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 Wheaton Village Nrsg & Rhb Ctr during CMS and state inspections, most recent first.
The facility failed to implement its grievance process for concerns about delayed call light response and missing or misdirected laundry and personal items. A resident and a representative reported call light response delays of 15–20 minutes or longer, sometimes up to an hour with no response, and the DON acknowledged receiving weekly concerns and Ombudsman complaints about call lights without corresponding grievance documentation or follow-up. Multiple residents and staff reported ongoing problems with missing clothing, items returned to the wrong rooms, and laundry staff turnover, while records lacked complete admission inventories or documentation of refusals. Resident council minutes and an Ombudsman grievance reflected repeated laundry concerns, yet there was no evidence that these grievances were consistently documented, investigated, or resolved in accordance with the facility’s grievance and resident rights policies.
Two cognitively intact residents with multiple chronic conditions, including diabetic polyneuropathy, osteoarthritis, hemiplegia, COPD, and respiratory failure, did not receive ordered doses of Gabapentin and Combivent Respimat as scheduled, even though an agency LPN had documented afternoon medications as administered. Video review showed the LPN at the nurses’ station, bathroom, medication room, and medication cart, but not moving the cart to resident rooms or preparing and giving medications in accordance with physician orders and facility policy.
The facility failed to maintain proper food safety and sanitation standards, affecting all residents receiving oral nutrition. Issues included using a dishwasher with a broken detergent line and low chlorine levels, improper food storage and labeling, and inadequate garbage disposal and sanitation practices. These deficiencies were observed during a kitchen tour, with expired and improperly stored food items, uncovered garbage cans, and low sanitizer levels noted.
The facility failed to ensure accessible call lights for five residents, impacting their ability to request assistance. Observations showed call lights were either missing, unreachable, or improperly placed, despite residents' ability to use them and needing assistance for ADLs. This was confirmed by staff and contradicted the facility's policy on call light accessibility.
The facility failed to properly store medications for five residents who were not assessed or had orders to self-medicate or store medications at the bedside. Medications were found unsecured in residents' rooms, and staff interviews confirmed that medications should be locked and residents supervised during administration. The facility's policy required a written order and assessment for self-administration, which was not followed.
The facility failed to provide written notification to two residents and their representatives about the reasons for discharge, and did not inform the Ombudsman. One resident with Alzheimer's and chronic kidney disease was transferred to a hospital for dehydration and a UTI without proper notification. Another resident with end-stage renal failure experienced multiple hospitalizations without receiving written notices. The facility's policy did not address these notification requirements.
The facility failed to provide written notification of its bed hold policy to two residents or their representatives upon hospital transfer, as required by its policy. One resident was transferred due to a sudden change in mental status, while another had multiple hospitalizations. The facility's leadership admitted to not following the practice of providing written notice, despite the policy requirements.
Two residents in the facility did not receive necessary nail care despite being dependent on staff for assistance due to conditions like arthritis. Their nails were excessively long, and staff interviews revealed that nail care was not provided as per facility guidelines, which emphasize regular trimming to prevent infections and maintain hygiene.
The facility failed to ensure proper respiratory care and infection control for three residents. One resident used a nasal cannula that had fallen on a dirty floor, while another had CPAP tubing on the floor, and a third stored her CPAP mask unbagged among clothing. The facility's policy lacked infection control guidelines.
The facility failed to provide the required square footage per resident in 12 rooms, affecting 35 residents. Rooms designed for three residents provide only 74 square feet each, while those for four residents offer 78 square feet. The administrator noted this issue is cited annually.
The facility was found to have resident rooms below ground level, affecting all residents reviewed. The administrator confirmed that the facility's structure has not changed since its inception, and this deficiency is cited annually.
Two residents experienced significant delays in receiving trust fund cash withdrawals due to procedural issues and missing signatures, with one resident waiting weeks for a requested amount. The facility's policy did not specify timely disbursement for larger withdrawals, contributing to the delay.
A CNA reported an allegation of abuse involving another CNA hitting a resident, but the facility failed to report this to the IDPH or police as required by their policy. The DON did not investigate the new allegation, as the initial investigation attributed the injury to the resident's combativeness. The facility's records show no investigation into the new allegation, despite policy requirements for immediate reporting.
