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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunny Hill Nursing Home Of Will County during CMS and state inspections, most recent first.
A resident fell from a bath chair during a whirlpool bath when only one CNA was present and no safety belt was in use, despite manufacturer instructions requiring residents to be securely belted. The CNA reported the resident slid off the chair when the tub door was opened, and the resident landed between the tub and the door on his hip. Observation showed the bath chair had only half of a safety belt attached. The ADON stated new safety straps had recently been placed but was unaware that straps were missing or in disrepair, and maintenance reported no work orders or log entries to repair the chair. This occurred despite facility policies on preventative maintenance and fall prevention requiring a safe environment, adequate supervision, and appropriate assistive devices.
A resident with multiple medical conditions was administered Zoloft, an antidepressant, despite the POA explicitly declining consent for the medication. The RN failed to discontinue the order in the EMR after the POA's refusal, leading to LPNs administering the medication without consent until the issue was discovered at a care plan meeting.
Staff inconsistently used PPE and failed to enforce universal masking during a respiratory infection outbreak, despite recommendations from health authorities. A CNA entered a resident's isolation room without full PPE, a rehab nurse and an LPN were observed without masks in care areas, and residents participated in group activities without masks. The facility's infection control policy did not address adherence to state and local health department guidance.
The facility failed to maintain proper food safety and hygiene standards in the kitchen, affecting all residents receiving oral nutrition. Observations revealed improper hair restraint use by kitchen staff and failure to label, date, and remove expired food items, including shredded carrots, milk, celery, and potatoes. Unlabeled trays of sausage and biscuits were also found, violating facility policies.
The facility failed to implement fall interventions for high-risk residents, as observed during a survey. A resident with Parkinson's and dementia was found without a call light within reach and only one fall mat, contrary to her care plan. Another resident with severe cognitive impairment did not have her bed against the wall as required. A third resident had fall mats folded and her bed in a high position, not against the wall. Staff interviews revealed inconsistencies in implementing fall prevention measures, resulting in a deficiency in providing adequate supervision and accident hazard prevention.
The facility failed to follow its catheter care policy, resulting in deficiencies such as leaking catheters, unsecured tubing, and the reuse of catheter bags. A resident experienced urine leaks due to a delayed catheter change, and another had unsecured tubing, increasing the risk of tension at the insertion site. Multiple residents were found with reused catheter bags, contrary to policy and manufacturer guidelines. The DON acknowledged these practices were against policy, highlighting the need for adherence to aseptic techniques and proper catheter care.
The facility failed to provide written notice of hospital transfer reasons to residents and their representatives, affecting three residents. Despite policy requirements, staff only provided verbal notifications, and no written documentation was given. This deficiency was confirmed through staff interviews and resident feedback.
The facility did not provide a written bed hold policy to a resident or their representative before a hospital transfer. After an unwitnessed fall, a resident was transferred to the hospital with hyponatremia, but the required bed hold notice was not sent to the family. The facility's policy mandates written notification of bed-hold policies before transfers, which was not followed.
A facility failed to prevent further decline in range of motion for a resident with severe cognitive impairment. The resident was observed with a right-hand contracture without a palm protector, which was supposed to be used to prevent further contraction. The charge nurse acknowledged the absence and planned to notify the therapist, while the DON confirmed the staff's responsibility to apply the protector as per the care plan.
The facility failed to properly label, store, and dispose of insulin for two residents, leading to unsafe medication administration. An LPN did not label insulin Glargine with a use-by date, and another LPN believed insulin Aspart was still effective past the recommended 28-day period. The DON was unaware of insulin expiration guidelines, and facility policies lacked clear instructions on insulin disposal.
The facility failed to follow infection control practices, including a CNA not wearing a mask during an outbreak and improper room placement of a COVID-19 positive resident. Additionally, a CNA did not perform hand hygiene between care tasks, violating the facility's hand-washing policy.
