Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Dupage Care Center during CMS and state inspections, most recent first.
Residents seated at the same table were not served their meal trays together during lunch in the 1 North dining room. Several residents were observed eating while their tablemates waited without trays, and staff said the missing trays were on the second cart. The FSD stated the kitchen sends the second cart later so residents on the second seating can get hot food, while the DON stated her expectation was that residents seated together should be served together.
A resident with a venous stasis ulcer had a soiled Unna boot dressing left in place beyond the ordered schedule, with discharge visible on the elastic wrap and the wound care nurse noting the dressing had overflowed with new and old drainage. In a separate event, an RN pre-poured multiple residents’ meds into cups in the med room and set them aside instead of administering them at the time of the med pass, contrary to the DON’s expectations and the facility’s Medication Administration policy.
Failure to provide a hand positioning device for a resident with limited ROM. A resident with hemiplegia, aphasia, vascular dementia, and weakness was observed in bed and non-verbal with the left hand held in one position and no splint or palm protector in place. The RN noted the resident required total ADL assistance, and the PT later found tightness in the fingers and stated the resident may benefit from a palm protector or similar device to open the hand and fingers.
Feeding While Resident Was Asleep: A resident with dementia and dysphagia, on a Purple Swallow program with orders for pureed foods, thick liquids, and feeding only when alert, was observed being fed while asleep in the dining room. Staff had to repeatedly prompt the resident to wake up, open her eyes, and swallow as food pocketed and remained in her mouth; the SLP, MD, and DON all confirmed the resident should not be fed while sleeping.
Delayed Nutrition Intervention for Significant Weight Loss: A resident with severe cognitive impairment, vascular dementia, and COPD experienced significant weight loss, dropping from 172 pounds to 154.9 pounds in about one month. The care plan called for weight monitoring and notification of the physician and RD for significant weight changes, but the record showed a delayed response, with a re-weigh requested and fortified foods not added until later. The DON stated interventions should have been implemented sooner after the weight loss was identified.
Medication administration errors resulted in a 7.69% error rate, with 2 errors in 25 medication opportunities. A nurse left residual Esomeprazole in the cup after giving it via g-tube to one resident, and another nurse mixed Rifampin oral suspension with water and did not give the full dose to another resident because medication remained in the cup. The DON stated nurses are expected to follow physician orders and the 5 rights of medication administration.
A resident with dementia, DM2, CKD, and ventricular tachycardia did not receive the pneumococcal vaccine after the POA had already consented for it. The vaccine was only given later when the ADON was compiling immunization information and found it had not been administered, and the DON stated it should have been given sooner.
The facility failed to follow proper food handling and hygiene practices, affecting all residents receiving oral nutrition. A chef was observed not washing hands after touching contaminated surfaces and using the same gloves to handle food and equipment. Additionally, undated and unsealed food items were found in storage, and a package of roast beef was improperly labeled, posing a risk of serving expired or contaminated food.
The facility failed to date and discard insulin vials when opened and did not store medications in their original packaging until administration. Insulin vials were not dated or discarded after the 'do not use after' date, and a nurse improperly stored medications in a cart before administration. These actions violated the facility's medication administration policy.
The facility failed to adhere to infection control protocols, with staff not using appropriate PPE or performing hand hygiene during resident care. CNAs were observed neglecting to change gloves or wash hands after handling soiled materials, and a resident on contact isolation was not assisted with hand hygiene before therapy. These actions contravened the facility's policies on Enhanced Barrier Precautions and contact isolation.
The facility failed to ensure call lights were within reach for residents, impacting their ability to request assistance. One resident, with a history of falls and cognitive impairment, was unable to reach her call light, while another resident with severe cognitive impairment also had her call light out of reach. A third resident was found in pain with her arm trapped, unable to access her call light. Staff interviews confirmed the expectation for call lights to be accessible, aligning with the facility's protocol.
A resident with multiple diagnoses reported verbal abuse by a CNA, but the facility failed to report the allegations to the IDPH within the required 24-hour timeframe. Despite the resident informing the DON and Social Services Manager about the abuse, the report was delayed until the DON received a voicemail, prompting the filing. The facility's policy requires immediate reporting of such allegations, which was not followed.
Two residents in an LTC facility were inadequately monitored and cared for, leading to deficiencies. One resident, with multiple health issues, developed a new wound due to improper incontinence management and lack of repositioning. Another resident, with dementia and mobility issues, experienced pain from her arm being trapped in her wheelchair, with her call light out of reach. The facility failed to adhere to care plans and ensure resident safety.
