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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Patrick's Residence during CMS and state inspections, most recent first.
A CNA turned a resident in bed during incontinence care and looked away to reach for wipes, during which the resident slid off the bed and landed on the floor in a kneeling position while holding the siderail. The resident had hemiplegia, dementia, poor balance, and required substantial to maximum assistance for bed mobility. She later reported pain and was found to have bilateral distal femur fractures requiring bilateral femoral rodding.
A resident with severe cognitive impairment, multiple psychiatric and pain diagnoses, and a history of trauma alleged that a CNA hurt her during care, while CNA students reported witnessing the CNA hit the resident’s shoulder, forcefully push her shoulder and knee into the mattress, and lean on her with unnecessary force as the resident cried out in pain. When the students reported this to a nurse supervisor and QA staff, they were repeatedly told the CNA was a single mother who could lose her job, were interrupted, and were asked to physically reenact the incident, including asking a student who had not witnessed the abuse to demonstrate, which made them feel guilty and doubt their reports. Although the students provided handwritten statements, the facility did not retain these documents, relied instead on unsigned, less aggressive typed summaries by staff, did not have the DON interview the resident, concluded the abuse was unsubstantiated, and allowed the alleged perpetrator to continue working two more shifts with the resident, resulting in an Immediate Jeopardy finding for failure to conduct a thorough and impartial abuse investigation.
A vulnerable resident with dementia, psychosis, depression, anxiety, hemiplegia, legal blindness, and a history of trauma and prior abuse was allegedly subjected to physical and mental abuse by a CNA during care. Multiple CNA students reported seeing the CNA hit the resident’s shoulder with an open hand, forcefully push her shoulder and knee into the bed and toward the wall while the resident screamed for help, and use force on the resident’s chest to wake her. The resident cried afterward, reported pain, and told the students the CNA had hurt her and was a liar. The CNA was also reported to have stated she did not care if the resident ate because the resident was going to die and removed the meal tray while students were still assisting with fluids. Although the Wound Nurse/Manager on Duty, QA staff, and DON were informed and obtained verbal reports and written statements from the students, the written statements were later reported as missing, the resident was not directly interviewed by the DON, and the final abuse report concluded the allegation was unsubstantiated without referencing the eyewitness student accounts, resulting in a failure to protect the resident from abuse and to conduct an adequate abuse investigation.
The facility failed to notify local law enforcement about two separate abuse allegations despite having a policy requiring such reporting. In one case, CNA students reported witnessing a CNA use unnecessary force while repositioning a resident in bed, with the resident crying, stating she was hurt, and later describing pain and fear to the students. In another case, a resident reported that staff pulled her arm, were rough during oral care, and laughed at her, and a skin assessment showed bruising on the front and back of both arms. Both allegations were reported to the state survey agency, and the DON acknowledged that police should be notified of abuse allegations, but the abuse investigations contained no evidence that law enforcement was contacted.
The facility's Arbitration Agreement lacked required language informing residents that signing was not a condition of admission and that they had 30 days to rescind. This affected all 170 residents. The Administrator confirmed the agreement is part of the admission packet, and the Assistant Administrator noted it has been in use since 2018.
The facility's Arbitration Agreement was found deficient due to the lack of a process for selecting a neutral arbitrator and limited venue options for residents. The agreement, part of the admission packet since 2018, mandates cooperation in selecting an arbitrator from a specific company's panel and holds hearings in the facility's county. The Administrator confirmed no refusals to sign the agreement.
The facility failed to follow its Water Management Plan for Legionella, conducting only one test in 2024 and lacking documentation for required monitoring. Additionally, staff did not adhere to hand hygiene protocols during resident care, using the same gloves for multiple tasks and not performing hand hygiene between tasks. These deficiencies could increase the risk of infection for residents.
A facility failed to assess, document, and follow physician orders for a resident's skin lesion. The resident, with a history of vascular dementia and other conditions, had red lesions on her nose and forehead. Despite orders for a dermatology consult, the facility did not ensure it was completed, and the lesions were not documented in medical records. The DON and Wound Care Doctor were unaware of the nose lesion until the survey, highlighting a deficiency in care practices.
