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 Thrive Of Lisle during CMS and state inspections, most recent first.
Failure to Verify Advance Directive Status: A resident admitted with multiple serious diagnoses had hospital records showing DNAR/DNR status, but the facility did not verify or incorporate that information into the care plan. Admission paperwork left advance directive questions blank, the resident was later documented as Full Code due to no record on file, and staff reported code status was not discussed or confirmed with family. When the resident was found unresponsive, CPR was initiated and continued until death, and the resident’s daughter later stated the resident’s wishes were not honored.
The facility failed to offer influenza and/or pneumonia vaccines to four residents with high-risk medical conditions, despite having a policy to do so. The residents had outdated or no records of vaccinations, and there was no documentation of vaccine offers or declinations. The facility's high turnover rate and reliance on monthly pharmacy clinics contributed to the oversight.
The facility failed to complete daily weights for a resident with CHF and did not ensure offloading devices were in place for two residents with vascular wounds. The CHF resident's weights were not documented on several days, despite an order for daily monitoring. One resident with a transmetatarsal amputation was observed without the required offloading boot, and another resident with impaired skin integrity was found without heel protectors. These deficiencies were contrary to the residents' care plans and physician orders.
A resident's indwelling urinary catheter drainage bag was improperly handled, being placed on the bed and lap instead of below the bladder, during a transfer. The catheter tubing was also found on the floor, contrary to facility policy. CNAs and an LPN acknowledged the correct procedures, which were not followed, posing infection risks. The resident's care plan required regular checks of tubing placement, which were not adhered to.
A facility failed to follow its IV catheter care policy for a resident with a midline catheter. The resident had an undated dressing with dried blood, and there were no documented orders for IV line care. The midline was later removed without documentation or orders, and staff were unaware of its removal. The nurse responsible admitted to forgetting to enter necessary orders, leading to a deficiency in care.
A resident with chronic respiratory failure did not receive continuous oxygen therapy as prescribed, as the nasal cannula was found off and hanging on the flow meter. Family members expressed concern, and staff interviews revealed a lack of awareness about the issue. The resident's care plan required continuous oxygen at 3 liters per nasal cannula.
A resident's Lidocaine patch was not removed as ordered, risking skin irritation and incorrect dosage. Additionally, two residents' controlled medications were not documented immediately upon administration, contrary to facility policy, risking errors and potential diversion. The DON confirmed the importance of timely documentation.
A facility failed to implement its infection control policy for a resident with C.Diff, a multi-drug resistant organism. The resident was under strict contact isolation, but the required signage and communication were inadequate. Staff interviews revealed a lack of awareness about the necessary precautions, such as handwashing, to prevent the spread of infection. The Infection Preventionist confirmed the need for handwashing, but the facility's policy was not properly followed.
The facility failed to offer the COVID-19 vaccine to two residents, despite their eligibility and medical conditions. The Infection Preventionist admitted that the facility had not documented any offer or declination of the vaccine for these residents. Plans to increase vaccine clinic frequency were discussed but not yet implemented.
Failure to Verify and Honor Prior DNAR Status
Penalty
Summary
The facility failed to ensure that advance directive information from the resident’s prior care setting was verified and incorporated into the treatment plan for one resident. The resident was admitted from the hospital with diagnoses including atrial fibrillation, hypertension, hyperlipidemia, asthma, COPD, stool infection with positive C. difficile, failure to thrive, diarrhea, UTI, BPH, weight loss, and severe malnutrition. Hospital records before admission documented that the resident was DNAR/DNR, including the face sheet, demographics, physician progress notes, history and physical, and discharge summary, which also noted the resident’s goal of care was DNR. The facility admission packet contained advance care planning questions, but the section asking whether the resident had an advance directive was left blank. The signature line indicated the resident refused to sign, and the facility representative line was also blank. A speech pathology evaluation later showed the resident had cognitive impairment, including moderate memory impairment and a SLUMS score of 11/30, consistent with the dementia range. The MDS also documented moderately impaired cognition. Despite the prior hospital documentation of DNAR/DNR status and the resident’s impaired cognition, the nurse progress notes stated the resident was Full Code because there was no available record of an advance directive. Social services documentation showed that the resident did not have an advance directive on file and did not want assistance with advance directive planning. The social service designee stated that although care plans were discussed with the family, code status was not discussed or followed through for verification. On the morning the resident was found unresponsive, CPR was initiated, 911 was called, and compressions continued during transport to the hospital, where resuscitation efforts ended shortly after arrival and the resident died. The resident’s daughter, listed as the primary emergency contact, later expressed concern that the resident’s wishes were not honored because the resident was DNAR, and the EMR contained no documentation that the facility contacted the family to verify or discuss the prior DNAR status.