Two residents with cognitive and mobility impairments were improperly transferred by staff using their pants instead of gait belts, contrary to care plans and facility policy. Staff interviews confirmed the correct procedure was not followed.
A resident with multiple medical conditions, including recurrent UTIs and parkinsonism, did not receive adequate hydration despite being dependent on staff for assistance with drinking. Over several days, the resident reported not having enough water and was observed without water at the bedside. Facility staff confirmed that residents should be offered fluids, but this was not consistently done, leading to a deficiency in care.
A facility failed to manage and label feeding tube equipment for a resident with a G-tube. The tubing was used beyond the recommended period and was not labeled, contrary to protocol. Staff interviews revealed inconsistencies in understanding the policy for changing and labeling feeding tube equipment, and the DON could not provide a specific policy. The resident had severe cognitive impairment and relied on staff for eating.
A facility failed to document monthly medication reviews and obtain physician responses to pharmacy recommendations for a resident with multiple diagnoses, including paraplegia and hypertension. The pharmacy manager noted missing documentation for specific review dates and a lack of physician response to a recommendation for a dose reduction of Citalopram Hydrobromide due to QT prolongation risks. The Director of Nursing indicated that while the facility expects daily physician rounds, there is no policy on the timeframe for addressing pharmacy recommendations.
A resident, dependent on assistance for ADLs, fell and sustained injuries during a transfer when a CNA attempted to use a mechanical lift alone, contrary to the facility's policy requiring two staff members. The resident, with a history of falls and other medical conditions, reported discomfort with the sling used before falling and was later treated for a tibia fracture and occipital contusion.
Residents Seated Together Were Not Served Their Meal Trays Together
Penalty
Summary
The facility failed to provide residents their meal trays with others seated at the same table, affecting 6 of 9 residents observed for dining in the sample of 35. During lunch observation on the first floor in the 1 North dining room, several residents were eating while other residents seated at the same table had not yet received their trays. R160 was being fed by a CNA and had almost finished her meal while R161 and R25, seated at the same table, had not received their trays. At another table, R68 was eating lunch while R165 and R116, seated with her, were still waiting and watching. Staff stated that the trays for these residents were on the second cart and had not yet arrived. Later in the same dining observation, R90 was being fed by a CNA while R153 and R62, seated at the same table, were looking on and had not received their trays; R62 stated she had not received her tray. When the second cart arrived, R68 received her tray after R90 had already finished his meal. The Food Service Manager stated that the first cart was delivered at 11:25 AM and the second cart at 11:57 AM so residents on the second seating could get hot food, and that nursing communicated with dietary by email about which residents to place on the first cart so residents could eat together. The DON stated her expectation was that residents seated at the same table should be served together, and the facility policy titled Tray Delivery Schedule listed the 1 North tray delivery times as 11:25 AM and 11:57 AM.
Soiled wound dressing left in place and medications pre-poured outside policy
Penalty
Summary
The facility failed to change a wound dressing as ordered for a 93-year-old resident with an unspecified open wound of the right lower leg and a venous stasis ulcer. The resident’s right leg was observed covered with an elastic bandage stained with red and brown discharge, and the wound care nurse later found the Unna boot dressing stained with new and old dry discharge that had overflowed onto the elastic wrap. The resident stated the dressing had last been changed on Sunday, and the wound care nurse stated the dressing was to be changed every Tuesday, Thursday, and Saturday and as needed when soiled. The physician order summary directed cleansing with normal saline, application of an Unna boot, and securing with elastic wrap three times a week and as needed for wound care. The DON stated that a wound cannot be left with a soiled dressing and that if discharge was seeping out, the dressing should be changed. The facility also failed to prepare medications per policy during a medication pass. An RN was observed in the medication room opening medication packages, pouring medications into cups, writing residents’ last names on the cups, discarding the packages, and setting the cups aside for three residents before administration. The medications prepared included Depakote 125 mg for one resident, Magnesium Oxide 400 mg for another, and baclofen 10 mg, Carbidopa-Levodopa 25-100 mg, and Gabapentin 300 mg for a third resident. The DON stated that the nurse should take the cart to the resident’s room, check the EMAR, pull medications from the drawer, verify the five rights and any parameters, and administer the medication, and said nurses are not to pre-pour medications. The facility policy titled Medication Administration, revised July 2024, states tablets and capsules should be torn open and placed directly into a souffle cup at the time of administration and that pre-pouring is not allowed.