A resident experienced significant weight loss, but the facility failed to notify the physician or consult the dietitian as per policy. The resident lost 19.18% of their weight over six months and 7.5% in one month, yet there was no documentation of a dietitian evaluation or physician notification. The dietitian confirmed the last evaluation was months prior, and the resident was not receiving supplements. The facility's policy requires documentation and care plan updates for significant weight changes, which were not completed.
A facility failed to follow physician orders for a resident receiving IV hydration. The resident, with multiple diagnoses including hyperosmolality and hypernatremia, had orders for lab tests to be conducted before IV fluids were administered. However, the IV fluids were given before the lab tests were collected, contrary to the physician's orders. The DON confirmed the expectation for lab tests to be drawn prior to starting IV fluids.
Failure to Maintain Resident Safety During Incontinence Care
Penalty
Summary
The facility failed to ensure a resident was kept safe during incontinence care when staff turned her in bed and she slid off the bed onto the floor. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting her left side, osteoarthritis, and dementia with impaired thought processes. Her care plan and MDS showed she was at increased risk for falls, had poor balance and coordination, required substantial to maximum assistance to roll in bed, used a pressure-relieving air mattress, and needed staff assistance for transfers and bed mobility. During incontinence care, a CNA told the resident he was going to turn her to her left side while she was lying in the middle of the bed. He turned her by pushing her away from him and then turned his head away to retrieve wipes from a table behind him. While his attention was away from the resident, her feet slid off the bed and her body followed, and she landed on the floor in a kneeling position while still holding the bed rail. Witness statements and staff interviews described that the resident was on her knees with her buttocks on her feet and was screaming in pain after the fall. The resident complained of ongoing knee pain after the fall and was later sent to the hospital, where imaging showed an acute complex fracture of the distal left femur and fractures of the distal right femur. A nurse practitioner note stated the resident suffered a fall while staff were repositioning her in bed, resulting in bilateral distal femur fractures and bilateral femoral retrograde rodding. The DON stated the resident should have had supplies prepared in front of the staff member so he would not have needed to look away during care, and the facility noted the resident was using an air mattress at the time of the incident.
Failure to Conduct Impartial Abuse Investigation and Protect Resident from Alleged Abuser
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough and impartial investigation of an allegation of staff-to-resident abuse and to maintain the original witness documentation. A cognitively impaired resident with multiple diagnoses, including dementia with psychotic disturbance, anxiety, major depressive disorder, chronic pain, hemiplegia, and legal blindness, alleged that a CNA had hurt her. The resident’s care plan identified her as a vulnerable adult with a history of significant trauma and financial abuse/exploitation, and noted that she was a trauma survivor requiring 24‑hour care. The care plan also documented that she could exhibit manipulative behavior and make accusations related to her dementia and anxiety, and included an intervention for two staff to be present during care in her room and during showers. Multiple CNA students reported witnessing or hearing about physical abuse of the resident by a CNA. One student stated she saw the CNA hit the resident’s left shoulder hard with an open hand, push the shoulder forcefully into the mattress while holding the resident down, shove the resident’s knee down forcefully into the mattress, and push the right side of the resident’s body toward the wall with force, while the resident screamed that she was being hurt and asked for help. Another student stated she and another student witnessed the CNA pushing the resident on her left side using a lot of unnecessary force, pressing very hard on the resident’s shoulder while leaning over her and putting her weight onto the resident, while the resident told the CNA to stop and said she was being hurt. The students further reported that when they later assisted with feeding, the resident was sobbing, said the CNA had hurt her, tried to show where her knee hurt, and told the students not to be like the CNA. When the students reported the allegation to the wound nurse/nurse manager on duty and quality assurance staff, the investigation process was described by multiple witnesses as coercive and dismissive. The wound nurse/nurse manager repeatedly emphasized that the alleged perpetrator was a single mother who could lose her job and be unable to feed her child, which the students and the CNA student instructor described as making them feel guilty, uncomfortable, doubting themselves, and as if they were lying. The wound nurse/nurse manager interrupted the students as they tried to explain what they saw, characterized the resident as combative and behaving this way often, and asked the students to physically demonstrate on the quality assurance nurse what the CNA had done, including asking a student who had not witnessed the abuse to demonstrate. The students were asked to provide handwritten statements, which they did, but those original statements were not retained in the investigation file and later could not be located by the DON, wound nurse/nurse manager, or quality assurance nurse. The facility’s Final Abuse Investigation Report concluded that the allegation of abuse was not substantiated and described the incident only as the resident reporting to students during meal assistance that the CNA hit her, without reference to the students’ direct eyewitness accounts of physical actions by the CNA. The investigation file contained only handwritten statements from the alleged perpetrator and the CNA student instructor, and not from the student witnesses. Instead, the file included typed documents authored by the wound nurse/nurse manager and the quality assurance nurse that summarized the students’ accounts in a less aggressive manner than what the students later described in interviews, and these