Inspection Reports for Sunrise of Naperville

IL, 60540

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Inspection Report Summary

The most recent inspection on November 8, 2024, identified deficiencies related to staffing qualifications and incident reporting at Sunrise of Naperville. Earlier inspections were not provided for comparison, but this report noted failures to employ adequately skilled staff to monitor a high-risk resident who developed pressure wounds and to maintain complete incident records, including a lack of a quality improvement program. Inspectors cited issues with personnel qualifications and establishment records, and a facility-reported incident investigation substantiated one violation without imposing a fine. No enforcement actions such as fines or license suspensions were listed in the available reports. This recent inspection suggests areas needing improvement in staff training and incident management.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

14% worse than Illinois average
Illinois average: 3.5 deficiencies/year

Deficiencies per year

4 3 2 1 0
2024

Inspection Report

Annual Inspection
Deficiencies: 2 Date: Nov 8, 2024

Visit Reason
The inspection was conducted as an Annual Licensure Survey to evaluate compliance with personnel qualifications, record keeping, and incident reporting requirements at Sunrise of Naperville.

Findings
The facility failed to employ adequately skilled staff to monitor and intervene timely for a high-risk resident who developed severe pressure wounds, and failed to maintain and report all required incident and accident records, including a lack of a quality improvement program to address non-reportable incidents. The facility's incident reporting system was inadequate to identify patterns and trends, posing a substantial risk of harm to residents.

Deficiencies (2)
Failed to employ staff with adequate skills and experience to provide monitoring and timely/effective interventions to a high-risk resident who developed two facility-acquired pressure wounds.
Failed to report and maintain all state reportable incidents and accidents and provide documentation of a quality improvement program addressing non-reportable resident incidents.
Report Facts
State reportable incidents: 10 Resident age: 81 Pressure wound size: 7.5 Pressure wound size: 5.5 Pressure wound size: 6 Pressure wound size: 8 Pressure wound size: 0.1 Resident weight: 209 Resident age: 102 Fall dates: 7

Employees mentioned
NameTitleContext
E1Executive DirectorProvided binder of reportable incidents and stated prior ED did not keep copies of state reportables
E2Director of Nursing (DON)Stated caregivers monitor skin alterations but no documentation exists; also stated misunderstanding about incident reporting requirements

Inspection Report

Plan of Correction
Deficiencies: 2 Date: Nov 8, 2024

Visit Reason
The document is a Statement of Correction submitted in response to violations cited during the Annual Licensure Survey conducted on 11/8/2024 and a facility reported incident investigation on the same date.

Complaint Details
The facility reported incident investigation conducted on 11/8/2024 found the allegation substantiated with 1 Type 2 violation related to establishment records. No fine was imposed for this incident.
Findings
The facility was cited for two Type 2 violations related to personnel requirements and establishment records. The Statement of Correction outlines corrective actions including staff training, audits, and ongoing monitoring to ensure compliance with care and reporting requirements.

Deficiencies (2)
Violations cited for Section 295.7010 (Establishment Records)
Violations cited for Section 295.3000 (Personnel Requirements, Qualifications, and Training)
Report Facts
Fine amount: 1000 Number of violations: 2 Number of violations: 1

Employees mentioned
NameTitleContext
Sandra L. GourleyExecutive DirectorSigned the Statement of Correction and responsible for compliance reporting
Edward PittsRN-BSN, PSAIllinois Department of Public Health staff who signed enforcement and investigation letters

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