Failure to Provide Hand Positioning Device for Resident With Limited ROM
Penalty
Summary
The facility failed to provide a device or equipment for a resident with limited ROM to prevent further decrease in ROM. The resident, who was 75 years old, had diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non-dominant side, aphasia following cerebral infarction, vascular dementia without behavioral disturbance, and weakness. The MDS dated July 25, 2025, showed the resident was cognitively impaired and totally dependent on staff for ADL care. On September 8, 9, and 10, the resident was observed multiple times lying in bed and non-verbal. The resident's left hand was noted in one position, slightly closed, with the index and middle fingers in a straight position while the ring and other fingers were bent to the joints. No splint or palm protector was present on the hand during these observations. The 4th Floor Head Nurse stated the resident was confused and required total assistance with ADL care. The PT later assessed the resident's left fingers and stated the resident had locked-in syndrome related to CVA, with tightness in the fourth and pinky fingers and that the resident may benefit from a palm protector or a carrot to open the hand and fingers and prevent skin irritation.
Feeding While Resident Was Asleep
Penalty
Summary
The facility failed to implement feeding interventions to ensure safety for a resident with dementia, anxiety, urinary retention, depression, cochlear implants, and dysphagia, oropharyngeal phase. The resident’s MDS showed severe cognitive impairment and dependence on staff for eating and all ADLs. The care plan dated February 11, 2025, identified a need for hands-on feeding assistance, and the ADL care plan dated February 26, 2024, directed use of Purple Swallow precautions, including a pureed diet with thick liquids, eating only when alert, sitting upright, taking small bites and sips, and eating and drinking slowly. During observation, the resident was seen sleeping in the dining room and was later wheeled to a table and fed a pureed diet while still asleep. While being fed, the resident required repeated prompting to wake up, open her eyes, and swallow; food remained in her mouth, streamed out at times, and she pocketed food. Her head slumped to the side, her eyes remained closed, and she did not speak during the feeding. Staff interviews confirmed the resident was often sleepy, and the SLP stated the resident should stay alert when fed because food can remain in her mouth and there is a risk of aspiration if she is fed while not awake and alert. The Medical Director stated it is basic nursing care knowledge not to feed someone who is sleeping for risk of aspiration, and the DON stated staff should not feed the resident if she is sleeping.
Delayed Nutrition Intervention for Significant Weight Loss
Penalty
Summary
The facility failed to put nutrition interventions in place in a timely manner for a resident with significant weight loss. The resident was admitted with multiple diagnoses including sequelae of cerebral infarction, vascular dementia, and COPD, and the MDS showed severe cognitive impairment. The nutrition care plan identified the resident as having a potential nutritional problem related to vascular dementia, depression, and anxiety affecting meal intake, and it included monitoring weight and notifying the physician and RD of significant weight changes or sudden weight loss. The resident’s recorded weights showed 172 pounds in early July 2025 and 154.9 pounds in early August 2025, reflecting a 9.94% weight loss in one month. A Nutrition/Dietary note later documented that the August weight represented a significant loss and that a re-weigh had been requested, but no re-weigh was available at that time. The DTR stated fortified foods were added on August 27, 2025, and the DON stated interventions to prevent further weight loss should have been implemented sooner than 25 days after the re-weigh was obtained. The facility policy required significant weight changes to be reviewed and assessed by clinical nutrition staff, with individualized intervention provided as needed.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
Medication administration errors resulted in a 7.69% error rate, exceeding the 5% threshold, based on 25 medication opportunities with 2 errors. During observation on September 9, 2025, a nurse administered multiple medications to R13, including Esomeprazole via g-tube, but the medication cup still contained a noticeable amount of residual medication after administration was completed. R13’s MAR directed Esomeprazole 20 mg via g-tube once daily for GERD. Also on September 9, 2025, a nurse administered Rifampin oral suspension to R9 via g-tube after mixing the thick suspension with water, but the full dose was not given because residue remained in the medicine cup. R9’s MAR directed Rifampin Oral Suspension 10 mg/ml, 60 ml (600 mg) via g-tube one time only for prophylaxis. The DON stated that nurses are expected to follow physician orders and the 5 rights of medication administration, including the right time, dose, patient, medication, and route.