Failure to Use and Maintain Bath Chair Safety Belt Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from a fall during bathing activities by not ensuring proper use and maintenance of required safety equipment and adequate supervision. The resident reported falling in the shower after slipping off a shower chair and stated that only one staff member was present at the time. The CNA who provided care stated that the resident had been placed on the bath chair with assistance from another staff member, but that the second staff member did not remain for the whirlpool bath. The CNA reported that she placed the resident in the whirlpool tub while he was seated on the bath chair and, when she opened the tub door to assist him out, he slid off the chair and fell between the tub and the tub door onto his left hip. The CNA did not recall placing a safety belt on the resident and acknowledged that if a belt had been used, the fall likely would not have occurred. The resident also did not recall whether a safety belt had been in use. Further observations and interviews showed that the bath chair on the resident’s unit had only half of the black safety belt attached. The ADON stated that white safety straps had recently been placed on bath chairs because the previous ones were soiled, and denied prior knowledge that safety straps were missing or in disrepair. The maintenance staff member stated that he would replace safety straps if he received a work order or a request from nursing, but he did not recall receiving any such request, and no repair requests for the bath chair were documented on the unit’s maintenance repair log. The bath chair instruction manual specifies that all residents must always be securely belted at the waist when using the lift systems and warns that failure to secure the resident properly with the safety belt could result in injury. Facility policies on Preventative Maintenance Responsibilities and Fall Prevention and Management require maintaining a safe physical environment and ensuring the resident environment remains as free from accident hazards as possible, with adequate supervision and assistive devices to prevent accidents.
Failure to Honor POA Refusal for Antidepressant Administration
Penalty
Summary
A deficiency occurred when the facility failed to honor the wishes of a resident's Power of Attorney (POA) regarding the administration of an antidepressant medication. The resident, who had multiple diagnoses including congestive heart failure, cognitive communication deficit, major depressive disorder, and osteoarthritis, was admitted to the facility and subsequently had an order placed by a Nurse Practitioner for Zoloft. The Registered Nurse (RN) received the order and delegated it to the next shift, but after speaking with the resident's POA, who declined consent for the medication, the RN forgot to discontinue the order in the Electronic Medical Record (EMR). As a result, the medication remained active on the Medication Administration Record (MAR), and Licensed Practical Nurses (LPNs) continued to administer Zoloft to the resident without the required consent. The issue was discovered during a care plan meeting when the POA became aware that the resident had been receiving Zoloft despite his explicit refusal. Documentation in the progress notes confirmed that the POA had declined the medication and did not want it administered. The facility's policy required nursing staff to obtain all necessary consents from the POA for psychotropic medications, but this protocol was not followed, resulting in the resident receiving medication against the POA's wishes for nearly two weeks.
Failure to Implement Universal Source Control and PPE During Respiratory Outbreak
Penalty
Summary
The facility failed to follow state and local health authority guidance to control the spread of a respiratory infection, affecting all 142 residents. Observations revealed that a CNA entered a resident's room on contact and droplet precautions wearing only a surgical mask and gloves, stating she did not need a gown unless providing direct care. A rehab nurse was seen walking in the affected and unaffected wings without a mask, and an LPN was observed passing medication without a mask, only putting one on when addressed. Residents were brought to the main dining room for activities without masks. The facility's acute respiratory illness line list showed a significant outbreak, with 42 cases and 19 hospitalizations, and new symptomatic residents identified during the survey period. Interviews with the DON and ADON confirmed that appropriate PPE for contact and droplet isolation includes a gown, face mask, face shield, and gloves, and that all staff should wear masks in care areas. However, staff compliance was inconsistent. State and local health officials recommended universal source control, including masking for all residents, visitors, and staff, but the facility did not enforce resident masking, citing challenges due to illness and cognitive function. The facility's infection control policy lacked information on following state and local health department guidance during outbreaks.
