Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Complete Care At Wheaton during CMS and state inspections, most recent first.
The facility failed to ensure that several GNAs had current annual performance evaluations and skills competencies on file. Record review showed missing documentation for multiple GNAs, and the RDO reported recent HR and staff educator/ADON changes affected the ability to locate the records. The DON stated a mandatory skills clinic with return demonstrations did not go well because GNAs elected not to attend, and the required competency documentation was still not provided to the Surveyor by exit.
Medication Storage and Labeling Deficiencies: An LPN observed expired Heparin bags for a resident, a Heparin bag stored outside required refrigeration, and an opened tuberculin vial without a date opened in the med room. Multiple opened bottles on two med carts, including aspirin, Tylenol, senna, risperidone, folic acid, zinc, iron, bisacodyl, and a probiotic, were also missing dates opened; the LPNs confirmed the missing documentation.
Failure to Complete Required PASARR Before Admission: A resident was admitted without documentation of a required Level II PASARR after a Level I screen indicated the need for further evaluation. Record review showed no completed Level II PASARR in the chart, and the facility could not provide evidence that the screening had been completed. The Administrator acknowledged the resident was accepted without verifying completion of the required PASARR.
Activities Program Did Not Match Resident Preferences: A resident with dementia, palliative care, and severe cognitive impairment was observed in bed with no activity or engagement other than a TV positioned behind the headboard. The resident’s care plan identified preferred activities such as daily socializing with residents and staff, drinking hot tea, and joining the coffee klatch, but the 30-day activity record documented TV watching almost every day. The Activity Director confirmed the resident was not a TV viewer and acknowledged the resident had not received activities based on assessed preferences and cognitive abilities.
A resident with necrotic toes and dry gangrene of the left foot had a vascular surgery consult that recommended podiatry follow-up, but the podiatry consult was not documented as completed for several weeks. The resident later developed warmth, swelling, drainage, and cellulitis, was finally seen by podiatry, and was sent to the ER for significant gangrenous changes; hospital records noted multiple gangrenous toes and no surgical intervention was recommended.
Failure to perform hand hygiene during wound care: An LPN was observed caring for a resident’s wounds and repeatedly changed gloves without performing hand hygiene between glove changes. The LPN also moved from cleansing the wound to packing and dressing it without changing gloves, and later donned new gloves without hand hygiene after wound care was completed. The LPN confirmed the missed hand hygiene during interview.
Surveyors found that the facility did not consistently revise care plans or hold timely care plan meetings for several residents. One resident attended only one care plan meeting in two years, while another had outdated care plans for discontinued medications. Additional residents had unresolved care plans for healed conditions or lacked documentation of required care plan meetings, with staff unable to provide missing records.
A resident with severe cognitive impairment and a history of aggressive behaviors was physically abused by an LPN after becoming agitated and striking the staff member. Two GNAs witnessed the LPN grab, pinch, and slap the resident but did not immediately intervene or report the incident, resulting in a delay in notifying facility leadership and addressing the abuse.
A resident experienced a witnessed fall, but facility staff did not complete a post-fall assessment, document the incident, or update the resident's care plan to reflect the event and the resident's condition. The Regional Clinical Nurse Manager confirmed that these required actions were not performed.
A resident was not invited to participate in their care plan meetings, with no documentation showing they were notified or invited to attend, despite facility policy requiring such invitations.
Surveyors found that the facility did not offer the opportunity to complete advance directives or provide educational materials about them to three residents or their representatives, as confirmed by documentation and staff interviews.
A resident who was recently hospitalized did not receive written notification of the facility's bed hold policy at the time of transfer. Review of the medical record and staff interviews confirmed that, although the bed hold policy was acknowledged at admission, the required written notice was not provided during the hospital transfer, and facility leadership stated this notification is not given.
A deficiency occurred when a resident's PASRR Level I screening was completed inaccurately, with all answers in a key section marked 'No', which should have triggered a Level II evaluation referral. No evidence of a Level II evaluation was found in the record, and the Social Worker confirmed the screening was not filled out correctly, resulting in the resident not receiving the required PASRR process.
The facility did not update care plans for three residents after significant events, including falls and G-tube dislodgement with hospital transfers. Despite documentation of these incidents and staff expectations that care plans be revised after changes in condition, no updates or new interventions were added to address the residents' needs.