Failure to Provide Pneumococcal Vaccine After Consent Obtained
Penalty
Summary
The facility failed to provide a resident with a pneumococcal vaccine. R34 was a [AGE] year-old resident admitted on [DATE] with multiple diagnoses including dementia, type 2 diabetes mellitus, chronic kidney disease, and ventricular tachycardia. The resident’s Pneumococcal Vaccine Consent/Declination Form showed that on June 23, 2025, the resident’s POA consented for the pneumococcal vaccine to be given. R34’s Immunization Report dated September 10, 2025, showed the pneumococcal vaccine was not administered until September 9, 2025. On September 10, 2025, the DON stated the vaccine was given after the ADON began compiling vaccination information and discovered that R34 had not yet received the pneumococcal vaccine. The DON stated the resident should have received the vaccine sooner since consent had been obtained in June 2025.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to adhere to proper food handling and hygiene practices in the kitchen, affecting all residents who receive oral nutrition. During an observation, a chef was seen pureeing lunch items without washing hands after touching potentially contaminated surfaces, such as a garbage can and a face mask. The chef used the same gloves to handle food, equipment, and utensils, which could lead to cross-contamination. This lack of hand hygiene and improper use of gloves violated the facility's hand hygiene policy, which requires washing hands with soap and water after handling soiled equipment or touching the face mask. Additionally, the facility did not comply with its policy on labeling, dating, and storing food items. During a kitchen tour, undated and unsealed bags of crispy onions and croutons were found in dry storage. In Cooler #2, a package of roast beef deli meat was improperly labeled with a handwritten date that did not match the use-by date, leading to confusion about its safety. The Dietary Manager acknowledged that all food items should be labeled, dated, and sealed to prevent contamination and ensure resident safety. The failure to properly label and store food items poses a risk of serving expired or contaminated food to residents.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly date and discard insulin vials when opened, as well as store medications in their original packaging until administration. During an inspection, it was observed that several insulin vials for residents were not dated with the open date, which is necessary for proper medication storage. Additionally, some insulin vials were not discarded after the indicated 'do not use after' date, which is a requirement for ensuring safe medication storage and administration. Furthermore, a nurse was found to have removed medications from their original packaging and stored them in a medication cart before the scheduled administration times. This included loose pills and a powdery substance, which were not supposed to be stored in the cart once removed from their packages. The facility's policy requires that medications be prepared and administered at the scheduled times and not stored in the medication carts once removed from their packages. These actions were contrary to the facility's medication administration policy, which aims to ensure safe medication storage and administration.
Infection Control Deficiencies in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, as evidenced by multiple instances of staff not using appropriate personal protective equipment (PPE) and neglecting hand hygiene protocols. For instance, a CNA was observed providing personal hygiene and incontinence care to a resident on Enhanced Barrier Precautions (EBP) without changing gloves or performing hand hygiene when transitioning from handling a soiled brief to a clean one. Additionally, the CNA left the resident's room without removing PPE, contrary to the facility's policy that requires PPE to be removed before exiting the room. Another incident involved two CNAs providing incontinence care to a resident without changing gloves or performing hand hygiene after handling soiled materials. One of the CNAs used a single towel multiple times without folding it, potentially spreading contaminants. The CNA then touched various surfaces and equipment with contaminated gloves, further breaching infection control protocols. The Director of Nursing confirmed that these actions were against the facility's expectations for infection control practices. Further deficiencies were noted with a CNA handling garbage and meal trays without wearing gloves or performing hand hygiene, despite the resident being on contact isolation due to an infection. Additionally, a resident with a diagnosis of enterocolitis due to Clostridium Difficile reported not receiving assistance with hand hygiene before attending therapy sessions, which is a requirement for residents on contact isolation. The facility's policies on contact isolation and hand hygiene were not adhered to, as evidenced by these observations.
Failure to Ensure Call Lights Within Reach of Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach of residents, which is a critical aspect of accommodating their needs and preferences. On August 20, 2024, a resident, R145, was left in her wheelchair at the foot of her bed with the call light lying across the center of the bed, out of her reach. Despite her attempts to propel herself to reach the call light and asking another resident, R168, for help, neither could access it. R145 had a history of repeated falls, cognitive impairment, and required substantial assistance for daily activities, making the accessibility of the call light crucial for her safety and well-being. Similarly, R168 was observed sitting in her wheelchair with the call light out of reach on the bed. R168 had severe cognitive impairment and required assistance for personal hygiene and other activities, emphasizing the importance of having the call light accessible. Interviews with several CNAs and RNs confirmed that call lights should be within reach and sight of residents, typically clipped to their clothes or blankets. The facility's Call Light Protocol also mandates that a working call light must remain within reach of residents at all times. Another incident involved R155, who was found in her wheelchair with her right arm trapped and crying in pain. Her call light was tied to the bedrail at the head of the bed, out of her reach. Her husband confirmed that the call light was consistently out of reach during his visits. R155's situation highlights the facility's failure to adhere to its protocol, as her call light was not accessible, preventing her from calling for help when needed.
