Wheaton Village Nrsg & Rhb Ctr

Inspectors wroteBased on interviews and record review, the facility failed to provide adequate supervision during meals for a resident identified as being at high risk for choking. This failure resulted in a choking episode that required emergency intervention, hospitalization, and placement of a tracheostomy tube to establish and maintain the resident's airway. This applies to 1 of 1 resident (R6) reviewed for a choking incident. The Findings Include:Review of the Electronic Medical Record (EMR) showed that R6, a [AGE] year-old resident, was admitted to the facility on [DATE]. Diagnoses included drug-induced dyskinesia, schizophrenia, bipolar disorder, anxiety disorder, depression, hypertensive heart disease, type 2 diabetes mellitus, asthma, atherosclerotic heart disease, repeated falls, and right below-knee amputation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff promptly reported an allegation of neglect to the facility's abuse coordinator/administrator for investigation. This applies to 1 of 9 residents (R8) reviewed for neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician-ordered treatment for skin alterations was implemented to promote healing. This applies to 1 of 3 residents (R8) reviewed for skin alterations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately assess pain management effectiveness and failed to notify the physician for additional interventions when pain relief measures were ineffective. This applies to 1 of 3 residents (R8) reviewed for pain management.

Inspectors wroteBased on interviews and record review the facility failed to address complaints and grievances from residents or significant others concerning issues with resident laundry and call light response. This failure applies to 4 of 4 residents (R1, R2, R3, R4) reviewed for grievances.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure significant medications were administered to residents as indicated by physician orders. This applies to 2 of 5 residents (R3, R4) who were reviewed for medication administration in a sample of 7. Findings Include:On 01/21/2026 at 11:40 AM, this writer asked V4 (Licensed Practical Nurse-Agency) if she could observe medication administration for residents with scheduled medications at 12:00 PM -1:00 PM. V4 said she already finished her afternoon medications, and the review of manual medication administration showed medications were signed off. At 2:00 PM, V2 (Assistant Director of Nursing) said she asked V4 why the residents had finished their afternoon medication so early, and V4 told her she started medication by 10:45 AM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label/date/store/discard items, ensure the dishwasher was functioning, dispose of garbage, and maintain proper levels of chlorine in the dishwasher and quaternary in sanitizer buckets. 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 provide access to resident call system to obtain needed assistance. This applies to 5 of 5 (R2, R9, R35, R37, R67) residents reviewed for call lights in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, 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 applies to 5 of 5 residents (R65, R94, R98, R14, R44) reviewed for medication storage in a sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident/resident's representative of the reason for the discharge in writing. The facility also failed to send a copy of the notice to the Ombudsman. This applies to 2 of 2 (R51, R73) residents reviewed for discharge in a sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to provide bed hold policy in writing to resident/resident's representative upon their transfer to the hospital. This applies to 2 of 2 (R51, R73) residents reviewed for discharge in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care for residents dependent on staff. This applies to 2 of 2 residents (R71, R107) reviewed for ADL (Activities of Daily Living) care in a sample of 23.

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to ensure resident received respiratory care and services in accordance with professional standards of practice for 3 of 3 residents (R2, R33 and R95) reviewed for respiratory therapy in the sample of 23.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide at least 80 square feet for residents for 12 of 48 resident rooms. This applies to rooms A18, A19, A22, A24, A26, A28, A30, A31, A33, A34, B7 and B8.

Inspectors wroteBased on observations and interviews, the facility failed to have the floor of the resident rooms at the garden or above the ground level. This applies to 36 of the 36 (R1, R4, R6, R7, R11, R14, R15, R16, R18, R26, R29, R31, R34, R36, R39, R42, R43, R45, R46, R47, R52, R53, R66, R67, R68, R76, R87, R91, R98, R99, R101, R102, R103, R104, R108) residents reviewed for physical environment.

Inspectors wroteBased on interview and record review the facility failed to provide resident trust fund cash to residents within three business days. This applies to 2 of 3 residents (R6 and R7) reviewed for trust funds in a sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse per facility policy. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 8.

Inspectors wroteBased on interview and record review the facility failed to keep residents free of abuse from other residents. This applies to 3 of 3 residents (R2, R3, R12) reviewed for abuse in the sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to notify either the resident or their representative of a significant change in condition and room changes. This applies to 2 of 4 residents (R1, R8) reviewed for notifications when changes occur in the sample of 4.

