Inspection visit
Inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review, the facility failed to have call lights accessible and in
good working condition to dependent residents. This applies to 2 of 2 residents (R8 and R22) reviewed for
accommodation of needs in a sample of 22.
Residents Affected - Few
The findings include:
1. On 7/25/23 at 10:26 AM during initial tour rounds, R8 was in bed, bed was in low position and had 2 floor
mattresses on the floor next to his bed. Surveyor asked R8 where his call light was, R8 pointed to his
nightstand and said over there; the floor mattress was between R8's bed and the nightstand. The call light
was not within R8's reach. Surveyor asked how R8 notifies staff if he need assistance, R8 stated he calls
out for help, or he knocks on the wall; R8 proceeded to knock on the wall. At 11:25 AM, R8's call light still
on the nightstand, not within R8's reach.
R8's face sheet (7/26/23), showed R8 had following diagnoses hemiplegia and hemiparesis following
cerebral infarction affecting right dominant side, muscle wasting and atrophy, lack of coordination, dementia
and need for assistance with personal care.
R8's current Minimum Data Set (MDS) shows R8's cognition is moderately impaired; needs extensive
assistance with two or more-person physical assist with transfers and toilet use, and extensive assistance
with one-person physical assist with personal hygiene.
R8's care plan (revised 1/1/8/23) shows R8 is high risk for falls, has poor safety awareness, cognitive
deficit, and is impulsive; intervention is for staff to place call system within R8's reach.
2. On 7/25/23 at 11:01 AM, R22 was observed in bed in her room; R22 said she was hungry and wanted
some black coffee. Surveyor asked R22 where the call light was, R22 picked up her bed control and
adjusted the bed; R22 was unable to locate the call light. Surveyor left R22's room to locate facility staff. At
11:13 AM, V5 (CNA- Certified Nurse Aide) came to R22's room said R22 does not use her call light and
staff checks on her regularly.
On 7/25/23 at 12:04 PM, R22 was observed eating lunch in bed in her room, call light was next to her.
Surveyor asked if R22 was able to use the call light. R22 pushed the call light button and the light did not
flash. At 12:13 PM, V6 CNA came in R22's room: V6 said R22 can use the call light. Surveyor informed V6
that the call light was not working, V6 said if the call light was working, it should flash when pushed; V6
pushed the call light and it did not flash, the call light was not working.
R22's face sheet (7/26/23) showed R22 had the following diagnoses fracture of left femur, pain in left hip,
dementia, need for assistance with personal care, fall, and lack of coordination.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 8
Event ID:
145213
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145213
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wynscape Health & Rehab
2180 Manchester Road
Wheaton, IL 60187
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0558
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
R22's current MDS showed that R22's cognition is severely impaired; is total dependence with two or more
physical assist with transfers, total dependence with one person physical assist with toilet use and personal
hygiene.
R22's current care plan shows that R22 has high risk for fall due to poor balance and limited mobility. R22 is
alert and oriented and can use call light and to have call light system within reach.
On 7/27/23 at 10:56 AM, V2 DON said call lights should be working and should be within reach for
residents to use, if they need help.
The facility's Call light Response policy (reviewed 3/30/23) states to have call light within reach.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145213
If continuation sheet
Page 2 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145213
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wynscape Health & Rehab
2180 Manchester Road
Wheaton, IL 60187
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to follow accurate procedure to obtain
blood glucose measurements and did not administer insulin using correct technique to ensure
administration into subcutaneous tissue. This applies to 3 of 3 residents (R9, R18, R306) reviewed for
quality of care in the sample of 24.