Failure to Address Resident Grievances on Call Light Response and Laundry/Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to voice grievances without reprisal and to establish and implement an effective grievance process, specifically regarding call light response times and laundry/personal belongings. A resident representative reported that one resident’s call light responses often took 15–20 minutes, leading the resident to attempt to toilet independently to avoid accidents; the resident confirmed this account. Another resident reported that staff sometimes took an hour to respond to his call light, with occasions of no response, and stated he used his call light or cell phone to request assistance and wore pullups due to bed sores. The DON acknowledged receiving call light concerns approximately once per week, including complaints from the Ombudsman, and stated such concerns should be documented on grievance forms and followed up on, but could not provide evidence of follow-up or documentation. Review of grievances from December 2025 through March 2026 showed no reports, findings, or resolutions related to poor call light response times. The facility also failed to address and document grievances related to laundry and missing personal items. A resident representative stated that one resident’s family had been doing her laundry due to missing items, including comforters in winter, and both the representative and resident reported that clothing sometimes went missing; the resident’s clothes at bedside were not labeled, and no inventory beyond admission was found in the record. The same representative reported that other residents’ clothes were routinely returned to another resident’s room, that something of that resident’s was missing every week, and that this was a common issue; the resident confirmed missing items from laundry, and the facility had only attempted to inventory her belongings about six months after admission with no subsequent updates. Another resident reported missing clothes, seeing other residents wearing his shirts, and missing about five pairs of shoes; his record contained no admission inventory or documentation that he declined an inventory. A fourth resident reported issues with clothes being returned from laundry and stated he had reported this to nurses. Staff interviews and facility documents further demonstrated unaddressed grievances and inadequate protection of personal property. A CNA reported recent issues with missing items from laundry related to laundry staff turnover, and another CNA stated she had received resident complaints about not receiving their clothes, noting that the former permanent laundry aide had left and new staff were unfamiliar with residents’ clothing, although she stated that residents’ clothes were labeled. Resident council minutes from December 2025 documented concerns about clothes not being returned correctly due to laundry staff not reading labels, and minutes from January and February 2026 documented concerns about clothes going to the wrong rooms and missing from laundry. A grievance form dated 02/21/2026 included Ombudsman-reported concerns about a resident’s missing items. The DON and ADON stated that the facility had an inventory form to be completed on admission and uploaded to the chart, that refusals should be documented, and that families were educated to label belongings or the facility would do so, and the DON acknowledged prior staffing issues in laundry and ongoing clothing return problems over several months. The facility’s Resident Rights Policy required reasonable care to protect personal property from loss, and the Grievance Policy required investigation and written findings to the administrator within five working days of receiving a written grievance, but the surveyors found no documentation showing that reported concerns about call lights or laundry were consistently documented, investigated, or resolved.
Failure to Administer and Accurately Document Scheduled Medications
Penalty
Summary
Surveyors identified a failure to ensure residents were free from significant medication errors when an agency LPN did not administer ordered medications as scheduled, despite documenting them as given. On the survey date around midday, the LPN reported she had already completed afternoon medications, and the manual medication administration record showed medications signed off. However, review of video footage between 10:45 AM and 11:40 AM showed the LPN at the nursing station, bathroom, medication room, and medication cart, but did not show her moving the cart to resident rooms, preparing medications, or entering resident rooms to administer medications, contrary to the facility’s medication administration policy requiring the cart to be moved close to residents before preparing and administering medications. One resident with diagnoses including diabetic polyneuropathy, osteoarthritis, and hemiplegia, and with intact cognition per MDS, reported in the afternoon that she had not received her scheduled dose of Gabapentin 800 mg ordered three times daily at 8:00 AM, 1:00 PM, and 5:00 PM. Another resident with diagnoses of COPD and acute and chronic respiratory failure, also cognitively intact per MDS, had an order for Combivent Respimat 20-100 mcg, one puff every six hours at 5:00 AM, 11:00 AM, 5:00 PM, and 11:00 PM. The evidence from resident report, EMR review, and video review showed that ordered medications for these residents were not administered as prescribed, despite being documented as given.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to proper food safety and sanitation standards, impacting all residents receiving oral nutrition from the facility kitchen. During a kitchen tour, it was observed that the low-temperature dishwasher was used despite having a broken detergent line and low chlorine levels, which are essential for proper dish sanitation. The Dietary Manager acknowledged that the dishwasher should not have been used under these conditions, yet the Dietary Aide continued to use it until instructed otherwise. Additionally, the facility did not maintain appropriate storage and labeling practices for food items. The milk cooler was found to be operating at temperatures above the recommended 40 degrees Fahrenheit, with milk cartons inside also measuring above this threshold. Several food items, including thawed frozen egg products, tomatoes, cottage cheese, raisins, and sweetened coconut, were either not dated, expired, or improperly stored, violating the facility's policy on labeling and dating foods. The facility's failure to use the first-in, first-out method for food storage further contributed to the risk of serving expired or spoiled food to residents. The facility also neglected proper garbage disposal and sanitation practices. Uncovered garbage cans with visible food debris were observed near the dishwasher, and small black flies were seen in the hallway outside the kitchen. Clean plates were improperly stored near a handwashing sink, risking contamination. The sanitizer bucket used by the cook showed low quaternary levels, indicating inadequate sanitization. These observations highlight the facility's failure to maintain a clean and safe kitchen environment, as outlined in their policies.