A resident receiving oxygen therapy was observed without an oxygen warning sign posted on the room door, contrary to the facility's oxygen administration policy. Staff, including the ADON/IP, were unaware of the requirement to post such signage, and the facility did not routinely place oxygen signs on rooms where oxygen was in use.
The facility did not complete required annual performance evaluations for two GNAs, as confirmed by a review of employee records and staff interview. This deficiency was identified during the annual survey, with no evidence provided to show that evaluations for the previous two years had been conducted.
Surveyors identified that licensed staff failed to maintain a medication error rate below 5%, with three errors observed among 26 opportunities. An LPN withheld a scheduled antihypertensive without a physician's order and documented it as given, administered an eye drop to only one eye instead of both as ordered, and documented a vitamin as administered when it was not available. These actions resulted in inaccurate MAR entries and were confirmed through observation and staff interviews.
Surveyors found that medications were improperly stored and labeled, with loose and unlabeled pills, undated opened bottles, and expired medications for discharged or deceased residents left in medication carts and storage rooms. Staff interviews revealed inconsistent practices for medication disposal, including discarding refused medications in the trash and failing to document refrigerator temperatures for medication storage. These actions did not comply with facility policy or regulatory requirements.
A resident with dementia and cognitive communication deficit did not receive a dental evaluation or necessary dental services after admission, despite reporting pain while chewing and being observed eating with difficulty. Clinical review confirmed the absence of dental care, and an oral health assessment later identified decayed or broken teeth.
Surveyors identified multiple sanitation and food storage deficiencies, including undated opened food containers in the kitchen, lack of internal thermometers in cold storage, and unlabeled food items in a unit nourishment refrigerator. Staff confirmed that food items should be labeled and dated according to facility policy.
Surveyors found that dumpsters were left uncovered and items such as an old mattress, dresser, and soda can were placed next to the dumpsters. The Food Services Director confirmed that dumpsters are expected to be covered with lids.
A resident with a physician's order to wear an Aspen cervical collar at all times was observed without the collar on multiple occasions, and nursing staff inaccurately documented on the TAR that the collar was worn, even on days when the resident refused or was not wearing it. The Unit Manager confirmed the documentation errors after reviewing the records.
The facility did not ensure that the QAA committee included all federally required members, specifically the Infection Preventionist, and failed to maintain clear and accurate attendance records for its meetings. The attendance sheets were inconsistent, and the listed federal requirements were incomplete, as confirmed by the Administrator.
A GNA provided a bed bath to a resident with an indwelling urinary catheter without wearing a gown, despite Enhanced Barrier Precautions being in place and clearly posted. The staff member was unaware of the resident's EBP status and did not use the required PPE during a high-contact care activity, resulting in non-compliance with infection control protocols.
A surveyor observed visibly dirty floor tiles with brown spills and a dirt-like substance in the laundry room, as well as an HVAC unit with rusty, dust-covered vent covers. The Environmental Services Supervisor acknowledged the need for cleaning during the inspection.
Surveyors found that the facility did not provide required written notifications to residents or their representatives when residents were transferred to the hospital. Multiple residents experienced hospital transfers without documented evidence that they or their representatives received written notice explaining the reason for transfer. Staff and management confirmed that no process was in place to ensure these notifications were provided.