Residents Affected - Few
The findings include:
1. On 07/26/2023 at 11:20 AM, V2 (DON/Director of Nursing) took the blood glucose measurement for R9.
V2 put the test strip into the blood glucose monitor, wiped R9's finger with an alcohol pad, wiped the first
drop of blood away with the same alcohol pad, and measured the blood glucose levels with the second
drop of blood. At 11:33 AM, V2 administered insulin using an insulin pen to R9. R9 was sitting in her
wheelchair with a sweatshirt and t-shirt on. V2 stood in front of R9, lowered her left sweatshirt sleeve and
lifted her t-shirt sleeve, exposing the deltoid muscle, which is a thick, triangular shoulder muscle, causing
the skin to stretch flat. V2 wiped the deltoid muscle with an alcohol pad and did not pinch R9's
subcutaneous fat prior to administering insulin through the insulin pen. V2 administered one unit of insulin.
On 07/27/2023 at 8:26 AM, V10 (LPN/Licensed Practical Nurse) entered R9's room to check R9's blood
glucose level. R9 was eating her breakfast tray when V10 explained he was going to take her blood glucose
level. R9 said I beat ya to it, I already ate. V10 continued to take R9's blood glucose level.
R9's face sheet showed R9 was admitted to the facility with diagnoses including Alzheimer's disease, heart
failure, cognitive communication disorder, and type 2 diabetes mellitus. R9's current MDS (Minimum Data
Set) showed R9 had moderate cognitive impairment and required extensive assistance for bed mobility,
eating and personal hygiene, and was totally dependent on staff for transfers, dressing, and toileting.
2. On 07/26/2023 at 12 PM, V2 took the blood glucose measurement for R18. V2 entered R18's room and
R18 was sitting in his chair eating his lunch. V2 asked to take R18's blood glucose measurement. V2
opened the alcohol swab and wiped R18's finger, pierced the finger with the lancet, and wiped the first drop
of blood away using the same alcohol swab. V2 used the second drop of blood to obtain the blood glucose
level. At 12:06 PM, V2 returned to R18's room to administer insulin using the insulin pen. V2 lifted R18's
t-shirt to expose the stomach and wiped the left middle quadrant of R18's stomach with an alcohol pad,
held his skin flat, and administered two units of insulin using the pen.
R18's face sheet showed R18 was admitted to the facility with diagnoses including heart failure, type 2
diabetes mellitus, and hyperlipidemia. R18's current MDS shows R18 had moderate cognitive impairment
and required limited assistance for eating, and extensive assistance for bed mobility, transfers, dressing,
toileting, and personal hygiene.
3. On 07/26/2023 at 11:45 AM, V2 administered insulin through an insulin pen for R306. V2 cleaned the
right middle quadrant on R306's stomach, did not pinch to get the subcutaneous fat, and administered 19
units of insulin.
R306's face sheet shows R306 was admitted to the facility with diagnoses including hyperlipidemia, type 2
diabetes mellitus with diabetic nephropathy, and heart failure. R306's MDS was not due to be
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145213
If continuation sheet
Page 3 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145213
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wynscape Health & Rehab
2180 Manchester Road
Wheaton, IL 60187
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
completed.
Level of Harm - Minimal harm
or potential for actual harm
On 07/27/2023 at 11:50 AM, V2 said the facility's policy shows using alcohol can alter the results of the
blood glucose measurement. V2 also said the blood glucose level should be checked prior to the resident
eating as it can alter the blood glucose level and could result in a higher reading. V2 said a higher result
would mean more insulin would be given, which could cause the blood glucose levels to become too low,
potentially leading to a coma. V2 said the nurse and the CNA (Certified Nurse Assistant) should have
communicated that the blood glucose measurement needed to be completed and to hold the meal tray. V2
said she did not communicate to the CNA that she needed to check the blood glucose level.
Residents Affected - Few
The facility's Obtaining a Fingerstick Glucose Level policy reviewed on 05/02/2022 shows If alcohol is used
to clean the fingertip, allow it to dry completely because the alcohol may alter the reading. Obtain a blood
sample by using a sterile lancet. Discard the first drop of blood if alcohol is used to clean the fingertip
because alcohol may alter the results.