Failure to Provide Accessible Call Lights
Penalty
Summary
The facility failed to provide access to the resident call system for five residents, which is essential for obtaining needed assistance. Observations revealed that one resident's call light was on the floor entangled among personal items, making it unreachable. Another resident was found without a call light on multiple occasions, confirmed by both a CNA and an RN. This resident was cognitively intact and required extensive assistance for activities of daily living (ADLs), yet was unable to communicate needs due to the absence of a call light. Additional observations showed a resident verbally calling for help without a call light, and another resident's call light was found behind a dresser, inaccessible. A fifth resident's call light was under the bed, out of reach, despite being able to communicate needs and use the call light for assistance. The facility's policy requires call lights to be accessible from various positions, yet this was not adhered to, as confirmed by the Director of Nursing.
Improper Medication Storage and Lack of Assessment for Self-Administration
Penalty
Summary
The facility failed to properly store medications for residents who were not assessed or had orders to self-medicate or store medications at the bedside. This deficiency was observed in five residents, each with different medications left unsecured in their rooms. For instance, one resident had a medication cup with a pill on her dresser without an order to keep medications at the bedside, and the facility could not provide an assessment form to show she was evaluated to self-administer medications. Another resident had three bottles of Flonase on her bedside table, and although she was cognitively intact, there was no assessment form to show she was evaluated to self-administer medications. The resident's care plan was updated during the survey to allow her to self-administer Flonase, but prior to this, there was no documentation supporting her ability to do so. Similarly, another resident had an inhaler on his bedside table without a physician's order to self-administer or store medications at the bedside, and his care plan did not indicate he could self-administer medications. Additional observations included a tube of prescription cream and Nystatin powder left on bedside tables without proper orders or assessments for self-administration. Staff interviews revealed that medications should be locked in the medication cart and that residents should be supervised when administering their medications. The facility's policy required a written order and an assessment for residents to self-administer medications and store them at the bedside, which was not followed in these cases.
Failure to Notify Residents and Ombudsman of Discharge
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding the reasons for discharge, as well as failing to notify the Ombudsman. This deficiency was identified in two residents, R73 and R51, who were reviewed for discharge. R73 was admitted to the facility with multiple diagnoses, including Alzheimer's Disease and chronic kidney disease. On a specific date, R73 experienced a sudden change in mental status and was transferred to a hospital for dehydration and a urinary tract infection. The facility administrator admitted that they do not notify residents or their representatives in writing about the reasons for hospital transfers, nor do they inform the Ombudsman. No documentation of such notifications was found in R73's medical records. Similarly, R51, who has diagnoses including end-stage renal failure and chronic anemia, reported multiple hospitalizations without receiving written notices of transfer. The facility's progress notes confirmed these hospitalizations, but there was no evidence of written notifications to R51 or the Ombudsman. The facility's existing policy on discharge did not address the requirement for written notification to residents, their representatives, or the Ombudsman, as confirmed by the facility's administrator and director of nursing.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to residents or their representatives upon transfer to a hospital, as required by its own policy. This deficiency was identified in the cases of two residents. The first resident, admitted with multiple diagnoses including Alzheimer's Disease and chronic kidney disease, was transferred to a hospital due to a sudden change in mental status and was diagnosed with dehydration and a urinary tract infection. The Director of Nursing acknowledged that the facility forgot to provide the bed hold notice to the resident's representative at the time of transfer, and no documentation of such notice was found in the resident's medical records. The second resident, who had diagnoses including end-stage renal failure and chronic anemia, reported multiple hospitalizations without recalling receiving a bed hold notice. The clinical records for this resident also lacked documentation of providing the required notice to the resident and the Ombudsman. The facility's Administrator and Director of Nursing admitted that the practice of providing written notice to residents, families, and the Ombudsman was not followed, despite the facility's policy stating that such notification should be given at the time of transfer.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide adequate nail care for two residents, both of whom were dependent on staff for assistance with activities of daily living. Resident R71 had nails that were a quarter of an inch long and jagged, and despite repeatedly asking staff for help due to his arthritis, his nails had not been cut since his admission. His care plan indicated a need for substantial assistance with personal hygiene due to decreased mobility and endurance. Similarly, Resident R107 had fingernails that were one inch long and expressed a preference for shorter nails, but was unable to cut them herself due to arthritis. She could not recall the last time staff had assisted with her nail care. Interviews with facility staff, including CNAs and the Director of Nursing, revealed that nail care was typically performed on shower days or as needed. However, the CNAs responsible for these residents admitted they had not provided nail care. The facility's policies emphasized the importance of regular nail trimming to prevent infections and maintain hygiene, yet these guidelines were not followed for the residents in question. The lack of nail care was a clear deficiency in meeting the residents' needs for personal hygiene assistance.
