aware of the call light's function and expressed the need for it, especially in emergencies. The deficiency was further highlighted by staff interviews and policy reviews. Staff members, including the Director of Nursing and Certified Nursing Assistants, acknowledged that residents should have access to call lights. The facility's policy, revised in June 2024, mandates that residents capable of using call lights should have them accessible at all times, with regular checks by direct care staff and maintenance. Despite this policy, the facility did not ensure compliance, resulting in residents being unable to call for help when needed.
Deficiency in ADL Assistance and Bathing
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for four residents, specifically incontinence care and bathing, as per their needs and the facility's policy. Resident R6, who has multiple diagnoses including diabetes and peripheral vascular disease, was found with a saturated brief and reported not receiving a scheduled shower. The Director of Nursing was unaware of any schedule changes, and documentation confirmed the missed shower. Resident R1, diagnosed with ALS and other conditions, reported not receiving showers as scheduled and expressed dissatisfaction with bed baths. Documentation showed significant gaps between showers, contrary to the facility's schedule. Similarly, Resident R5, with acute kidney failure and other health issues, reported inadequate assistance with showers, with documentation indicating only one shower in a month. Resident R3, who is the Resident Council President and has multiple health conditions, reported delays in incontinence care and missed showers. Documentation showed a lack of recorded showers over a ten-day period. The facility's policy mandates that residents unable to perform ADLs independently should receive necessary services, including regular showers, which were not consistently provided as per the residents' care plans.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of residents, particularly during the evening and night shifts. The staffing pattern described by the staff scheduler was not consistently followed, resulting in insufficient numbers of CNAs on several shifts. This led to a high staff-to-resident ratio, which impacted the ability of staff to provide timely care, including bathing, incontinence care, and mobility assistance. Several residents reported not receiving necessary care due to staffing shortages. One resident, who was cognitively intact and required substantial assistance with ADLs, reported not being able to get out of bed or receive showers due to staff time constraints. Another resident, also cognitively intact, experienced delays in call light responses and did not receive incontinence care as needed. Additional residents reported similar issues with receiving scheduled showers and incontinence care. The facility's policy on Activities of Daily Living Support was not adhered to, as evidenced by the lack of documentation for showers and the inequitable distribution of shower assignments among staff. Staff members, including agency and PRN CNAs, expressed concerns about the workload and the difficulty in providing quality care due to the high number of residents assigned to each CNA. These staffing issues were corroborated by the facility's own records and staff interviews.
Failure to Provide Dignified Care and Timely Assistance
Penalty
Summary
The facility failed to provide an environment where residents are treated with dignity and respect, as evidenced by the experiences of two residents. One resident, who was admitted with multiple diagnoses including ALS and anxiety disorder, reported not being assisted to get out of bed into his electric wheelchair since October 2024, despite being capable of sitting in it with assistance. The resident expressed frustration over being left in bed and not being offered help to get out of bed, even though there was no medical order for bedrest. Additionally, the resident reported an incident where CNAs left him soiled after providing incontinence care, stating their shift was over. Another resident, who is cognitively intact and serves as the Resident Council President, reported not receiving timely incontinence care and not being provided with a shower for over a week. The resident stated that after requesting assistance for incontinence care, staff did not respond promptly, and she was left unchanged for several hours. The resident expressed concern about complaining due to fear of staff retaliation, highlighting a lack of respect and dignity in care provision. The facility's policy on Activities of Daily Living emphasizes maintaining residents' dignity and ensuring they are clean and well-groomed. However, the incidents reported by the residents indicate a failure to adhere to these policies, resulting in residents feeling neglected and disrespected. The facility's maintenance staff confirmed that the resident's wheelchair was in good repair, yet the resident had not been assisted to use it, further underscoring the deficiency in providing dignified care.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to administer medications as ordered by the physician, resulting in a medication error rate of 11.11%, which exceeds the acceptable threshold of 5%. This deficiency was identified during the review of one resident's medication administration. The resident, who was admitted with multiple diagnoses including chronic kidney disease, pulmonary hypertension, and hypertension, was on a medication regimen that included diuretic therapy. The facility's medication care plan required the administration of diuretic medications as ordered and monitoring for side effects and effectiveness every shift. On the day of the observation, a registered nurse (RN) prepared and administered medications to the resident, including spironolactone and vitamin D3, but failed to administer the correct doses as per the physician's orders. Additionally, the RN applied a lidocaine patch to the resident's left lower back instead of the prescribed area on the left knee. The Director of Nursing (DON) confirmed that the RN did not follow the physician's orders, which is against the facility's medication administration policy. This policy mandates checking the medication administration record for the right medication, dose, route, patient, and time, and reading each order entirely before administration.