The facility's Insulin Administration policy dated 02/09/2020 shows Lightly grasp a fold of skin and insert the
needle into the skin at a 90-degree angle.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145213
If continuation sheet
Page 4 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145213
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wynscape Health & Rehab
2180 Manchester Road
Wheaton, IL 60187
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
5. On 7/25/23 at 11:01 AM, R22 was observed in bed in her room. R22's bed was positioned against the
wall. R22's bed was in high position, not low in low bed position and had two floor mattresses across the
room, stacked against the wall by the door. Surveyor asked R22 where the call light was, R22 picked up her
bed control and adjusted the bed; R22 was unable to locate the call light.
R22's face sheet (7/26/23) showed R22 had the following diagnoses fracture of left femur, pain in left hip,
dementia, need for assistance with personal care, fall, and lack of coordination.
R22's current MDS showed that R22's cognition is severely impaired; is total dependence with two or more
physical assist with transfers, total dependence with one person physical assist with toilet use and personal
hygiene.
R22's current care plan shows that R22 has high risk for fall due to poor balance and limited mobility. R22's
care plan shows that R22 had eased off the bed and off floor mattress. R22 is alert and oriented and is able
to use call light; has interventions to have call light system within reach, keep bed in low position, and bed
remote control to be at the foot of the bed.
On 7/27/23 at 1:45 PM, V3 (ADON-Assistant Director of Nursing) said after R22's last fall incident,
interventions put in place was to have her bed in low position, floor mattress on floor next to bed, bed
control to be at the foot of the bed and call light to be within reach; these were placed to prevent fall related
injuries.
Based on observation, interview and record review the facility failed to properly store cleaning supplies and
implement fall intervention to ensure residents safety. This applies to 5 of 24 residents (R2, R206, R44,
R52, and R22) reviewed for safety.
On 7/25/23 at 10:35 AM, in R2 and R206's shared bathroom there was a clear plastic bag tied to a water
shut off valve. The unlabeled bag was filled with clear yellow liquid and a toilet brush.
On 7/25/23 at 10:50 AM, R44's bathroom had a clear plastic bag tied to a water shut off valve. The
unlabeled bag was filled with clear yellow liquid and a toilet brush.
On 7/25/23 at 11:02 AM, R52's bathroom had a clear plastic bag tied to a water shut off valve. The
unlabeled bag was filled with clear yellow liquid and a toilet brush.
On 7/25/23 at 11:11 AM, V7 EVS (Environmental Services) was stopped while cleaning a resident's room
and asked what the clear yellow liquid was in the bags tied under residents' sinks. V7 stated the brush was
for cleaning the toilet, but she did not know what the yellow liquid was and would have to ask her boss.
On 7/25/23 at 11:18 AM, V8 (Housekeeping Supervisor), stated the clear yellow fluid in the bags stored in
resident's bathrooms is a disinfectant. Toilet brushes are stored with the disinfectant in all of the residents
bathrooms. They keep it stored in residents' bathrooms so the CNAs (Certified Nursing Assistants) can
clean the toilets if residents make a mess using the toilet. V8 provided the Safety Data Sheet for Peroxide
Multi Surface Cleaner stored in the residents' bathrooms.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145213
If continuation sheet
Page 5 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145213
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wynscape Health & Rehab
2180 Manchester Road
Wheaton, IL 60187
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
On 7/27/23 at 9:44 AM, V9 (Director of Facilities Services) stated he does HazCom (Hazard
Communication) training with all the staff including, housekeeping, clinical and maintenance. The training
he does is a general umbrella, and each manager is responsible for providing specific training to their staff
as it relates to their department. The training includes proper labeling of products. V9 said everything except
water needs to be labeled. V9 said he reviews how to treat spills, product dilution and how to store and
label products. V9 said storing cleaning products in a plastic bag is not a safe storage container and all
products should be labeled.
On 7/27/23 at 1:38 PM, V1 (Administrator) stated she was not aware that toilet brushes were being stored
in cleaning solution in residents' rooms. V1 stated there is a possibility for residents to inadvertently ingest
the product.