Food Safety and Hygiene Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to proper food safety and hygiene standards in the kitchen, affecting all residents who receive oral nutrition. During a kitchen tour, it was observed that the Dietician/Dietary Manager and other kitchen staff did not properly wear hair restraints, leaving their bangs uncovered. This lack of proper hair restraint was noted during food preparation activities, which is against the facility's policy requiring all hair to be covered by hairnets. Additionally, the facility did not properly label, date, or store food items, and failed to remove expired items from the kitchen. Specific observations included expired shredded carrots, fat-free milk, celery with milky liquid, and pre-diced potatoes. There were also unlabeled and undated trays of smoked breakfast sausage and biscuits. The facility's policy mandates that all foods be labeled with the date received, opened, and the date by which they should be discarded to prevent foodborne illness. The Dietician/Dietary Manager acknowledged these lapses, emphasizing the importance of labeling and removing expired foods to avoid serving them to residents.
Failure to Implement Fall Interventions for High-Risk Residents
Penalty
Summary
The facility failed to implement fall interventions for residents identified as high risk for falls, as observed during a survey. Resident R99, who had Parkinson's disease, dementia, and a history of falls, was found without a call light within reach and only one fall mat on the right side of the bed, contrary to her care plan which required a call light within reach and a floor mattress on the right side. Similarly, Resident R51, with severe cognitive impairment and a history of falls, did not have her bed against the wall as per her care plan, and her room lacked a falling star sign to alert staff of her high fall risk. Resident R107, with severe cognitive impairment and a history of multiple falls, was found with fall mats folded and placed against the wall, and her bed was in a high position, not against the wall as required by her care plan. Additionally, Resident R24, who had severe cognitive impairment and a history of falls, was observed with only one fall mat on the right side of the bed, despite her care plan indicating the need for a mattress on the left side and a floor mat on the right side. The facility's policy required staff to follow individualized care plans and use red stars to alert staff to high fall risk residents. Interviews with staff revealed inconsistencies in the implementation of fall prevention measures. The Restorative CNA and Restorative Nurse acknowledged the discrepancies, noting that residents with one fall mat should have their bed against the wall, and call lights should be within reach. The Director of Nursing confirmed that fall mats are used for residents with repeated falls, and call lights should be accessible. The facility's failure to adhere to care plans and policies for fall prevention resulted in a deficiency in providing adequate supervision and accident hazard prevention for high-risk residents.
Deficiencies in Catheter Care and Policy Adherence
Penalty
Summary
The facility failed to adhere to its catheter care policy, resulting in several deficiencies in the care of residents with indwelling catheters. One resident, a female with intact cognition, was observed with urine leaks and staining on her incontinent brief due to a leaking catheter. The CNA did not report the leak to the nursing staff, delaying the necessary catheter change. Additionally, the CNA used cleaning wipes instead of soap and warm water for catheter care, contrary to the facility's policy. Another resident with severe cognitive impairment was found with unsecured catheter tubing, which could cause tension at the insertion site. The facility's policy requires catheter tubing to be secured with a leg strap to prevent movement and friction. Furthermore, multiple residents were observed with reused catheter bags and leg bags, despite the facility's policy and manufacturer guidelines indicating that these bags should not be reused. The staff was found to be cleaning and reusing the bags for several days, which is against the sterile and single-use nature of the bags. The facility's Director of Nursing acknowledged that the catheter bags should not be reused and that residents should not be lying in bed with a leg bag on, as it could cause urine backflow. The facility's policy states that catheters and drainage bags should be changed based on clinical indications such as infection or obstruction, rather than at fixed intervals. However, the practice of reusing bags and not following aseptic techniques was observed, leading to potential risks for the residents involved.
Failure to Provide Written Notice for Hospital Transfers
Penalty
Summary
The facility failed to provide written notice of the reason for hospital transfers to residents and/or their representatives, as required by policy. This deficiency was identified in the cases of three residents who were transferred to the hospital without receiving the necessary written documentation. For one resident, an unwitnessed fall led to a hospital transfer due to hyponatremia, but there was no documentation of written notice provided. Another resident experienced multiple hospital transfers for chest pain and a critically high white blood cell count, yet neither the resident nor their representative received written notice of these transfers. The resident confirmed that they had never received written explanations for their hospitalizations. Interviews with facility staff, including a Registered Nurse, the Director of Nursing, and the Assistant Administrator, revealed that the facility's practice was to verbally inform residents and notify families by phone, but not in writing. The facility's policy, which requires written notification of transfer details, was not followed. The Assistant Administrator admitted that there was no proof of written communication being sent to families, as the facility relied on staff observations and did not receive diagnoses until after hospital admission. This lack of adherence to policy resulted in a failure to provide the required written notices for hospital transfers.