Failure to Timely Report Verbal Abuse Allegations
Penalty
Summary
The facility failed to report allegations of verbal abuse within 24 hours, as required by their policy. This deficiency involved a resident, identified as R141, who was admitted with multiple diagnoses including paraplegia, neuralgia, and depression, and was cognitively intact with a BIMS score of 15. On August 20, 2024, R141 reported that a CNA, identified as V40, verbally abused him by stating he was a bother and that no other CNAs wanted to work with him. Despite R141 informing the Director of Nursing (DON) and the Social Services Manager about these allegations the previous week, the initial report to the Illinois Department of Health (IDPH) was not submitted until August 19, 2024. Interviews revealed that the Social Services Manager and Social Worker were aware of R141's dissatisfaction with V40's care, but did not investigate the verbal abuse allegations thoroughly or report them promptly. The Assistant Administrator/Abuse Coordinator stated that any leadership member could file a report for abuse allegations, even on weekends, and that such reports should be submitted within two hours. However, the report was delayed until the DON received a voicemail from R141 on August 19, 2024, which prompted the filing. The facility's policy mandates immediate notification and reporting of alleged mistreatment, neglect, or abuse, which was not adhered to in this case.
Deficiencies in Resident Monitoring and Care
Penalty
Summary
The facility failed to properly monitor, assess, and treat a resident, R104, who was at risk for potential pressure ulcers. R104, a female resident with multiple diagnoses including chronic kidney disease, diabetes, and schizoaffective disorder, was observed with a stage 3 pressure ulcer on her coccyx and a new open wound on her left buttock. The wound nurse and doctor identified the new wound as moisture-associated skin damage due to incontinence. Despite the facility's care plan indicating the need for regular repositioning and incontinence management, R104 was found lying on her back during observations, and her electronic records did not document the new wound prior to the surveyor's visit. Another resident, R155, was not properly monitored, leading to her arm being trapped in her wheelchair, causing her pain. R155, who has cerebral ischemia, vascular dementia, and a history of falls, was observed leaning to her right side in her wheelchair, with her arm caught between adaptive devices. Her call light was out of reach, preventing her from calling for help. Despite her husband's daily visits and reports of the issue, the facility staff did not address the problem, and the resident continued to experience pain and discomfort. The facility's failure to ensure proper monitoring and care for these residents highlights deficiencies in adhering to care plans and ensuring resident safety. The Director of Nursing expressed expectations for regular repositioning and accessible call lights, but these were not met, resulting in inadequate care for both residents. The lack of documentation and failure to address known issues contributed to the deficiencies observed by the surveyors.
Improper Use of Gait Belts During Resident Transfers
Penalty
Summary
The facility failed to safely transfer residents using a gait belt, as observed in two cases. In the first instance, a CNA and a Restorative Aide assisted a resident with severe cognitive impairments and a history of falls from a lying to a sitting position. Despite the resident's care plan indicating the need for a two-person assist using a gait belt, the CNA pulled the resident up by her pants instead of using the gait belt. This action was contrary to the facility's policy and the resident's care plan, which required the use of a gait belt for transfers. In the second case, a CNA assisted another resident with moderate cognitive impairment and mobility issues into a wheelchair and later onto a toilet. The CNA used the resident's pants to pull her up instead of the gait belt, despite the resident's care plan indicating the need for substantial assistance with transfers. Interviews with various staff members, including CNAs, an RN, and the Director of Nursing, confirmed that the proper procedure was to use a gait belt for transfers, and pulling residents by their pants was not safe. The facility's Transfer-Gait Belt Policy also specified the correct method for using a gait belt, which was not followed in these instances.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to provide adequate hydration to a resident, identified as R30, who was at risk for dehydration. R30 had multiple medical diagnoses, including recurrent urinary tract infections and parkinsonism, and was dependent on staff for assistance with feeding and drinking. Despite being cognitively intact, R30 reported not receiving enough water and experiencing urinary discomfort. Observations over several days revealed that R30 did not have water at the bedside and was not offered sufficient fluids, even though she expressed a desire for more water. The facility's policy required offering fluids to residents, especially those with swallowing precautions like R30, but this was not adhered to. Interviews with facility staff, including the Head Unit Nurse and the Assistant Director of Nursing, confirmed that residents should be offered fluids between meals and have water available at the bedside. R30's care plan and nutritional assessment indicated a need for honey-thickened liquids and specified her estimated fluid needs. However, these interventions were not consistently implemented, as R30 continued to report inadequate fluid intake. The facility's hydration policy aimed to ensure residents received adequate fluids, but the procedures outlined were not followed, leading to the deficiency.
