Inspection Report
Annual Inspection
Deficiencies: 2
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.
Severity Breakdown
TYPE 2 VIOLATION: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| 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. | TYPE 2 VIOLATION |
| Failed to report and maintain all state reportable incidents and accidents and provide documentation of a quality improvement program addressing non-reportable resident incidents. | TYPE 2 VIOLATION |
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
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Provided binder of reportable incidents and stated prior ED did not keep copies of state reportables |
| E2 | Director 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
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.
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.
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.
Severity Breakdown
Type 2: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Violations cited for Section 295.7010 (Establishment Records) | Type 2 |
| Violations cited for Section 295.3000 (Personnel Requirements, Qualifications, and Training) | Type 2 |
Report Facts
Fine amount: 1000
Number of violations: 2
Number of violations: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sandra L. Gourley | Executive Director | Signed the Statement of Correction and responsible for compliance reporting |
| Edward Pitts | RN-BSN, PSA | Illinois Department of Public Health staff who signed enforcement and investigation letters |
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