Dupage Care Center

Inspectors wroteBased on observations, interview and record review, the facility failed to provide residents their meal trays with others seated at the same table. This applies to 6 of 9 residents (R25, R62, R116, R153, R161, and R165) observed for dining in the sample of 35.

Inspectors wroteBased on observation, interviews, and record review the facility failed to change a wound dressing as ordered by the physician and the facility failed to prepare medications per facility policy. This applies to 4 of 35 residents (R134, R165, R177, R195) reviewed for quality of care in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a device or equipment for a resident with a limited range of motion to prevent potential further decrease in the range of motion (ROM). This applies to 1 of 8 residents (R9) reviewed for range of motion in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement feeding interventions to ensure safety for a resident (R173) while eating meals. This applies to 1 (R173) of 35 of residents reviewed for accidents and supervision in the sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to put nutrition interventions in place in a timely manner for a resident with significant weight loss. This applies to 1 of 5 residents (R14) reviewed for nutrition in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician order for medication administration. There were 25 medication opportunities with 2 errors, resulting to 7.69% error rate. This applies to 2 of the 8 residents (R9, R13) reviewed for medication administration in the sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to provide a resident with a pneumococcal vaccine. This applies to 1 of 5 residents (R34) reviewed for immunizations in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label/date/seal/store items, remove expired items, and perform hand hygiene while in the facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date and discard as indicated insulin vials when opened. The facility failed to store medications in their original packaging until they were administered. This applies to 8 of 8 residents reviewed (R104, R96, R160, R197, R75, R121, R146, R73) for medication storage in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to use appropriate PPE (Personal Protective Equipment) for a resident on EBP (Enhanced Barrier Precautions) and failed to do proper hand hygiene to prevent the spread of infection. This applies to 5 of 5 residents (R68, R41, R155, R364, R365) reviewed for infection control in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place call lights within reach of residents. This applies to 3 of 3 residents (R145, R168, R155) reviewed for accommodation of needs in a sample of 37.

Inspectors wroteBased on interview and record review the facility failed to report allegations of verbal abuse within 24 hours. This applies to 1 of 2 residents (R141) reviewed for abuse in a sample of 37.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly monitor, assess and treat a resident who is at risk for potential pressure ulcers. The facility also failed to properly monitor, and assess 1 resident who is unable to reposition themselves. This applies to 2 of 2 residents (R104 and R155) reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely transfer residents using a gait belt. This applies to 2 of 2 residents (R68, R191) reviewed for mobility in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer hydration fluids for a resident at risk for dehydration. This applies to 1 of 2 residents (R30) reviewed for hydration in the sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change, date, and label a feed tubing for an enteral feed for a resident with a gastrostomy tube (G-tube). This applies to 1 of 1 (R68) resident reviewed for gastrostomy tubes in a sample of 37.

Inspectors wroteBased on interview and record review the facility failed to provide documentation of monthly medication reviews and obtain a documented physician response to pharmacy recommendations. This applies to 1 of 5 residents (R141) reviewed for unnecessary mediations in a sample of 37.

Inspectors wroteBased on record review and interview, the facility failed to ensure two staff assisted in transferring a resident safely while using a mechanical lift. This failure resulted in R2 falling from the mechanical lift to the floor, sustaining a right tibia fracture and an occipital contusion and transfer to the emergency department. This Applies to 1 of 5 residents (R2) reviewed for falls and accidents in a sample of 9. A care plan initiated on 10/30/2023 showed that R2 needs two staff members to assist with ADLs (Activities of Daily Living), including transfers from bed to wheelchair and vice versa. The MDS (Minimum Data Set), dated 11/22/2023, showed that R2 is cognitively intact and dependent on ADLs, requiring two or more staff members to complete activities such as transfers, dressing, personal hygiene, and bathing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity for 5 of 5 residents (R19, R61, R72, R79, R128) reviewed for dignity in the sample of 36.

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to serve residents trays at an appetizing temperature for eight residents (R5, R12, R128, R119, R19, R79, R72, & R61) outside of the sample.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light system was in reach for 1 of 1 resident (R42) reviewed for call lights not in reach in the sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was transferred in a safe manner for 2 of 5 residents (R69, R87) reviewed for falls in the sample of 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure incontinence care was performed in a manner to prevent cross contamination and failed to ensure urinary drainage bags were off the floor for 3 of 3 residents (R28, R200, R22) reviewed for incontinence care in the sample of 36.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was properly identified prior to medication administration to prevent medication errors as per facility policy. This applies to 1 of 3 residents (R1) reviewed for medication errors in a sample of 7.