On 7/28/23 at 8:45 AM, V12 (Health Information Specialist) stated the peroxide multi-surface cleaner
should be stored in a suitable labeled container. V12 said the product even diluted is an irritant to skin and
eyes and it should be washed off immediately. V12 said the product should not be accessible to individuals
that are not cognitively aware. V12 said someone would need to know if they came in contact with the
product wash the area and monitor for symptoms and the product should be stored in a suitable labeled
container. V12 said a plastic bag is not a suitable container for the product.
The Hazardous Communication Standard dated February 2023 states labels must provide the identity of
the chemical and appropriate hazard warning. Labels require: Pictogram (symbols) - to convey specific
information about the hazards of a chemical. Signal Words - to indicate the level of severity of hazard and
alert the reader to potential hazard on the label Danger and Warning are signal words. Hazard Statement a statement assigned to a hazard class and category that describes the nature f the hazard of a chemical,
including the degree of hazard. Precautionary Statement - Phrase that describes recommended measures
to be taken to minimize or prevent adverse effects resulting from exposure, improper storage, or handling.
Supplier Information - name address and phone number. Staff should educate themselves about the
chemicals. Before working with any chemical read the SDS (Safety Data Sheet). Check for leaking
containers. Remove only the amount of chemical that will be used. Return the sealed container to the
proper storage location. Never leave containers open. Never use a container that is not labeled.
The facility policy Cleaning Supply Storage dated 2/3/2023 states all carts must have a lockable
compartment for containers of cleaning and disinfectant solutions. While in use never leave them
unattended or out of sight.
The products Safety Data Sheet dated 06/27/2019 states product can cause serious eye irritation. Avoid
contact with skin and eyes. In case of eye and skin contact rinse with plenty of water. If swallowed rinse
mouth and get medical attention if symptoms occur. If inhaled get medical attention if symptoms occur.
Wash hands thoroughly after handling. In case of mechanical malfunction or if in contact with unknow
dilution of product wear full personal protective equipment. Keep out of children. Store in suitable labeled
containers. Good general ventilation should be sufficient to control worker exposure to airborne
contaminants
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145213
If continuation sheet
Page 6 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145213
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wynscape Health & Rehab
2180 Manchester Road
Wheaton, IL 60187
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to administer medications as ordered
(at ordered times or in ordered dosage). There were 35 opportunities with 2 errors resulting in a 5.71%
error rate.
Residents Affected - Few
This applies to 2 of 6 residents (R9, R18) observed in the medication pass.
The findings include:
1. On 07/26/2023 at 11:33 AM, V2 (DON/Director of Nursing) prepared R9's insulin pen for administration.
V2 explained to R9 she was about to receive insulin and stood in front of R9. R9 was sitting in her
wheelchair wearing a t-shirt with a sweatshirt over it. V2 lifted R9's t-shirt sleeve and lowered R9's
sweatshirt sleeve to expose an area of skin to administer the insulin. The exposed area of skin was the
deltoid muscle, which is the thick, triangular muscle of the shoulder. V2 used her left-hand fingers to hold
the articles of clothing apart to prevent the clothes from touching the area after wiping it clean with an
alcohol swab. V2 did not pinch for subcutaneous fat to ensure proper administration. V2 then injected the
insulin pen into the area of exposed skin and administered R9's insulin.
R9's face sheet showed R9 was admitted to the facility with diagnoses including Alzheimer's disease, heart
failure, cognitive communication disorder, and type 2 diabetes mellitus. R9's current MDS (Minimum Data
Set) showed R9 had moderate cognitive impairment and required extensive assistance for bed mobility,
eating and personal hygiene, and was totally dependent on staff for transfers, dressing, and toileting.
2. On 07/27/2023 at 11:33 AM, V10 (LPN/Licensed Practical Nurse) prepared R18's insulin pen for
administration. V10 cleaned the top of the insulin pen with an alcohol pad and attached the needle to the
top. V10 did not prime the insulin pen. V10 turned the insulin pen to two units. V10 went to R18's room and
administered the insulin.