documents were not signed by the students. The DON stated she did not interview the resident and relied on the wound nurse/nurse manager and quality assurance nurse to do so, and she did not receive any statements with the resident’s interview. During the period after the allegation was reported and while the investigation was incomplete and unsubstantiated, staffing records showed the alleged perpetrator CNA was again assigned to provide care to the resident on two subsequent shifts. These actions and omissions—coercive and biased interviewing of witnesses, failure to obtain and preserve signed witness statements from all student witnesses, failure to interview the resident by the DON, reliance on altered or second-hand typed summaries instead of original statements, and allowing the alleged perpetrator to continue caring for the resident—constituted the facility’s failure to conduct a thorough and impartial abuse investigation and to protect the resident from further potential abuse. This failure resulted in an Immediate Jeopardy situation as determined by the surveyors.
Failure to Protect a Vulnerable Resident From Alleged Physical Abuse and Inadequate Abuse Investigation
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from physical and mental abuse by staff and to conduct an adequate abuse investigation. The resident had multiple diagnoses including metabolic encephalopathy, dementia with psychotic disturbance, major depressive disorder, anxiety, psychosis not due to a substance, hemiplegia, legal blindness, chronic pain, and muscle weakness. The care plan identified the resident as a vulnerable adult with a history of financial abuse/exploitation by her son, significant lifetime trauma, and trauma survivor status. The care plan also documented that the resident exhibited manipulative behavior and made accusations against staff and other residents related to dementia with psychotic disturbance and anxiety, and included an intervention requiring two staff to be present during care in the resident’s room and during showers. On the date of the incident, multiple CNA students reported witnessing and/or receiving reports of abusive conduct by a CNA toward the resident during care. One CNA student stated that when she and another student delivered the resident’s dinner tray, they saw the CNA standing on the left side of the bed, hitting the resident several times with an open hand on the left shoulder, forcefully pushing the shoulder downward into the mattress and holding it down for several seconds, and forcefully shoving the resident’s left knee down on the bed. The student further reported that the CNA placed one hand on the resident’s left knee and the other on the left shoulder and forcefully pushed the resident toward the wall, even though the resident was already close to the wall. The resident was described as screaming for help, asking the CNA to stop because she was being hurt. Another CNA student reported that the CNA had earlier stated she did not care if the resident ate because the resident was going to die, and that the CNA used force with the palm of her hand on the resident’s chest to wake her without saying anything beforehand. After the CNA left, the resident cried, stated that the CNA had pushed her knee and hit her in the chest, and reported she was still in pain. A third CNA student corroborated that when she and another student entered the room to deliver the dinner tray, they observed the CNA pushing the resident from the left side using a lot of unnecessary force, leaning over the resident and putting most of her weight down on the resident’s left shoulder while the resident lay on her back. This student stated the resident’s hand was not raised toward the CNA and that the resident told the CNA to stop because she was being hurt, but the CNA continued. The students later found the resident sobbing, with the resident stating that the CNA had really hurt her, grabbing the student’s shoulder to demonstrate and telling the student not to be like the CNA. The CNA was also reported to have removed the resident’s tray while the students were still assisting the resident with milk, stating it did not matter if the resident ate because she was on hospice and directing the students to stop and return to the dining room. The CNA denied pushing the resident’s knee or rolling her in bed, stating she only touched the resident’s arms while putting on a gown and that the resident said, “No, it hurts,” during care. The facility’s abuse investigation was incomplete and failed to incorporate or preserve key eyewitness evidence. The Wound Nurse/Manager on Duty and the Quality Assurance staff obtained verbal reports and had the CNA students write statements and physically demonstrate what they witnessed, but later reported they were unable to locate the written statements. The DON acknowledged she did not interview the resident directly and relied on verbal accounts from others, expressed a lack of confidence in the students’ allegations, and stated that the written statements conflicted but could not be found. The final abuse report concluded the allegation was unsubstantiated, attributing the resident’s report to misinterpretation of staff cues and medication-related delusions and hallucinations, and described the resident as restless, combative, manipulative, and preferring not to be touched. The final report did not reference the CNA students’ eyewitness accounts or their written statements, despite the facility’s policy defining abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and including hitting and harassment as examples of physical and mental abuse. Video footage reviewed later showed that CNA students and the CNA were present in the resident’s hall around the time of the alleged incident, consistent with the students’ accounts of delivering trays and returning to feed the resident. The footage showed the students working with a CNA to bring a food tray cart into the hall, the CNA exiting the hall, the students exiting the hall and entering the dining room, and later the students and CNA returning to the hall without a meal tray, with the CNA leaving and returning to the room and eventually exiting with a meal tray. The facility’s failure to protect the resident from alleged physical and mental abuse, to follow the care plan intervention requiring two staff during care, and to conduct and document a thorough, evidence-based abuse investigation using the CNA students’ eyewitness accounts and written statements led to the deficiency.