Deficiency in Respiratory Care and Infection Control
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents, as observed during a survey. One resident, who had a diagnosis of Chronic Obstructive Pulmonary Disease and Schizoaffective Disorder, was seen using a nasal cannula that had fallen on the dirty floor, which was not in accordance with professional standards of practice. The resident's oxygen order was for 2-5 liters per minute as needed, but the resident was using it continuously. The RN acknowledged that the nasal cannula should have been bagged when not in use and replaced if it fell on the floor, but this was not done. Another resident with Dementia, Obstructive Sleep Apnea, and Diabetes Mellitus had a CPAP machine with tubing on the floor, and the room was noted to be dirty. A third resident, diagnosed with Asthma, Heart Failure, Depression, and Obstructive Sleep Apnea, stored her CPAP machine and mask unbagged among her clothing, which was also against infection control practices. The Director of Nursing confirmed that respiratory equipment should be bagged when not in use to prevent contamination, but the facility's policy on oxygen administration did not address infection control aspects.
Inadequate Room Size for Residents
Penalty
Summary
The facility failed to provide adequate square footage per resident in 12 of 48 rooms, as required by regulations. Specifically, rooms A22, A24, A26, A28, A30, A31, A33, and A34, which are designed to accommodate three residents each, only provide 74 square feet per resident. Additionally, rooms A18, A19, B7, and B8, intended for four residents each, offer only 78 square feet per resident. This deficiency affects 35 out of 110 residents, as indicated by the facility's daily roster. The administrator acknowledged that the facility has maintained the same room sizes since its inception and receives this deficiency annually during surveys.
Resident Rooms Below Ground Level
Penalty
Summary
The facility failed to ensure that resident rooms were at or above ground level, affecting all 36 residents reviewed for physical environment. Observations and interviews revealed that rooms B1 through B14 were located below the garden or ground level. The facility administrator acknowledged that the structure has remained unchanged since the facility's inception, and this deficiency has been cited annually during surveys.
Delayed Trust Fund Cash Disbursement
Penalty
Summary
The facility failed to provide resident trust fund cash to residents within three business days, affecting two of the three residents reviewed for trust funds. Resident R6 reported waiting weeks for her requested trust fund cash, with delays ongoing for several months. On June 6, 2024, R6 requested $450.00 from her trust fund, but the check was not issued until June 24, 2024, due to missing resident signatures. The check arrived at the facility on June 25, 2024, but was not cashed immediately, causing further delays. Staff interviews confirmed the delay in processing and disbursing the funds. Resident R7 also experienced significant delays in receiving trust fund cash withdrawals, stating that the checks were not arriving and that he had waited a month for a withdrawal when the facility changed banks. The facility's policy and procedures for resident personal trust funds did not specify that withdrawals of $100.00 or greater should be honored within three banking days, contributing to the delay. The facility's admission packet outlined residents' rights to manage their money and access their financial records, which were not upheld in these instances.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse according to its policy. A Certified Nursing Assistant (CNA) reported to the Administrator that another CNA allegedly hit a resident in the face, causing the resident to fall back and hit the bed. The reporting CNA attempted to contact the Illinois Department of Public Health (IDPH) using a number from a poster at the facility entrance but later realized it was a corporate number. The Administrator was unaware of any abuse allegations, and the Director of Nursing (DON) stated that the incident had been investigated and attributed the resident's facial injury to the resident becoming combative during care. Despite the new allegation of abuse, the DON did not report it to IDPH or the police, as the initial investigation concluded that the injury was due to the resident's combativeness. The facility's abuse prevention policy requires immediate reporting of any abuse allegations to the administrator and IDPH within two hours. However, the facility's records from April to July show no investigation into the new allegation. The policy also mandates contacting local law enforcement in cases of physical injury inflicted by staff, which was not done in this instance.
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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 | 0.9 mi | ★★★★★ | 3 | 0 |
| Dupage Care Center | 1 mi | ★★★★★ | 13 | 0 |
| Ahva Care Of Winfield | 1.3 mi | ★★★★★ | 0 | 0 |
| Covenant Living - Windsor Park | 2.6 mi | ★★★★★ | 0 | 0 |
| West Chicago Living And Rehab Center | 4.1 mi | ★★★★★ | 4 | 0 |
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