Resident Exposed to Sexual Abuse by Facility Employee
Penalty
Summary
The facility failed to protect a resident from sexual abuse, resulting in a significant deficiency. A resident, who is cognitively intact and has been diagnosed with major depressive disorder and dementia, reported an incident involving a former employee, a laundry aide, who exposed himself to her while she was in her room. The resident was asleep and awoke to find the employee standing with his genitals exposed. She immediately reported the incident to staff members in the hallway, expressing fear and shock. The employee, who was part of a community program for individuals with mild cognitive deficits, was terminated following the incident. Despite the employee's denial and confusion about the event, video footage confirmed his presence in the resident's room at the time of the alleged incident. The resident's account was corroborated by staff members who witnessed her distress and immediate report of the incident. The facility's abuse prevention policy emphasizes the residents' right to be free from abuse, yet this incident highlights a failure in ensuring that protection. The resident involved is known to be alert and oriented, with no history of fabrication, further supporting the credibility of her report. The incident was reported to the facility's administration, and the employee was subsequently removed from the facility.
Failure to Investigate and Report Allegation of Abuse/Neglect
Penalty
Summary
The facility failed to investigate and report an allegation of potential abuse/neglect involving a resident who was cognitively intact and required substantial assistance with activities of daily living. The resident reported that a CNA from a staffing agency was rude and refused to provide care, specifically assistance with brushing teeth. This complaint was made to the Assistant Director of Nursing and the manager on duty, but no investigation was conducted, and the allegation was not reported to the designated abuse task coordinator. The facility's policy requires that any allegations of abuse or neglect be reported immediately and investigated with a written report completed within 24 hours. However, the designated abuse task coordinator was not informed of the allegation, and no investigation was initiated. The failure to follow the facility's abuse policy resulted in a deficiency as the resident's complaint was not addressed appropriately, and the required procedures for handling such allegations were not followed.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate incontinence care to two residents, R7 and R10, who were dependent on staff for assistance with activities of daily living, including toileting and hygiene. R7, an elderly resident with severe cognitive impairment and multiple health conditions, was observed on September 30, 2024, to have been left in a heavily saturated incontinence brief from 11:00 AM to 2:30 PM, despite being dependent on staff for toileting needs. Additionally, a complaint was made by R7's power of attorney on September 21, 2024, regarding R7 being found heavily saturated with urine, which was confirmed by the LPN on duty. This indicates a pattern of neglect in providing timely incontinence care to R7. Similarly, R10, another elderly resident with severe cognitive impairment, was found on October 1, 2024, to be wearing a heavily saturated incontinence brief that had not been changed since the start of the shift at 6:00 AM. The facility's policy requires incontinence care to be provided every shift based on the resident's needs, yet this was not adhered to, resulting in R10 being left in a saturated brief for an extended period. These incidents highlight a failure to meet the facility's policy for incontinence care, which aims to keep residents clean and dry and prevent urinary tract infections.
Failure to Provide Nutritional Supplement to Resident
Penalty
Summary
The facility failed to provide a nutritional supplement to a resident with a history of significant weight loss, which was necessary to prevent further weight loss. The resident, who is cognitively intact and has a diagnosis of ALS, was prescribed a High Calorie drink twice daily. However, due to intolerance causing loose stools and abdominal pain, the dietitian changed the supplement to a clear type on September 18, 2024. Despite this change, the resident did not receive the supplement on several days in September, as confirmed by the Interim DON and a nurse. The failure to provide the supplement was attributed to the ancillary staff being off for 10 days, during which the clear supplement was not ordered. It was only ordered on September 24, 2024, arrived on the 26th, and was administered to the resident on the 27th. The resident confirmed the lack of supplement provision during this period, which was crucial for maintaining their nutritional status and preventing further weight loss, as outlined in the facility's Weight Management Policy.