R18's face sheet showed R18 was admitted to the facility with diagnoses including heart failure, type 2
diabetes mellitus, and hyperlipidemia. R18's current MDS shows R18 had moderate cognitive impairment
and required limited assistance for eating, and extensive assistance for bed mobility, transfers, dressing,
toileting, and personal hygiene.
On 07/27/2023 at 11:46 AM, V10 said he did not prime the insulin pen prior to administering it. V10 said the
insulin pen should be primed first and then administer the dose of insulin.
On 07/27/2023 at 11:50 AM, V2 said the subcutaneous injections should be administer in the fat. V2 also
said insulin pens should be primed with two units of insulin prior to administering the insulin to the resident.
The facility's Insulin Administration policy dated 02/09/2020 shows Insulin may be injected into the
subcutaneous tissue of the upper arm. Lightly grasp a fold of skin and insert the needle into the skin at a
90-degree angle. For very thin residents, insert at a 45-degree angle to avoid intramuscular injection.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145213
If continuation sheet
Page 7 of 8
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145213
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/28/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Wynscape Health & Rehab
2180 Manchester Road
Wheaton, IL 60187
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to label and secure resident's medication in a
locked compartment. This applies to 1 out of 7 residents (R31) reviewed for medication labeling and storage
in a sample of 24.
The findings include:
R31's admission Record shows R31 was admitted on [DATE]. Diagnoses includes gout, muscle spasm and
pain in left knee.
On 07/25/23 at 10:50 AM, 07/26/23 at 09:11 AM and 07/27/23 at 09:23 AM, R31 had five topical painkillers
(Aleve, Salonpas, Arthritis Pain, Calmoseptine, and Joint Flex) in a pink bin on the floor on the right side of
R31's recliner. All topical painkillers were not labeled.
On 07/26/23 at 09:11 AM, R31 said he had just applied Joint Flex Cream on his knees and shoulders. R31
said he used the Aleve Cream and Joint Flex Cream for pain in his knees, Salonpas Cream for pain in his
toes, and Arthritis Pain Cream and Calmoseptine Cream for pain in his legs. R31 said he brought the
topical painkillers from home when he was admitted on [DATE].
On 07/27/23 at 09:38 AM, V2 (DON-Director of Nursing) said all medications are kept in the medication cart
or the medication room. V2 (DON) said all medications should be labeled. V2 (DON) said there is no
resident in the facility with an order to keep medication by the bedside. V2 (DON) said there was no
resident in the Facility with an order for Self-Administration of medication. V2 (DON) said the facility does
not allow medication from home. She said if medication from home is found, staff takes it from the resident.
On 7/26/2023 at 1:30 PM, R31's POS (Physician Order Sheet) showed there is no order for Aleve Cream,
Salonpas Cream, Joint Flex Cream and Calmoseptine Cream. R31's POS did not have an order for
medication to be kept at bedside or to self-administer medication.
Facility's Policy on Labeling of Drugs and Biologicals dated April 2019 stated the following: . All medications
maintained in the facility are properly labeled in accordance with current state and federal guidelines and
regulations.6. Labels for over-the-counter drugs include all necessary information, such as: a. the original
label indicating the name, strength, and quantity of the medication; b. the expiration date when applicable;
and c. directions for use and appropriate accessory/cautionary statements.
Facility's Policy on Storage of Medications dated April 2019 stated: The facility stores all drugs and
biologicals in a safe, secure, and orderly manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145213
If continuation sheet
Page 8 of 8
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
FAQ · About this visit
Common questions about this visit
What happened during the July 28, 2023 survey of WYNSCAPE HEALTH & REHAB?
This was a inspection survey of WYNSCAPE HEALTH & REHAB on July 28, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WYNSCAPE HEALTH & REHAB on July 28, 2023?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.