Missing Annual GNA Performance Evaluations and Skills Competencies
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) were provided with annual performance evaluations and skills competencies. Record review showed that GNAs #9, #10, #11, and #13 did not have documentation of current annual performance evaluations or skill competencies, and this was identified during the recertification and complaint survey. During interviews, the Regional Director of Operations reported that recent changes in the Human Resources department and the Staff Educator/ADON contributed to the facility being unable to locate the required documentation. The Director of Nursing stated that she had recently held a skills clinic with return demonstrations for GNAs, but also reported that the clinic did not go well and that although it was mandatory, GNAs elected not to attend. As of exit, the Surveyor had not been provided skill competencies for GNAs #9, #10, #11, and #13.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not properly stored and labeled in the facility’s East Wing medication areas. During observation in the East Wing 1 medication room, two bags of Heparin 30,000 units/1000 mL Normal Saline labeled for Resident #8 were found in the refrigerator with pharmacy use-by dates of 02/27/2026 and 03/02/2026, both beyond the labeled dates. Another bag of the same medication for Resident #8 was stored on a shelf even though the label required refrigeration. An opened vial of Tuberculin Purified Protein 5 IU/0.1 mL was also observed without a documented date of opening, so the appropriate use period and stability after opening could not be determined. In the East Wing medication carts, multiple opened bottles were observed without dates documenting when they were opened. In the East Wing 1 medication cart, Aspirin 81 mg, Pain Relief (Tylenol) 325 mg, Senna-Plus, Tylenol Regular Strength 325 mg, and Risperidone Oral Solution 1 mg/mL were opened without a documented date. In the East Wing 2nd medication cart, Folic Acid 400 mcg, Zinc 50 mg, Geri-Kot 8.6 mg, Non-Aspirin Extra Strength, Iron (Ferrous Sulfate), Bisacodyl 5 mg, and Probiotic were also opened without documentation of the date opened. The LPNs interviewed confirmed that medications are required to be labeled with the date upon opening and acknowledged the observed medications lacked that documentation.
Failure to Complete Required PASARR Before Admission
Penalty
Summary
The facility failed to ensure completion of the required Preadmission Screening and Resident Review (PASARR) prior to admission for Resident #14. A Level I PASARR screening completed on 03/09/2026 indicated the need for a Level II PASARR evaluation, but the resident was admitted to the facility without documentation of a completed Level II PASARR in the chart. Record review also showed that the Social Services assessment documented “No” in response to whether the resident was considered by the state Level II PASARR process to have a serious mental illness and/or intellectual disability, despite the Level I screening indicating further evaluation was needed. On 04/16/2026, the surveyor requested documentation of the Level II PASARR screening for Resident #14, and the facility was unable to provide evidence that it had been completed. During interview, Admissions staff stated PASARR screenings are expected to be completed prior to admission, typically by the hospital, and that if a resident is admitted without a completed PASARR, the facility is responsible for ensuring completion. The Administrator acknowledged that the facility accepted Resident #14 without verifying completion of the required Level II PASARR and stated that this had been overlooked.
Activities Program Did Not Match Resident Preferences
Penalty
Summary
The facility failed to provide an activities program that met the needs and preferences of Resident #36. During observations on 04/15/2026 and 04/17/2026, the resident was seen lying in bed with the TV pushed against the back wall behind the headboard, and no other forms of activity or engagement were observed in the room. A review of the resident’s 30-day activity documentation on 04/17/2026 showed that watching TV was documented as the activity for all days except 03/28/2026. The resident’s care plan identified preferred activities as socializing with other residents and staff daily, drinking hot tea, and participating in the coffee klatch program. Record review on 04/20/2026 showed the resident had dementia, palliative care, and a BIMS score of 2 out of 15, indicating severe cognitive impairment. During interview, the Activity Director confirmed the resident was not a TV viewer and acknowledged that the resident had not received activities based on assessed preferences and cognitive abilities. The NHA also confirmed that the resident does not watch TV and can become agitated if the TV is pulled away from the wall and in the resident’s sight.
Missed Podiatry Consult for Resident With Gangrenous Left Foot
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for a resident with necrotic toes and gangrenous changes to the left foot. A nurse practitioner documented necrotic toes on the left foot and requested a vascular surgery consult, and vascular surgery later noted possible dry gangrene with palpable pedal pulse and recommended a podiatry consultation. A podiatry consult order was placed and signed off on the TAR, but there was no documentation that the consult was completed in February or March. Later record review showed continued progression of the left foot condition, including stable dry gangrene eschar of the left second and fifth toes and left lateral foot, followed by new warmth, swelling, and light drainage of the fifth toe with a diagnosis of cellulitis. Another podiatry consult was ordered, and the resident was eventually seen by a podiatrist, who recommended transfer to the emergency room for further evaluation. The resident was then transferred to the hospital for significant gangrenous changes to the left foot and admitted with gangrene of the foot; hospital records noted multiple gangrenous toes, soft tissue swelling on x-ray, and no surgical intervention was recommended by podiatry.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to ensure staff performed appropriate hand hygiene during wound care. During an observation of Resident #2’s wound care, LPN #21 removed an old bandage, changed gloves, and did not perform hand hygiene between glove changes. The LPN cleansed the wound and then packed it without changing gloves between the cleansing of the wound and applying the clean dressing. During the continued observation, the LPN also failed to perform hand hygiene when donning a new pair of gloves after the wound care was completed. The same LPN then removed the old bandage on the next wound and changed gloves, but again did not perform hand hygiene between the glove change. She cleaned the wound, removed her gloves, and failed to perform hand hygiene before donning a new pair of gloves to place the clean dressing and bandage on Resident #2’s wound. On interview, LPN #21 confirmed she did not perform hand hygiene between glove changes.