Significant Medication Errors in Resident Care
Penalty
Summary
The facility failed to administer significant medications as per physician orders for two residents. The first resident, diagnosed with ALS, did not receive their prescribed Riluzole medication for several days in September 2024. The EMAR review confirmed that the resident missed eight doses of Riluzole, a medication critical for delaying the progression of ALS. The resident reported the missed doses to the Assistant Director of Nursing, who subsequently reordered the medication. The second resident, with a diagnosis of diabetic neuropathy, did not receive their scheduled morning dose of Gabapentin, a pain management medication, on the day of the survey. The EMAR review showed that the 9:00 A.M. dose was not administered, which was confirmed by the resident and a registered nurse. The Nurse Practitioner acknowledged that the failure to administer these medications constituted significant medication errors, as they are essential for managing the residents' conditions.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage in the kitchen, affecting 85 residents who receive meals prepared there. During an inspection, it was observed that the dish machine was heavily soiled with lime debris, and the floor beneath it had a buildup of black debris resembling mud. The pipe leading to the sewer drain was rusted. Additionally, plastic buckets used for mixing beverages were stacked wet, and washed pans were stored without being air-dried, leading to water droplets inside them. The walk-in cooler contained unlabeled pitchers of orange beverage, and the freezer had an open, unlabeled bag of deli meat. Staff lunches were improperly stored next to residents' food, and the dry storage area had an open, undated bag of elbow macaroni. The facility's policies on kitchen cleanliness, air drying utensils, labeling, and staff food storage were not adhered to. The kitchen had not been deep cleaned for an unspecified period, contributing to the buildup of debris. The Food Service Dietary Manager acknowledged the issues but was unaware of the last deep cleaning. The facility's failure to follow its policies resulted in unsanitary conditions, with staff lunches stored in the wrong area and food items not properly labeled or dated. These deficiencies were observed over two days, with repeated issues noted during follow-up inspections.
Failure to Implement Water Management Plan for Legionella
Penalty
Summary
The facility failed to adhere to its water management plan for Legionella, affecting all 87 residents. The Maintenance Director, responsible for monitoring the water management plan, admitted to not having started the required weekly checks of water temperatures, including the hot water tank, and chlorine testing. Additionally, the Maintenance Director only cleaned and tested the eye wash stations twice in two months and did not perform the necessary flushing of the eye wash stations. During an interview, the Administrator confirmed that the Maintenance Director had been in charge of the water management plan for about two months but had not documented any monitoring activities, including temperature checks and chlorine testing. The facility had just received chlorine testing kits, indicating a lack of preparedness in implementing the water management plan. The facility's Water Management Plan outlined specific controls and monitoring frequencies, such as weekly chlorine testing and daily flushing of plumbing fixtures, which were not being followed. The facility's policy required systematic water flushing, emergency disinfection, and regular testing of chlorine levels at various points in the water system. However, there was no documentation to show that these procedures were being carried out. The policy also specified that the Maintenance Supervisor should fill out water management log sheets, but as of the survey date, no such documentation was available, indicating a significant lapse in the facility's infection prevention and control program.
Failure to Implement COVID-19 Immunization Policy
Penalty
Summary
The facility failed to develop and implement a comprehensive COVID-19 immunization policy for both staff and residents. Despite multiple requests, the facility did not provide a COVID-19 immunization policy and procedure. The existing policy, dated May 25, 2023, lacked specific procedures for offering the COVID-19 vaccine to residents and staff, providing education on the vaccine's benefits, risks, and potential side effects, and documenting vaccination status in medical records. This deficiency affected all 87 residents in the facility. Additionally, the facility did not offer the COVID-19 vaccine to staff members without health insurance. The Assistant Director of Nursing/Infection Preventionist indicated that these staff members were expected to obtain the vaccine independently. During a vaccine clinic in January 2024, several staff members consented to receive the vaccine but were unable to do so at the facility due to lack of health insurance. This issue was confirmed by a CNA who had to pay for the vaccine at a pharmacy. A list provided by the facility showed that eight employees requested the vaccine but did not receive it at the facility due to insurance issues.