Failure to Offer Vaccines to High-Risk Residents
Penalty
Summary
The facility failed to offer influenza and/or pneumonia vaccines to four out of five residents reviewed for immunizations. The residents involved had various medical conditions, including chronic kidney disease, heart disease, chronic obstructive pulmonary disease, and others, which placed them at high risk for complications from influenza and pneumonia. The facility's records showed that these residents either had outdated pneumococcal vaccinations or no record of influenza vaccinations. Despite the facility's policy to offer vaccines to all residents, there was no documentation to show that these residents were offered the vaccines or that they declined them. The Infection Preventionist (IP) acknowledged the facility's high turnover rate and stated that a local pharmacy conducts monthly vaccine clinics. However, the IP admitted that the facility had not documented offering vaccines to the residents in question. The facility's administrator mentioned plans to increase the frequency of vaccine clinics to twice a month to ensure all eligible residents are offered vaccines. Despite these plans, the lack of documentation and failure to offer vaccines to the residents at the time of the survey constituted a deficiency.
Failure to Implement Weight Monitoring and Offloading Devices
Penalty
Summary
The facility failed to ensure daily weights were completed for a resident with congestive heart failure (CHF). The resident's medication administration record indicated an order for daily weights starting on January 12, 2025, but weights were not documented on several days. The resident, who was cognitively intact, stated he never refused to be weighed and was unaware of the importance of weight monitoring. The Director of Nursing explained that daily weights are crucial for CHF residents to monitor fluid retention, which can lead to serious health issues. The facility also failed to ensure that residents with vascular wounds had offloading devices in place. One resident, who had undergone a transmetatarsal amputation due to gangrene, was observed without the required offloading boot on his foot. The resident's family member and the Director of Nursing confirmed that the boot should have been in place to prevent further complications. The resident's care plan and physician orders emphasized the need for pressure redistribution and heel elevation to prevent skin breakdown. Another resident with impaired skin integrity and a history of vascular disease was found without offloading measures for his heels while in bed. The resident's care plan and physician orders specified the use of heel protectors to prevent pressure injuries. Certified Nursing Assistants acknowledged the importance of elevating heels to prevent sores and reduce swelling, but the necessary interventions were not consistently implemented. The facility's skin integrity policy outlined the need for regular assessment and intervention to prevent skin problems, but these measures were not adequately followed.
Improper Handling of Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure proper handling and positioning of an indwelling urinary catheter drainage bag for a resident, identified as R140, during observations and interviews. On multiple occasions, the drainage bag was found improperly placed on the resident's bed and lap, rather than being positioned below the bladder level as required. During a transfer from bed to wheelchair, the drainage bag was placed on the resident's lap, contrary to the facility's policy and best practices for infection control. Certified Nursing Assistants (CNAs) involved in the transfer acknowledged that the drainage bag should be kept below the bladder to prevent urine backflow. Additionally, the catheter tubing was observed lying on the floor under the resident's wheelchair, posing a risk of infection and potential damage to the tubing. The Licensed Practical Nurse (LPN) confirmed that the drainage bag should not be on the bed or lap and that the tubing should not be on the floor. The resident's care plan indicated the need for checking the placement of the tubing each shift, but this was not adhered to. The resident's medical history includes conditions such as alcoholic cirrhosis, acute kidney failure, and congestive heart failure, which necessitate careful management of catheter care to prevent complications.
Failure to Implement IV Catheter Care Policy
Penalty
Summary
The facility failed to implement its intravenous catheter care policy and procedures for a resident with a midline catheter. The resident, who had a history of urinary tract infection, chronic kidney disease, and other conditions, was observed with an undated transparent dressing covering the IV insertion site, which had dried blood. The resident was unable to recall when the IV line was inserted or when the dressing was last changed. The surveyor noted that the IV medication bag was empty and not connected to the resident's line, and there were no documented orders for IV line care or maintenance. The resident's care plan, initiated after the midline insertion, included interventions to observe the IV dressing every shift and change it weekly, but there was no documentation of these actions being performed. On a subsequent observation, the dressing had been changed, but there was no record of when this occurred or any monitoring for signs of infection. The midline was later found to be removed without any documentation or orders for its discontinuation, and the staff was unaware of who removed it or when. The facility's policy required that all PICC line treatments and dressings have a physician's order and that only trained RNs could remove a PICC line with a physician's order. However, the nurse responsible for entering the orders after the midline insertion admitted to forgetting to do so. This oversight led to a lack of documented care and monitoring for the resident's midline, resulting in a deficiency in the facility's adherence to its own policies and procedures for intravenous catheter care.