Failure to Provide Bed Hold Notice Prior to Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold policy to a resident and/or their representative prior to the resident's transfer to the hospital. This deficiency was identified during a review of a resident who was transferred to the hospital following an unwitnessed fall. The resident, identified as R103, was admitted to the hospital with hyponatremia. The facility's Assistant Administrator confirmed that the bed hold notice was not sent to the resident's family for the hospital transfer. The facility's policy requires that residents and their representatives be informed in writing about the bed-hold and return policy prior to any transfers, which was not adhered to in this case.
Failure to Prevent Decline in Range of Motion for a Resident
Penalty
Summary
The facility failed to implement necessary services to prevent further decline in range of motion and contractures for a resident with severe cognitive impairment. The resident, an elderly female, was observed with a right-hand contracture without a palm protector in place, which was supposed to be used to prevent further contraction. The charge nurse acknowledged the absence of the palm protector and mentioned using a towel roll temporarily while notifying the therapist to obtain a palm protector. The Director of Nursing confirmed that the staff should have applied the palm protector to prevent deterioration of the resident's condition. The care plan for the resident included an intervention to apply a palm protector to the right hand if the resident permitted, with the option to remove it for hygiene purposes.
Improper Insulin Storage and Labeling
Penalty
Summary
The facility failed to properly label, store, and dispose of medications, specifically insulin, which led to unsafe administration practices for two residents. Resident 41, diagnosed with type 2 diabetes mellitus with unspecified diabetic retinopathy, had a physician's order for insulin Glargine to be injected subcutaneously at bedtime. During a review of the medication cart, it was found that the insulin Glargine vial had an opened-on date of 11/21/24 and an expiration date of 12/19/24, but it was not labeled with a use-by date. The LPN responsible for the cart acknowledged the oversight and stated that the insulin should be discarded 28 days after opening, which was not done. Similarly, Resident 114, diagnosed with type 2 diabetes mellitus with diabetic nephropathy, had a physician's order for insulin Aspart to be injected as per a sliding scale before meals. The medication cart review revealed that the insulin Aspart vial was opened on 12/29/24 without a use-by date. The LPN in charge believed the insulin was still effective, although it was past the 28-day period recommended by the pharmacist. The Director of Nursing admitted to not knowing the specific duration insulins remain effective after opening, and the facility's policies did not provide clear instructions on when to discard opened insulin vials, contributing to the deficiency.
Infection Control Lapses in Facility
Penalty
Summary
The facility failed to adhere to infection control practices, as evidenced by multiple incidents involving staff and residents. A Restorative CNA was observed in a resident's room without wearing a mask, despite the facility being in an outbreak status with flu and norovirus present. The CNA admitted to being unaware of the COVID-19 status and acknowledged the need to wear a mask. Additionally, a resident who had tested positive for COVID-19 was placed in a room with a new roommate who did not have COVID-19, due to an oversight by the Admissions and Marketing Coordinator. This resulted in a complaint from the family of the new resident. Another incident involved a CNA who failed to perform hand hygiene between providing incontinent care and indwelling catheter care for a resident. The CNA acknowledged the lapse in protocol, and the Director of Nursing confirmed that hand hygiene should have been performed between these tasks. The facility's hand-washing policy mandates hand hygiene before applying non-sterile gloves, which was not followed in this instance.
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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 Joliet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spring Creek | 2.4 mi | ★★★★★ | 11 | 0 |
| Pearl Of Joliet, The | 3.1 mi | ★★★★★ | 3 | 0 |
| Joliet Living & Rehab Center | 3.4 mi | ★★★★★ | 5 | 0 |
| Parc Joliet | 3.4 mi | ★★★★★ | 29 | 0 |
| Avantara Joliet | 3.7 mi | ★★★★★ | 8 | 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.