Alden Estates of Naperville: Medication Storage Failures - IL
The inspection, conducted May 28, 2026, was triggered by a complaint. What investigators found in those drawers, sitting unsecured on a unit housing 28 residents with dementia, was a snapshot of how medication management can quietly fall apart on a floor where residents cannot advocate for themselves.
The nurses' station drawers held two 1,000-milliliter bags of 5% dextrose IV solution labeled with the name of a resident identified in the report as R9. R9 had Alzheimer's disease, chronic kidney disease, and several other diagnoses. R9 was also dead. The IV bags had not been discarded.
A tube of B & C ointment for wound dressing sat in the same drawer, labeled with the name of R8. R8 had been admitted with a stage 3 pressure ulcer on his left buttock, dementia, a history of falling, and chronic pain. He too had died at the facility before the inspection. The ointment stayed.
Also in the drawer: a box of lidocaine 4% pain relief patches prescribed for R7, a resident living with ataxia, dementia, mood disorder, anemia, chronic pain, and psychosis. R7 had an active order for the patches to be applied to both knees each morning, left on for 12 hours, then removed. The patches were sitting in an unlocked nurses' station drawer rather than in the medication cart or medication room where the facility's own policies required them to be stored.
A box of silicone-faced foam and border sacrum dressing labeled for R10, a resident with dementia, prostate cancer, thrombocytopenia, a stage 3 pressure ulcer, osteoarthritis, and pancytopenia, was also in the drawer.
That was not all. Inspectors also found a bottle of multivitamin dietary supplement that had passed its expiration date, a box of 10-milliliter normal saline flushes, a tube of TheraHoney gel with no resident name on it, and a tube of miconazole nitrate 2% antifungal cream, also unlabeled.
Eight items in a single drawer. Medications for residents who were still alive mixed in with medications for residents who had died. None of it stored where the facility said medications were supposed to be stored.
The Licensed Practical Nurse on duty, identified in the report as V22, was present during the drawer inspection at 12:45 p.m. Two minutes later, she acknowledged that the IV bags had belonged to a deceased resident and should have been thrown away. She said all nurses working on the unit were responsible for storing medications in either the treatment cart or the nurses' medication cart.
That explanation raised its own question. If every nurse on the unit shared responsibility, and this drawer held medications going back to at least two residents who had died, how long had those items been sitting there? The inspection report does not say. The dates of R8's and R9's deaths are redacted, as is standard practice in CMS reports to protect resident confidentiality. What the report makes clear is that by the time inspectors arrived, the IV bags and the wound ointment were still there.
The Director of Nursing, V2, told inspectors at 3:05 p.m. that medications are stored in medication rooms and medication carts, not in residents' rooms and not at nurses' stations. She said medications are kept in the medication rooms when not in use. Asked again at 12:55 p.m. on a separate occasion, she said medications should be kept in the nurses' medication cart, the wound treatment cart, or the medication room. She also said some of the medications found in the drawer should have been discarded.
The facility's own written policy on medication storage, dated September 2020, states that when a resident is discharged, all medications are to be moved to one designated area determined by the facility. A second policy, on storage, labeling, and packaging of medications, dated December 2023, states that each resident's medications are kept separately from others.
Both policies were violated by what inspectors found in that drawer.
The significance of the location matters. This was not a general nursing floor. This was a locked dementia unit. The 28 residents living there have, by definition, cognitive impairments serious enough to require a secured environment. Several of the residents whose medications were found in the drawer were documented with diagnoses of dementia, Alzheimer's disease, and senile degeneration of the brain. Residents on a unit like this cannot be expected to recognize that a medication belongs to someone else, or that it belonged to someone who has since died, or that an unlabeled cream sitting in a drawer is not something they should touch.
CMS classified the harm level for this violation as minimal harm or potential for actual harm. The violation affected four residents directly and had the potential to affect all 28 residents on the unit.
The inspection report does not document any harm that resulted from the storage failures. But the medications found in that drawer were not theoretical risks sitting in a locked cabinet. They were in an unlocked nurses' station drawer on a floor full of people who, by the nature of their conditions, cannot reliably distinguish between what is theirs and what is not.
R7, the resident whose lidocaine patches were found in the drawer, had active prescriptions that required precise timing, applied each morning, worn for 12 hours, removed for 12 hours. Whether that schedule was being followed as written is not addressed in the report. The patches were in the drawer, not in the medication cart.
R8 died with a stage 3 pressure ulcer on his left buttock. The wound ointment prescribed for that ulcer remained in the nurses' station drawer after his death. The report does not say how long it had been there.
R9 died with Alzheimer's disease and chronic kidney disease. Two large IV bags prescribed in his name remained in the drawer. The nurse who found them with inspectors said they should have been discarded.
Nobody had discarded them.
R10, living with prostate cancer, a blood disorder, and a stage 3 pressure ulcer, had wound dressings sitting in the same unlocked drawer as the dead men's medications, the expired vitamins, and the unlabeled creams.
The Director of Nursing confirmed what should have happened. The facility's own policies confirmed what should have happened. The nurse on duty confirmed what should have happened. What the drawer confirmed was that it hadn't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alden Estates of Naperville from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
ALDEN ESTATES OF NAPERVILLE in NAPERVILLE, IL was cited for violations during a health inspection on May 28, 2026.
The inspection, conducted May 28, 2026, was triggered by a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.