Failure to Revise Care Plans and Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to revise resident care plans and conduct timely care plan meetings as required, as evidenced by record reviews, staff and resident interviews, and documentation for four residents. One resident reported only attending a single care plan meeting over a two-year stay and did not recall receiving invitations for other meetings. Review of this resident's medical record confirmed that only two care plan meetings were documented in the past year, with attendance sheets and notes missing for other required periods. Staff interviews confirmed that no additional documentation could be found for the missing meetings. Another resident's care plan included anticoagulant therapy, but physician orders showed that the medication had been discontinued several months prior, and the care plan had not been updated to reflect this change. Similarly, a third resident had care plans for pressure ulcers, arterial ulcers, venous ulcers, and antiplatelet medication, despite no current physician orders or active conditions for these issues. Staff acknowledged that these care plans should have been resolved or updated to reflect the residents' current conditions. A fourth resident's family reported difficulty scheduling care plan meetings with the interdisciplinary team. Review of the electronic medical record showed only two documented care plan meetings and one scheduled meeting that the family did not attend, with no further documentation of additional meetings. Staff interviews confirmed that care plan meetings are expected to be held quarterly and documented, but no further records could be located for this resident.
Failure to Protect Resident from Physical Abuse and Delayed Reporting
Penalty
Summary
A resident with severe cognitive impairment, as indicated by a BIMS score of 0 out of 15, and a care plan noting potential for verbal and physical aggression related to dementia, was involved in an incident where a staff member allegedly engaged in physical abuse. The incident occurred when the resident became agitated and struck an LPN, after which the LPN was witnessed by two GNAs to have grabbed, pinched, and slapped the resident. Both GNAs present did not immediately intervene or report the alleged abuse as required by facility policy. The incident was not reported to the Nursing Home Administrator until several days after it occurred, resulting in a delay in the facility's awareness and response. Interviews with the involved staff confirmed the sequence of events, with one GNA expressing fear and lack of knowledge about reporting requirements. The delay in reporting and failure to immediately stop the alleged abuse constituted a failure to protect the resident from abuse as required by regulation.
Failure to Assess and Document Resident Fall
Penalty
Summary
A resident experienced a witnessed fall, but the facility failed to document the incident in the medical record. There was no incident report created for the fall, and no post-fall assessment was completed. The resident's care plan was not revised or updated to reflect the fall incident or the resident's condition following the event. During an interview, the Regional Clinical Nurse Manager confirmed that fall assessments are required after resident falls, but acknowledged that in this case, the required assessment and care plan revision were not completed. The deficiency was identified through a review of the resident's medical record and staff interviews, which revealed the lack of appropriate documentation and follow-up after the fall.
Resident Not Invited to Care Plan Meetings
Penalty
Summary
A deficiency was identified when a resident was not invited to participate in their care plan meetings, as required for person-centered care planning. The resident reported to the surveyor that they were not invited to and did not attend care plan meetings. Medical record review showed that while the resident attended one care plan meeting, there was no documentation that the resident was notified or invited to subsequent meetings. The facility's Regional Social Worker confirmed that there was no documented evidence of the resident being informed about the care plan meetings in question.
Failure to Offer Advance Directives and Provide Educational Materials
Penalty
Summary
Surveyor record reviews and staff interviews revealed that the facility failed to offer residents the opportunity to complete an advance directive and did not provide educational materials regarding advance directives. Specifically, for three residents reviewed, documentation in their social services assessments indicated that none had an advance directive in place, and there was no evidence that the facility had offered them or their representatives the chance to complete one or provided relevant educational materials. The deficiency was confirmed through interviews with the Regional Social Worker, who acknowledged that the residents and their representatives were neither offered the opportunity to complete advance directives nor given educational materials about them. The lack of documentation and absence of these required actions were consistently found across all three residents reviewed for advance directives.