Inspectors wroteBased on observation, interview and record review, the facility failed to comprehensively assess/evaluate and inform the physician of the residents complaint of pain to help manage existing pain and/or prevent pain. This applies to 2 of 6 residents (R38 and R105) reviewed for pain management in the sample of 29. This failure resulted in R38 verbalizing complaint of worsening pain for two consecutive days (10/30/23 and 10/31/23). R38's frequent pain level of eight, documented in the resident's October 2023 medication flowsheet pain scale.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food portion sizes to residents as planned on the facility menu. This applies to all 111 residents receiving oral diets at the facility The Long-Term Care Facility Application for Medicare and Medicaid form, dated 10/31/23, shows the facility census was 111 residents. Facility Order Report by Category, dated 9/30/23 to 10/3023, shows 19 residents had diet orders of mechanical soft or pureed diets and all other residents had diet orders of Regular/No Added Salt/No Added Sweets or Double Portions. Facility document, dated 10/30/23, shows the facility had zero residents who had physician orders of NPO (Nothing By Mouth). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store refrigerated potentially hazardous foods and failed to maintain kitchen equipment, floors, and walls in clean and sanitary conditions. This applies to all residents receiving oral diets in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy and ensure there was an assessment conducted that identified where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. The facility also failed to ensure they identified, implemented, and documented any preventative measures for waterborne pathogens. This applies to all 111 residents that reside in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms were maintained free of water damage and in good repair. This applies to 7 of 7 residents (R32, R37, R50, R51, R56, R72, and R93) reviewed for homelike environment.

Inspectors wroteBased on observation, interview, and record review, facility failed to have the floor of the residents' rooms in the garden level at or above ground. This applies to 37 of 37 residents (R1, R4, R6, R8, R12, R15, R16, R17, R18, R25, R29, R27, R30, R31, R32, R37, R40, R43, R46, R47, R49, R50, R51, R56, R57, R59, R66, R72, R80, R92, R93, R97, R101, R104, R107, R109, and R110) reviewed for rooms below ground.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident had a consistent medical order recorded resident's treatment wishes in the event of a medical emergency. This applies to 1 of 3 residents (R91) reviewed for advance directives in the sample of 29.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a comprehensive eye assessment for an eye injury sustained after a fall. This applies to 1 of 3 (R89) residents reviewed for falls in the sample of 29.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician's order with regards to administration of continuous oxygen and labeling of the oxygen tubing. The facility also failed to use of the oxygen humidity bottle per policy and procedure. This applies to 1 of 1 resident (R7) reviewed for oxygen therapy in the sample of 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inspect, and identify an infestation of insects, and mitigate the source of the infestation into a resident's room for at least 2 days. This applies to one of one residents (R31) reviewed for insect infestation in a sample of 29.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident dignity was maintained during personal care for one of one resident (R83) reviewed for dignity in the sample of 22.

Inspectors wroteBased on observation, interview and record review the facility failed to provide personal hygiene care for a dependent resident who was in the main dining room with urine soaked pants to the groin area for 1 of 1 resident (R77) reviewed for Activities of Daily Living (ADL's) in a sample of 22.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident medications were not left at the bedside for three of three residents (R85, R63, R3) reviewed for safety and supervision in the sample of 22.

Inspectors wroteBased on observation and interview, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms in 14 of 48 rooms. This applies to 40 of 40 (R75, R55, R38, R24, R83, R34, R86, R66, R35, R32, R2, R207, R10, R80, R81, R65, R5, R36, R88, R21, R25, R64, R3, R63, R85, R90, R12, R26, R49, R91, R58, R98, R18, R31, R59, R95, R41, R89, and R44) residents reviewed for room square footage.

Inspectors wroteBased on observation and interview the facility failed to have the floor of the residents' rooms in the garden level at or above ground level. This applies to 36 of 36 (R68, R99, R67, R255, R26, R49, R91, R58, R98, R18, R52, R93, R73, R100, R6, R19, R70, R57, R50, R37, R31, R59, R95, R41, R89, R44, R1, R56, R16, R17, R4, R29, R47, R13, R8, R30) residents reviewed for physical environment.