Failure to Conduct Timely PASARR Re-Screenings
Penalty
Summary
The facility failed to provide timely re-screening for residents with serious mental illness as required by the Level I PASARR (Preadmission Screening and Resident Review) process. This deficiency was identified in four residents who were reviewed for PASARR compliance. Resident R50 was admitted with multiple diagnoses, including schizoaffective disorder, and was initially screened for a 30-day stay. However, the re-screening was not conducted until more than seven months later, triggering a Level II PASARR assessment. Similarly, Resident R75, diagnosed with depression and schizoaffective disorder, was approved for a 60-day stay but did not receive the necessary re-screening before the expiration of this period. Additionally, Resident R6, with diagnoses including bipolar disorder and anxiety, was authorized for a 30-day stay but was not re-screened within the required timeframe. Resident R53, admitted with major depressive disorder and anxiety, also did not receive a timely re-screening after the initial 30-day authorization. The Admissions Director acknowledged the oversight, stating that the re-screening alerts were missed, leading to the failure in updating the PASARR screenings as required. The facility's policy mandates that all new admissions and readmissions undergo the PASARR process, but this was not adhered to in these cases.
Failure to Assist Residents with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary assistance with personal hygiene and grooming for residents who were unable to perform these activities independently. This deficiency was observed in four residents, each with significant medical conditions requiring staff support. Resident R23, with diagnoses including cerebral infarction and Alzheimer's disease, was observed with unclean fingernails containing black substances, despite needing staff assistance for personal hygiene. This was noted during meal times when R23 was eating with his fingers, and the issue persisted over multiple days without being addressed by the staff. Resident R77, diagnosed with ALS, was cognitively intact but had functional limitations in his upper extremity, requiring assistance with personal hygiene. Despite requesting help to trim his long and jagged fingernails, the staff did not fulfill this request over two consecutive days. Similarly, Resident R28, with severe cognitive impairment and multiple diagnoses, was observed with long, jagged fingernails with black substances underneath, indicating a lack of staff assistance with personal hygiene as outlined in her care plan. Resident R58, who was severely impaired cognitively and required maximum assistance with ADLs, was observed with white flaky debris on her clothing, indicating a lack of assistance with dressing. The facility's policy mandates that residents unable to perform ADLs independently should receive necessary services to maintain good hygiene and grooming. However, the observations and interviews revealed that the facility did not adhere to this policy, resulting in the identified deficiencies.
Failure to Notify Provider of Missed Anticoagulant Medication
Penalty
Summary
The facility failed to notify a provider about a resident not receiving prescribed anticoagulant medication. The resident, who had multiple diagnoses including cerebral infarction, atrial fibrillation, and peripheral vascular disease, was admitted to the facility with orders for anticoagulant therapy. The resident's care plan included administering anticoagulants as ordered and monitoring for side effects and effectiveness. However, the resident did not receive the prescribed rivaroxaban and enoxaparin due to a need for prior authorization from the insurance, and there was no documentation that a provider was notified of this issue. A nurse practitioner discovered the oversight during a chart review and noted that the resident had not received the anticoagulant medication since returning from the hospital. The facility's policy requires notifying a provider when there is a significant change in a resident's condition, but this was not done. Interviews with facility staff confirmed that the nurses should have notified the provider and documented the notification, but this did not occur. The facility lacked documentation to show that a provider was informed about the resident not receiving the anticoagulation medication.
Failure to Provide Beneficiary Protection Notification Forms
Penalty
Summary
The facility failed to provide the correct and complete Beneficiary Protection Notification forms to residents receiving Medicare Part A services. This deficiency was identified in two residents. The first resident was admitted with multiple diagnoses, including disorders of the nervous system and cellulitis. The resident's Medicare Part A services ended when the covered days were exhausted, but the facility did not issue a Notice of Medicare Non-Coverage (NOMNC). Instead, they documented on the SNF Beneficiary Notification Review form, which was not appropriate. The Social Services Director admitted to not issuing the required form due to being new to the facility and unaware of the requirement. The second resident was admitted with diagnoses including multiple rib fractures and muscle weakness. The resident was discharged from the facility when the family initiated the discharge, but there was no documentation to support this claim. A progress note indicated that the resident's family was not informed about the transition to private pay. The facility's process involves weekly Medicare meetings to discuss residents' remaining Medicare Part A coverage days, but the necessary notifications were not provided to the resident's family, leading to confusion about payment responsibilities.