Failure to Provide Written Bed Hold Notification Upon Hospital Transfer
Penalty
Summary
Facility staff failed to provide written notification of the bed hold policy to a resident or the resident’s representative when the resident was transferred to the hospital. The deficiency was identified during a surveyor’s review of the medical record and interviews with both the resident and facility staff. The resident, who had a recent hospitalization due to stomach collapse, confirmed the transfer, and the medical record showed no documentation that written notification of the bed hold policy was given at the time of transfer. Further review revealed that while the resident had signed an admission packet acknowledging the bed hold policy upon initial admission, there was no evidence that the required written notification was provided at the time of the hospital transfer. During interviews, facility leadership confirmed that the facility does not provide written notification of the bed hold policy when residents are transferred to the hospital. No additional information or documentation was provided by the facility to demonstrate compliance with this requirement.
Failure to Accurately Complete PASRR Screening for Mental Disorders
Penalty
Summary
A deficiency was identified when the facility failed to conduct an accurate Preadmission Screening and Resident Review (PASRR) for a resident with mental disorders. Record review showed that the PASRR Level I screening for this resident had all answers in section D marked as 'No', which, according to the form, should have triggered a referral to Adult Evaluation and Review Services (AERS) for a Level II evaluation. However, there was no evidence of a PASRR Level II evaluation in the resident's record. During an interview, the Social Worker confirmed that the PASRR Level I was not completed correctly and acknowledged that the resident's mental disorders were not properly reflected in the screening. The Social Worker stated that the resident did not require a PASRR Level II, but also confirmed that the documentation was inaccurate and should not have indicated the need for a Level II evaluation. This failure resulted in the resident not receiving the appropriate PASRR process as required by federal regulations.
Failure to Revise Care Plans After Resident Condition Changes
Penalty
Summary
The facility failed to revise and update care plans for residents following significant changes in their condition, as evidenced by medical record reviews and staff interviews. For one resident who experienced a fall, the care plan was not updated to reflect the incident, and no fall-specific interventions were added or revised. The original care plan for this resident had not been updated since its initial creation several months prior, despite the occurrence of a fall that was documented in the nurse's notes. Another resident experienced multiple hospital transfers due to gastrostomy tube (G-tube) dislodgement and replacement, yet there was no documentation that a care plan addressing G-tube dislodgement and replacement was initiated or updated. Additionally, a third resident had a witnessed fall, but there was no evidence that the care plan was revised to address this event. Staff interviews confirmed that care plans are expected to be updated immediately following changes in a resident's condition, but this was not done for the residents reviewed.
Failure to Post Oxygen Warning Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
Facility staff failed to follow appropriate respiratory care and services for a resident receiving oxygen therapy. During a tour, a resident was observed using oxygen with an oxygen humidifier bottle and tubing attached to a concentrator, but there was no oxygen usage sign posted on the resident's door or doorframe. Review of the resident's medical record confirmed physician orders for oxygen therapy and instructions to change the oxygen humidifier bottle tubing weekly. The resident's care plan also addressed oxygen therapy related to respiratory illness. Further review of the facility's oxygen administration policy revealed requirements to place an oxygen warning sign on the room door where oxygen is in use, change oxygen tubing and cannula weekly, and change the humidifier bottle every seventy-two hours or when empty. During an interview, the ADON/Infection Preventionist stated that tubing and humidifier bottles were changed weekly but was unaware of the requirement to post oxygen signage. The ADON acknowledged that the facility did not place oxygen signs on rooms where oxygen was in use, despite the policy stating this was required.
Failure to Complete Annual Performance Evaluations for GNAs
Penalty
Summary
The facility failed to complete annual performance evaluations for two Geriatric Nursing Assistants (GNAs) as required. A review of employee records on April 8, 2025, revealed that no performance reviews for 2023 and 2024 were present for these two GNAs. This was confirmed during an interview with the Nursing Home Administrator, who acknowledged that the annual evaluations had not been conducted for the specified years. No additional evidence was provided by the facility to demonstrate that the required performance evaluations had been completed for these staff members. The deficiency was identified during the annual survey, where it was noted that performance evaluations are necessary to determine in-service education needs and assess competencies of GNAs. The absence of these evaluations for the two staff members was directly observed in their employee records and confirmed by facility leadership.
