Above 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 Complete Care At Wheaton during CMS and state inspections, most recent first.
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 One resident attended only one care plan meeting in two years, while another had outdated care plans for discontinued medications.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.
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
We read the 1,519 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 9 | 1 |
| Layhill Nursing And Rehabilitation Center | 2.5 mi | ★★★★★ | 42 | 0 |
| Hebrew Home Of Greater Washington | 2.5 mi | ★★★★★ | 5 | 0 |
| Tuckerman Rehabilitation And Healthcare Center | 2.7 mi | ★★★★★ | 5 | 0 |
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