Failure to Notify Law Enforcement of Abuse Allegations
Penalty
Summary
The facility failed to notify local law enforcement regarding allegations of resident abuse as required by its abuse reporting policy. For one resident, an initial abuse report dated March 25, 2026, and a final report dated March 27, 2026, documented an allegation of physical abuse. A CNA student (V14) reported that she and another CNA student (V5) witnessed a CNA (V8) pushing the resident on her left side while the resident was lying in bed, using what appeared to be unnecessary force. The resident verbally told V8 to stop, stating she was being hurt, while V8 was described as pressing very hard on the resident’s shoulder and leaning her weight into the resident. Later, when V14 and another CNA student (V7) were sent into the room to feed the resident, the resident began sobbing, stated that V8 had hurt her, attempted to show where her knee hurt, and grabbed V14’s shoulder, telling the students not to be like V8. The allegation was reported to the state survey agency, but the abuse investigation contained no evidence that local law enforcement was notified. For a second resident, initial and final abuse reports dated December 9, 2025, documented allegations that someone pulled the resident’s arm during care, was rough during oral care, and that people were laughing at her. A skin assessment identified bruising on the front and back of both of the resident’s arms. The allegation was submitted to the state survey agency, but review of the abuse investigation showed no evidence that local law enforcement was notified. The DON (V12) stated that police should be notified of any allegations of abuse. The facility’s written policy on prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, exploitation, or misappropriation of resident property states that all alleged violations and substantiated incidents will be reported to the state agency and other required agencies, and that the Administrator shall also report to local police if the allegation meets the requirements. Despite this policy, there was no documentation that law enforcement was contacted for these two abuse allegations.
Deficient Arbitration Agreement Language
Penalty
Summary
The facility's Arbitration Agreement was found to be deficient as it did not include the required language informing residents or their representatives that signing the arbitration agreement was not a condition of admission to the facility. Additionally, the agreement failed to inform them that they had 30 days to rescind the agreement after signing. This deficiency affects all 170 residents residing in the facility. During an entrance conference, the Administrator acknowledged that the arbitration agreement is part of the admission packet and noted that no newly admitted resident or their representative had refused to sign it. The Assistant Administrator confirmed that the current admission packet, including the arbitration agreement, has been in use since 2018.
Deficiency in Arbitration Agreement Process
Penalty
Summary
The facility's Arbitration Agreement was found to be deficient as it failed to establish a process for selecting a neutral arbitrator and did not provide a selection of venues suitable for residents or their representatives. This deficiency was identified during a review of the facility's Admission Packet, which included the Arbitration Agreement. The agreement stated that the parties would cooperate in selecting an arbitrator from a panel provided by a specific arbitration company, and if that company was unavailable, the facility would select another service. Additionally, the arbitration hearing was to be held in the county where the facility is located, limiting venue options. The facility's Administrator confirmed that the arbitration agreement is part of the admission packet and noted that no new admissions or their representatives had refused to sign it. The Assistant Administrator revealed that the current admission packet, including the arbitration agreement, has been in use since 2018.