Failure to Administer Continuous Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident, identified as R134, received continuous oxygen therapy as prescribed. On a specific date, a family member of R134 discovered that the resident was not wearing the nasal cannula for oxygen delivery upon their arrival at the facility. The family member expressed concern and noted that this was not the first occurrence of such an issue. The resident, who is oxygen-dependent due to chronic respiratory failure with hypoxia, was found without the nasal cannula, which was hanging on the flow meter instead. The resident's care plan and physician orders indicated a requirement for continuous oxygen at 3 liters per nasal cannula. Interviews with facility staff revealed a lack of awareness regarding the resident's oxygen administration. A CNA who attended to R134 the previous day acknowledged finding the nasal cannula off and repositioned it but was unaware of any ongoing issues with its placement. The Director of Nursing confirmed that the resident should have had the oxygen on continuously unless there were specific orders for weaning, which were not present. The facility's oxygen administration policy requires staff to ensure that oxygen devices are properly placed and functioning, which was not adhered to in this instance.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration for a resident, identified as R129, who was prescribed a Lidocaine 5% patch for pain management. The order specified that the patch should be applied for 12 hours and then removed for 12 hours. However, during a medication administration observation, it was found that the previous patch had not been removed as per the order. The Licensed Practical Nurse (LPN) acknowledged that the patch should have been removed to prevent skin irritation and ensure the efficacy of the treatment. The Director of Nursing (DON) confirmed that the patch should have been removed according to the schedule to avoid potential skin irritation or incorrect medication dosage. Additionally, the facility failed to document the administration of controlled medications in a timely manner for two residents, identified as R142 and R144. During a review of the medication cart, it was observed that the LPN signed off on the controlled medication reconciliation binder after administering the medications, rather than at the time of administration. This delay in documentation could lead to errors in medication administration records and potential medication diversion. The DON emphasized the importance of signing out controlled medications immediately upon administration to ensure accurate documentation and prevent discrepancies. The facility's policy on narcotic monitoring requires that controlled substances be signed out in the individual Narcotic Sign Out record immediately upon administration. However, the observed practice did not align with this policy, as the LPN delayed signing the reconciliation binder. This discrepancy highlights a failure in adhering to established procedures for controlled medication management, which is crucial for maintaining accurate records and ensuring resident safety.
Failure to Implement Infection Control Policy for C.Diff Resident
Penalty
Summary
The facility failed to implement its infection control policy for a resident diagnosed with Clostridium Difficile (C.Diff), a multi-drug resistant organism. The resident, identified as R228, was admitted with a primary diagnosis of C.Diff and had an active order for strict contact isolation. However, the signage on R228's door did not adequately communicate the necessary precautions, such as the requirement for handwashing, to prevent the spread of infection. The standard yellow contact isolation sign was used instead of the required blue sign for special contact precautions, and there was no indication that staff assistance or notification was needed before entry. Interviews with facility staff revealed a lack of awareness and communication regarding the specific precautions required for residents with C.Diff. A Certified Nursing Assistant (CNA) assigned to R228 was unaware of the resident's C.Diff status and the necessary precautions, relying on nurses for this information. The Infection Preventionist confirmed that alcohol-based hand rubs are ineffective against C.Diff spores and that handwashing is essential. Despite this, the facility's policy was not followed, as the appropriate signage and communication were not in place to ensure staff and visitors were informed of the necessary precautions.
Failure to Offer COVID-19 Vaccine to Residents
Penalty
Summary
The facility failed to offer the COVID-19 vaccine to two residents, R56 and R228, as part of their immunization protocol. R56, who was admitted with multiple health conditions including paroxysmal atrial fibrillation and chronic obstructive pulmonary disease, had his last SARS-CoV-2 vaccine on September 21, 2023. R228, admitted with conditions such as chronic kidney disease and atrial fibrillation, had not received a SARS-CoV-2 vaccine since December 11, 2021. The facility's records did not show any documentation that these residents were offered the vaccine or that they declined it. The Infection Preventionist (IP) acknowledged the facility's high turnover rate and stated that a local pharmacy conducts monthly vaccine clinics. However, the IP admitted that the facility had not offered the vaccine to R56 and R228, as there was no documentation or declination forms available. The facility plans to increase the frequency of vaccine clinics to twice a month to ensure all eligible residents are offered the vaccine, but this plan was not yet implemented at the time of the survey.
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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 Lisle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookdale Plaza Lisle Snf | 1.4 mi | ★★★★★ | 11 | 0 |
| Arista Healthcare | 2.4 mi | ★★★★★ | 0 | 0 |
| Pearl Of Naperville, The | 3.2 mi | ★★★★★ | 10 | 0 |
| Alden Estates Of Naperville | 3.7 mi | ★★★★★ | 6 | 0 |
| Meadowbrook Manor - Naperville | 3.9 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.