Medication Error Rate Exceeds 5% Due to Administration and Documentation Failures
Penalty
Summary
Licensed staff failed to maintain a medication error rate below 5 percent, as evidenced by three errors out of 26 observed opportunities, resulting in an 11.54% error rate. For one resident, an LPN withheld a scheduled dose of Amlodipine due to a heart rate of 59 bpm without a physician's order to do so and documented the medication as administered on the Medication Administration Record (MAR), despite not giving it at the scheduled time. For another resident, the LPN administered Brimonidine Tartrate Ophthalmic Solution to only one eye when the physician's order specified both eyes, and failed to administer Cholecalciferol (Vitamin D) because it was not available, yet documented it as given on the MAR. The LPN stated that she would typically notify the pharmacy and physician when medication is unavailable and document accordingly, but in these instances, the MAR was inaccurately completed. The errors were confirmed during medication administration reconciliation and through staff interviews, with the LPN acknowledging the discrepancies in documentation and administration. The deficiencies were brought to the attention of facility leadership.
Improper Medication Storage, Labeling, and Disposal Practices Identified
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's medication storage and labeling practices during observations of medication carts and storage rooms. In one instance, two Tylenol tablets and a vitamin tablet were found stored in a medication cup inside a cart after a resident refused them, and the LPN stated that refused medications were discarded in a trash can. Additional issues included an open, undated insulin pen, loose pills, and individually packaged medications not labeled with resident names. Similar findings were observed in other medication carts, including loose tablets, opened and undated bottles of supplements, and expired medications belonging to discharged or deceased residents. Further observations in medication storage rooms revealed medications for discharged or expired residents stored in open pharmacy bags, as well as expired enteral feeding formula. The refrigerator temperature log for medication storage was missing signatures for several days, and the unit manager admitted to lapses in monitoring and documentation. Staff interviews confirmed inconsistent practices for disposing of medications, with some stating that medications were returned to the pharmacy, while others described crushing and flushing non-narcotics or using a drug buster for narcotics, often without clear documentation or adherence to policy. The facility's policies require proper labeling, dating, and secure storage of all medications, as well as appropriate disposal in accordance with state and federal regulations. However, staff interviews and direct observations demonstrated a lack of compliance with these requirements, including improper storage of loose and unlabeled medications, failure to date opened bottles, retention of expired medications, and inconsistent documentation of refrigerator temperatures.
Failure to Provide Timely Dental Services
Penalty
Summary
A resident with diagnoses including dementia and cognitive communication deficit was admitted to the facility and had not received a dental evaluation or dental services since admission. The resident reported experiencing pain when chewing food, which was observed by the surveyor during a breakfast meal, where the resident took small bites and consumed limited food, stating pain in the right jaw while chewing. Review of the clinical record confirmed that the resident had not seen a dentist since admission, and an oral health evaluation later revealed the presence of 1-3 decayed or broken teeth. The registered dietitian noted that during a previous interview regarding weight loss, the resident did not mention dental pain at that time.
Sanitation and Food Storage Deficiencies Identified
Penalty
Summary
Surveyor observations and facility record review revealed that the facility failed to maintain proper sanitation in food storage areas both in the kitchen and on one nursing unit. During an initial kitchen tour, a personal coffee mug was found on a meal tray cart, and employee personal items such as a coat, backpack, and keys were stored in the chemical storage room. Additionally, opened containers of stir fry sauce, distilled vinegar, and salt were found undated on a food prep table shelf. The walk-in freezer and refrigerator lacked internal thermometers, with only external thermometers present at the time of observation. On a nursing unit, the nourishment refrigerator contained two rolls of bread and a bag of red grapes, all stored without labels or dates, contrary to the facility's policy requiring labeling and dating of food items brought in by family and visitors. The LPN Unit Manager confirmed that the expectation was for all food items in the nourishment refrigerators to be labeled and dated. These sanitation and food storage concerns were acknowledged by facility staff during the survey.
Improper Disposal of Garbage and Refuse
Penalty
Summary
During a tour of the facility's outside dumpster area, surveyors observed that the dumpsters were not covered with their attached lids. Additionally, items such as an old mattress, a dresser, and a soda can were found next to the dumpsters. The Food Services Director confirmed that the expectation is for dumpsters to be covered with lids and acknowledged the surveyor's observation. These findings were reviewed with the Licensed Nursing Home Administrator and the Regional Clinical Nurse Consultant. No further information was provided by the facility at the time of exit. No residents or specific patient information was mentioned in relation to this deficiency.