Failure to Administer Anticoagulant Medication as Ordered
Penalty
Summary
The facility failed to administer anticoagulant medication as ordered for a resident with multiple diagnoses, including cerebral infarction, atrial fibrillation, and peripheral vascular disease. The resident was admitted with orders for Rivaroxaban, but the medication was not administered due to a lack of prior authorization from the resident's insurance. This oversight was not communicated to the provider, resulting in the resident not receiving the necessary anticoagulant therapy. Additionally, the resident's care plan indicated the use of aspirin and warfarin, but there was no documentation of the administration of Rivaroxaban or the bridging therapy with Enoxaparin as ordered. Further issues were identified when the resident was not administered warfarin on a specific date, despite a new order following lab results indicating subtherapeutic levels. The facility's policy on anticoagulant therapy required notification of the physician with lab results before administering medication, but there was no documentation of such communication. The failure to administer the prescribed anticoagulant medications and the lack of communication with the provider contributed to the deficiency, as confirmed by interviews with the nurse practitioner and the acting director of nursing.
Inadequate Personal Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate personal care to dependent residents, as evidenced by observations, interviews, and record reviews. Six out of seven residents reviewed for activities of daily living (ADL) care were found to have unmet needs. For instance, a male resident with intact cognition, who is deaf and blind, was observed with a soaked incontinent brief containing urine and feces. The staff, including the Manager on Duty, acknowledged being shorthanded, which contributed to the lack of timely care. Another resident with mild cognitive impairment reported waiting for 30 minutes to be changed, and was found with a urine-soaked brief. The care plans for these residents documented the need for regular checks and cleaning after each incontinent episode, which were not adhered to. Additional cases included a male resident with moderate cognitive impairment who was found with a soaked brief containing stool, and a female resident whose feeding pump was beeping for a while without staff response. Her husband reported that she had not been changed since his arrival. Other residents with intact cognition also reported delays in receiving care, with staff citing understaffing as a reason for the delays. The Director of Nursing confirmed that the facility's policy requires incontinent care every two hours and as requested by residents, which was not consistently provided.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the care needs of residents, as evidenced by observations, interviews, and record reviews. On the day of the survey, there were only four nurses and four CNAs available for 80 residents, which was insufficient to meet the residents' needs. The LPN on duty acknowledged the shortage and mentioned that an additional CNA was expected to arrive late. This staffing inadequacy resulted in several residents not receiving timely assistance with activities of daily living, such as toileting and changing of incontinent briefs. Multiple residents were observed in soiled conditions due to the lack of staff availability. For instance, a resident who is deaf and blind was found with a soaked incontinent brief, and another resident with mild cognitive impairment reported waiting for 30 minutes to be changed. Other residents were also found in similar situations, with staff acknowledging the delay in care due to being shorthanded. The Director of Nursing and the Administrator both recognized the staffing issues, citing call-offs and no-shows as contributing factors, and mentioned efforts to contract with staffing agencies to address the problem.
Failure to Remove Old Medicated Patch Before Applying New One
Penalty
Summary
The facility failed to ensure proper administration of a medicated patch for a resident, leading to a potential overdose. The resident, who had multiple diagnoses including end-stage renal disease, type 2 diabetes mellitus, and dementia, was prescribed a Scopolamine transdermal patch to be applied every three days. However, it was discovered that two patches were applied simultaneously behind the resident's ears, which was against the prescribed order. This incident was brought to attention by the resident's daughter, who noticed the two patches and took pictures. The Licensed Practical Nurse (LPN) on duty at the time of the discovery removed both patches and applied a new one, but there was confusion and lack of communication among the staff regarding the incident. The Director of Nursing was not informed until later, and the nurses involved could not recall the exact date of the incident. The facility's medication error report confirmed the occurrence of the error but lacked specific details about the timing. The Nurse Practitioner and Pharmacist both stated that the old patch should be removed before applying a new one to prevent an overdose, highlighting the deficiency in following proper medication administration procedures.