Failure to Properly Manage and Label Feeding Tube Equipment
Penalty
Summary
The facility failed to properly manage and label the feeding tube equipment for a resident with a gastrostomy tube (G-tube). On August 20, 2024, it was observed that the resident was receiving enteral feeding at a rate of 50 milliliters per hour, but the tubing used was dated August 15, 2024, which exceeded the recommended usage period. Additionally, on August 21, 2024, the feed tubing was found to be neither labeled nor dated, contrary to the facility's protocol and manufacturer guidelines. Interviews with the nursing staff revealed inconsistencies in the understanding and application of the facility's policy regarding the changing and labeling of feeding tube equipment. One RN stated that the tubing should be changed whenever a new bottle is opened and should not be used for more than 24 hours. Another RN confirmed that all equipment should be new with each feeding and should be dated. However, the Director of Nursing was unable to provide a specific policy on the frequency of tubing changes, indicating a lack of clear guidance. The resident involved had severe cognitive impairment and was dependent on staff for eating, highlighting the importance of adhering to proper feeding tube management protocols.
Failure to Document Medication Reviews and Physician Responses
Penalty
Summary
The facility failed to provide documentation of monthly medication reviews and obtain a documented physician response to pharmacy recommendations for one resident, identified as R141, out of a sample of 37. R141 was admitted with multiple diagnoses, including paraplegia, neuralgia, and hypertension, and was cognitively intact with a BIMS score of 15. The pharmacy manager, V7, acknowledged the absence of documentation for medication reviews conducted on specific dates and noted that pharmacy recommendations made in November 2023 did not receive a physician response. The recommendation involved a dose reduction of Citalopram Hydrobromide due to the risk of QT prolongation, but the psychiatrist deferred the recommendation to the primary care physician, whose response was not documented. The Director of Nursing, V2, stated that the pharmacy delivers the monthly medication review to the head or charge nurse, who should then present it to the physician. However, there was no policy specifying the timeframe for the physician to address these recommendations. Despite the expectation that the physician or nurse practitioner makes daily rounds, the nurse should contact the physician within a week if recommendations are not addressed. The facility's policy allows the pharmacist to contact the physician directly for clarification if needed, but this was not documented in this case. R141's current orders showed an increase in the medication dosage, contrary to the pharmacy's recommendation.
Failure to Ensure Safe Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a resident using a mechanical lift, resulting in a fall and subsequent injuries. The resident, identified as R2, required assistance from two staff members for transfers as per their care plan and MDS. However, on the day of the incident, a Certified Nursing Assistant (CNA), identified as V12, attempted to transfer R2 alone using a mechanical lift. During the transfer, R2 reported that the sling used was too small, causing discomfort. Despite R2's complaints, V12 proceeded with the transfer, leading to R2 falling from the lift and sustaining a right tibia fracture and an occipital contusion. R2, who is cognitively intact but dependent on assistance for ADLs, has a medical history that includes muscular dystrophy, osteoarthritis, and a history of falls, among other conditions. The incident occurred when V12, without waiting for additional staff assistance, attempted the transfer alone, contrary to the facility's policy requiring two staff members for such transfers. The fall was witnessed, and R2 was subsequently sent to the emergency department for evaluation and treatment of the injuries sustained.
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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 Wheaton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wynscape Health & Rehab | 0.2 mi | ★★★★★ | 3 | 0 |
| Ahva Care Of Winfield | 0.7 mi | ★★★★★ | 0 | 0 |
| Wheaton Village Nrsg & Rhb Ctr | 1 mi | ★★★★★ | 2 | 0 |
| Covenant Living - Windsor Park | 3 mi | ★★★★★ | 0 | 0 |
| West Chicago Living And Rehab Center | 3.3 mi | ★★★★★ | 4 | 0 |
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