Inaccurate Documentation of Cervical Collar Use
Penalty
Summary
A deficiency was identified when the facility failed to maintain accurate medical records for a resident who was required to wear an Aspen cervical collar at all times following a fall that resulted in a head injury and cervical fracture. The physician's order specified that the collar should remain in place at all times, with removal only permitted for skin checks and ADL care, and to be replaced every shift. However, during multiple observations, the resident was not wearing the cervical collar as ordered. Further review of the resident's medical records revealed inconsistencies in documentation. Although the resident had refused to wear the cervical collar on several occasions, nursing staff signed the Treatment Administration Record (TAR) indicating the collar was worn on those days, as well as on days when the resident was observed without the collar. The Unit Manager confirmed that the nurses were not accurately documenting the resident's refusals on the TAR, despite the refusals being noted in progress notes.
QAA Committee Lacked Required Members and Accurate Attendance Documentation
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee included the minimum required members and met the federal requirements for attendance documentation. Record review of QAA attendance sheets revealed inconsistencies, including missing signatures for the Infection Preventionist (IP) at several meetings and unclear documentation of who attended on multiple dates. The attendance sheets also incorrectly listed the federal requirements for committee membership, omitting the IP. During an interview, the Administrator acknowledged issues with the attendance system and confirmed that the documentation did not clearly indicate who was present at the meetings.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
A deficiency was identified when a Geriatric Nursing Assistant (GNA) provided a bed bath to a resident with an indwelling urinary catheter without wearing a gown, despite Enhanced Barrier Precautions (EBP) being in place. The EBP sign was posted on the resident's door, indicating that staff must use personal protective equipment (PPE), including gloves and a gown, during high-contact resident care activities. The resident's medical record confirmed an order for EBP, specifically requiring PPE during such activities. During an interview, the GNA was unaware that the resident was on EBP and acknowledged that gloves and a gown were required for care under these precautions. The failure to wear a gown during a high-contact activity, such as a bed bath, constituted non-compliance with the facility's infection prevention and control program as outlined by CMS and CDC guidelines for residents with indwelling medical devices.
Failure to Maintain Sanitary Laundry Room Environment
Penalty
Summary
During a tour of the laundry room, the surveyor observed that the floor tiles in the area with washing machines were visibly dirty, with brown spills covering an area of approximately 1.5 ft by 1.5 ft in front of a platform where washing machine chemicals were stored. A brown dirt-like substance was also noted throughout the length of the laundry room leading to the platform. In the clean area of the laundry room, an HVAC unit was found with three rusty grille vent covers that had thick layers of dust. The Environmental Services Supervisor acknowledged the need for cleaning. These observations were made in the presence of facility staff and were reported to the Nursing Home Administrator.
Failure to Provide Written Notification for Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to residents and, when applicable, their representatives regarding the reason for transfer to the hospital. This deficiency was identified through staff interviews and medical record reviews for three residents who were transferred to the hospital on multiple occasions. In each case, there was no evidence in the medical records that written notification was given to the resident or their representative at the time of transfer. The Regional Clinical Nurse Manager confirmed during interviews that the facility did not have a process in place for providing such notifications. For one resident, documentation showed multiple hospital transfers without written notification. Another resident's record indicated that a family member requested a hospital transfer and called 911, but there was still no documentation of written notification being provided. Staff interviews revealed that while the process for preparing transfer documentation was described, there was no evidence that the required written notifications were actually given to the residents or their representatives during these transfers.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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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) |
|---|---|---|---|---|
| Montcare At Wheaton | 1.5 mi | ★★★★★ | 0 | 0 |
| Turtle Creek Rehabilitation And Wellness Center | 1.9 mi | ★★★★★ | 32 | 1 |
| Layhill Nursing And Rehabilitation Center | 2.5 mi | ★★★★★ | 42 | 0 |
| Hebrew Home Of Greater Washington | 2.5 mi | ★★★★★ | 23 | 0 |
| Tuckerman Rehabilitation And Healthcare Center | 2.7 mi | ★★★★★ | 5 | 0 |
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