Failure to Discontinue and Maintain IV Catheter
Penalty
Summary
The facility failed to properly manage the intravenous (IV) catheter care for a resident with multiple diagnoses, including end-stage renal disease and congestive heart failure, who was on hospice care. The resident was ordered to receive a one-time administration of 1000 ml of 0.9% Sodium Chloride for hydration, which was completed as per the order. However, the facility did not remove the IV catheter after the infusion was completed, as was required by the order. The oversight was discovered when the resident's daughter reported to hospice that the catheter was still in place despite the completion of the IV fluid administration. The hospice nurse contacted the facility, and the catheter was eventually removed by a registered nurse, but there was no documentation of the removal in the resident's records. Additionally, the facility failed to perform and document the necessary maintenance care for the catheter while it remained in place, such as flushing the catheter, measuring arm circumference, and monitoring the insertion site. The Director of Nursing acknowledged the failure to remove the catheter and the lack of documentation regarding its maintenance. The facility's policy required regular flushing of midline catheters to maintain patency and documentation of the insertion site appearance every shift, which was not adhered to in this case. This lack of adherence to the facility's standard IV infusion orders and pharmacy policy contributed to the deficiency.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to dependent residents, as observed in three out of four residents reviewed for activities of daily living (ADL) care. Resident 2, a female with severely impaired cognition, was found in bed with a urine-soaked incontinent brief and discoloration from prolonged wetness. The assigned Certified Nursing Assistant (CNA) was unaware of their responsibility for Resident 2's care, leading to delayed intervention. Resident 2's care plan required peri care after each incontinent episode, which was not followed in this instance. Resident 3, a female with moderate cognitive impairment, reported being wet despite being changed the previous night. Upon inspection, her incontinent brief was found to be dirty and urine-soaked. The CNA responsible for her care acknowledged that Resident 3 should be checked every two hours but had not done so since 6:45 AM. Similarly, Resident 4, a male with intact cognition, was found with a urine-soaked incontinent brief after reporting that he had not been changed since the previous night. The facility's policy mandates incontinent care every two hours and as requested by residents, which was not adhered to in these cases.
Failure to Investigate and Revise Fall Care Plans
Penalty
Summary
The facility failed to investigate and revise fall care plans according to their fall policy and procedure for two residents. One resident, a [AGE] year-old male with moderate cognitive impairment, experienced multiple falls on 3/30/2024, 4/12/2024, and 4/22/2024. Despite being sent to the hospital for evaluation after the fall on 4/12/2024, the facility did not conduct a post-fall investigation or update the fall care plan with new interventions after the falls on 4/12/2024 and 4/22/2024. This was confirmed by the Director of Nursing, who could not find any documentation of the required investigations and updates to the care plan. Another resident, a [AGE] year-old female with severely impaired cognition and dependent on toileting hygiene, fell on [DATE] and 3/9/2024. The facility's fall care plan for this resident also lacked any revisions following the fall on 2/19/2024. The Director of Nursing confirmed the absence of updates to the fall care plan. The facility's Fall Prevention and Management Policy mandates that fall interventions be reviewed, revised, and updated based on the results of fall assessments and investigations, which was not adhered to in these cases.
Failure to Immediately Report Allegation of Abuse
Penalty
Summary
The facility failed to follow their policy and immediately report an allegation of abuse to the administrator and the state agency. A resident (R2) with multiple diagnoses, including heart failure, bipolar disorder, anxiety, schizoaffective disorder, and major depressive disorder, reported to a CNA (V6) that another CNA (V3) had abused her. This report was made on March 24, 2024, around 11:00 AM. V6 informed an RN (V4) about the allegation, who then assessed R2 and administered medication for anxiety but did not report the abuse immediately to the administrator or the state agency. Instead, V4 waited until the morning of March 25, 2024, to report the incident to the ADON (V8), who then reported it to the DON (V2) and the administrator (V1). The initial report to the state agency was submitted on March 25, 2024, at 9:38 AM, well beyond the required immediate reporting timeframe. The facility's policy mandates that any allegation of abuse must be reported to the administrator immediately and to the state agency within two hours. The failure to adhere to this policy was evident as V4 did not report the allegation immediately, leading to a delay in notifying the appropriate authorities. The facility's undated policy on abuse prevention clearly outlines the steps for internal reporting and the necessity for immediate action, which was not followed in this case. The delay in reporting the abuse allegation compromised the facility's compliance with its own policies and state regulations.
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What surveyors actually found near you
We read the 1,111 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
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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) |
|---|---|---|---|---|
| Arista Healthcare | 1.8 mi | ★★★★★ | 0 | 0 |
| Alden Estates Of Naperville | 2 mi | ★★★★★ | 6 | 0 |
| Meadowbrook Manor - Naperville | 2.2 mi | ★★★★★ | 8 | 0 |
| St Patrick's Residence | 2.2 mi | ★★★★★ | 4 | 1 |
| Thrive Of Lisle | 3.2 mi | ★★★★★ | 1 | 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.