Failure to Follow Water Management and Hand Hygiene Protocols
Penalty
Summary
The facility failed to adhere to its Water Management Plan for Legionella, which is designed to minimize the risk of Legionnaires' disease. The plan requires regular testing and monitoring of water systems, including cooling towers and decorative fountains, as well as daily and weekly checks of hot water systems. However, the facility only conducted one Legionella test in 2024 and lacked documentation for other required tests and monitoring activities. This oversight affects all 170 residents in the facility, as the water systems are integral to the facility's operations and resident safety. In addition to the water management issues, the facility did not follow proper hand hygiene protocols during resident care. In one instance, a CNA and a Nurse Manager assisted a resident with toileting without changing gloves or performing hand hygiene between tasks. The CNA used the same gloves to perform multiple tasks, including cleaning the resident and the toilet seat, which is against the facility's hand hygiene policy. This failure to change gloves and perform hand hygiene could lead to cross-contamination and increased risk of infection for the resident. Another deficiency was observed during wound care for a resident with multiple wounds. The Wound Care Nurse did not remove gloves or perform hand hygiene when moving from dirty to clean areas during the dressing change. This practice contradicts the facility's hand hygiene policy and could potentially contaminate the wounds, increasing the risk of infection. The Director of Nursing acknowledged the importance of removing gloves and performing hand hygiene to prevent contamination during wound care.
Failure to Document and Follow Up on Resident's Skin Lesion
Penalty
Summary
The facility failed to assess, identify, and document a resident's skin lesion and did not follow physician orders to consult a dermatologist for the skin lesions. The resident, an elderly female with a history of vascular dementia, chronic heart failure, and other conditions, was observed with red lesions on her nose and forehead. Despite the presence of these lesions, the facility staff did not document the condition in the resident's medical records, nor did they ensure that a dermatology consultation, which was ordered in 2023, was completed. The Director of Nursing and the Wound Care Doctor were unaware of the lesion on the resident's nose until it was brought to their attention during the survey. The facility's policy required documentation of new wounds and changes in existing wounds, but this was not adhered to in the case of the resident's lesions. The resident's family member was also unaware of any dermatology consultation being arranged. The Wound Care Doctor recommended a dermatology consult for a biopsy to determine if the lesions were cancerous, but there was no evidence that this was pursued. The failure to document and follow up on the resident's skin condition represents a deficiency in the facility's care practices.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to adhere to its policy of notifying the physician and consulting the dietitian for a resident's significant weight loss. This deficiency was identified for a resident who experienced a 19.18% weight loss over six months and a 7.5% weight loss in one month. Despite these significant changes, there was no documentation of a dietitian evaluation in November 2024 or January 2025. The dietitian confirmed that the last evaluation was conducted in August 2024, and the resident was not receiving any nutritional supplements at the time of the survey. Additionally, the facility did not document any progress notes indicating that the resident's physician was notified of the significant weight loss. The Director of Nursing acknowledged that both the physician and dietitian should have been informed, and a nutrition evaluation should have been completed. The facility's policy requires documentation of significant weight changes and care plan updates, which were not present in the resident's records since the weight loss was noted.
Failure to Follow Physician Orders for Lab Tests
Penalty
Summary
The facility failed to adhere to physician orders for laboratory tests for a resident receiving intravenous hydration. The resident, who was admitted with conditions including hyperosmolality, hypernatremia, Alzheimer's disease, dementia, and chronic kidney disease, had an order for laboratory tests to be conducted every Monday before the administration of intravenous fluids. However, the resident received the intravenous fluids on January 13, 2025, at 6:00 AM, but the laboratory tests were not collected until the following day, January 14, 2025. The Director of Nursing confirmed that the expectation was for the laboratory tests to be drawn before the intravenous fluids were started, indicating a failure to follow the physician's orders as required.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Naperville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadowbrook Manor - Naperville | 0.1 mi | ★★★★★ | 8 | 0 |
| Tabor Hills Health Care Fac | 1 mi | ★★★★★ | 0 | 0 |
| Arista Healthcare | 1.6 mi | ★★★★★ | 0 | 0 |
| Springs At Monarch Landing, The | 2.2 mi | ★★★★★ | 0 | 0 |
| Pearl Of Naperville, The | 2.2 mi | ★★★★★ | 10 | 0 |
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