Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Springs At Monarch Landing, The during CMS and state inspections, most recent first.
Failure to supervise a high-fall-risk resident and provide safe transfer care: one resident with dementia, poor safety awareness, and a history of falls was left unsupervised in the dining room and had an unwitnessed fall with a scalp laceration requiring sutures. Another resident with hemiplegia, impaired mobility, and fall risk fell during post-shower care when she was barefoot and no gait belt was used, resulting in a rib fracture.
The facility failed to sanitize dishware properly, affecting 81 residents on oral diets. The dish machine did not reach the required 180°F for sanitization, as confirmed by test strips and temperature logs. The issue was traced to a turned-off booster heater switch, contrary to facility policy requiring regular temperature checks.
The facility failed to label and manage medications properly, affecting four residents. Insulin pens and eye drops were found opened but not dated, and a discontinued eye medication was not removed from the cart. The DON confirmed that staff must date medications when opened, as per facility policy.
A resident's urinary catheter tube was observed dragging on the floor while she moved in her wheelchair, contrary to the facility's policy to keep catheter tubing off the floor to prevent infections. The DON confirmed the importance of this practice.
A CNA failed to follow infection control practices by not changing gloves or performing hand hygiene during incontinence care for a resident. The CNA completed multiple tasks, including cleaning the resident and assisting with a transfer, while wearing the same soiled gloves. The DON confirmed the requirement for hand hygiene and glove changes to prevent infection spread, as outlined in the facility's policy.
Failure to Supervise High-Fall-Risk Resident and Unsafe Transfer Care
Penalty
Summary
The facility failed to supervise a high-risk fall resident and failed to provide a safe environment during care for another dependent resident. One resident had diagnoses including dementia with anxiety disorder, muscle weakness, osteoporosis, osteoarthritis, and a history of falls. Her MDS said she had moderate cognitive impairment, limited memory recall, and required supervision and touch assistance for transfers and ambulation with a rolling walker. Her EMR also identified her as a fall risk requiring staff supervision. The resident was found on the floor in the dining room after an unwitnessed fall and sustained a laceration to the right posterior scalp that required sutures. She reported that she believed she stood up and fell in the dining room, but could not recall the details. Staff interviews showed that two CNAs were assigned to supervise residents in the dining room, but both left the area to assist other residents without notifying each other, leaving the dining room unsupervised. One CNA stated the fall could have been prevented if the resident had been supervised, and the nursing supervisor concluded the resident stood up and lost her balance after both CNAs left the dining area. A second resident had diagnoses including prior stroke with left-sided hemiplegia, kyphosis, osteoarthritis, generalized muscle weakness, abnormal gait, impaired mobility, and left upper extremity contracture. Her MDS said she was cognitively intact, required partial to moderate assistance with transfers, and was dependent for showering. She was at risk for falls and sustained a witnessed fall while being assisted after a shower and during transfer to bed. She was barefoot, no gait belt was in place, and she fell onto her left side, later being diagnosed with a closed fracture of the left ninth rib. The CNA involved stated she was not ready to transfer the resident, intended to continue drying her back, and confirmed that a gait belt was not applied. The nursing supervisor found that the resident was barefoot and without a gait belt, and the physician stated the resident required staff assistance and a safe environment when rendering care and transferring residents.
Failure to Sanitize Dishware Properly
Penalty
Summary
The facility failed to properly sanitize pots and pans according to its policy, affecting all 81 residents receiving oral diets. During an observation with the Food Service Manager, it was noted that the dish machine sanitizer temperature did not reach the required 180 degrees Fahrenheit. The test strip used to measure the temperature did not change color as expected, indicating that the sanitizing cycle was not effective. The dish machine's thermometer showed a maximum temperature of 174 degrees Fahrenheit, which is below the required 180 degrees Fahrenheit for proper sanitization. The facility's July Dish Washer Temperature Log confirmed that none of the test strips indicated the dish machine reached the desired temperature throughout the month. It was discovered that the booster heater switch was turned off, preventing the machine from reaching the necessary temperature. The facility's policy requires that a supervisor or designee check the machine for proper temperature and report any inadequacies for immediate correction, which was not adhered to in this instance.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to properly label and manage medications for four residents, leading to deficiencies in medication storage and handling. During a medication cart inspection, it was observed that insulin pens for two residents were opened but not dated, contrary to the pharmacy's procedure which requires insulin pens to be discarded 28 days after opening. Additionally, eye drops for another resident were also opened and not dated, with the pharmacy's procedure indicating they can be stored for up to six weeks after opening. Furthermore, a discontinued eye medication for a fourth resident was found in the medication cart, despite being discontinued earlier in the month. The Director of Nursing acknowledged that staff are required to date medications when opened to track their expiration. The facility's policy states that discontinued, outdated, or deteriorated medications should be returned or destroyed following instructions from the dispensing pharmacy. However, the failure to date medications and remove discontinued items from the medication cart indicates a lapse in adherence to these procedures, affecting the safe management of medications within the facility.
Infection Control Deficiency with Urinary Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control practices for a resident with a urinary catheter. During an observation, a resident was seen in her bedroom sitting in a wheelchair with her urinary catheter tube and bag positioned underneath the wheelchair. As the resident moved the wheelchair back and forth, the indwelling urinary catheter tube was dragging on the floor. This action was contrary to the facility's Urinary Catheter Care Policy and Procedure, which mandates that catheter tubing and drainage bags be kept off the floor to prevent potential infections. The Director of Nursing confirmed that the catheter tube should not touch the floor to avoid infection risks.
Infection Control Deficiency: Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to adhere to standard infection control practices concerning hand hygiene and glove use during care provision. Specifically, a Certified Nursing Assistant (CNA) provided incontinence care to a resident who was wet with urine, without changing gloves or performing hand hygiene between tasks. The CNA cleaned the resident's perineum, placed a new incontinence brief, adjusted the resident's clothing, repositioned the resident, and assisted the resident into a wheelchair, all while wearing the same soiled gloves. The Director of Nursing (DON) confirmed that staff are required to perform hand hygiene and change gloves before and after, and between tasks, to prevent cross-contamination and infection spread. The facility's hand hygiene policy emphasizes hand hygiene as the primary means to prevent infection spread, requiring hand hygiene before moving from a contaminated to a clean body site, after contact with a resident's skin, and after handling contaminated items.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Naperville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tabor Hills Health Care Fac | 1.2 mi | ★★★★★ | 0 | 0 |
| St Patrick's Residence | 2.2 mi | ★★★★★ | 4 | 1 |
| Meadowbrook Manor - Naperville | 2.3 mi | ★★★★★ | 6 | 0 |
| Arista Healthcare | 3 mi | ★★★★★ | 14 | 0 |
| Thrive Of Fox Valley | 3.7 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.