Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
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.
There were 35 opportunities with 3 errors resulting in an 8.57% error rate. This applies to 2 of 3 residents
(R38 and R6) observed in medication pass. The findings include: 1. On 8/20/25 at 8:22 AM, V6
(RN/Registered Nurse) was observed for medication pass for R38. At 8:37 AM, V6 took R38 his Breyna
inhaler to him. V6 put the inhaler in R38's mouth and administered one puff of the inhaler and held it there
for 10 seconds prior to removing the inhaler. V6 did not instruct R38 to take water, swish, and spit the water
after administration of the inhaler. V6 also did not administer R38's Metformin 850 MG (Milligrams). R38's
face sheet showed he was admitted to the facility with diagnoses including Type 2 diabetes mellitus and
wheezing. R38's POS (Physician Order Sheet) showed an order for Symbicort 160-mcg-4.5 mcg/actuation
aerosol (Breyna inhaler) dated 8/12/25. R38's Breyna medication packaging showed to rinse and spit after
administration of Breyna inhaler. R38's POS also showed an order for pioglitazone 15 MG/Metformin 850
MG two times daily starting 7/31/25. On 8/20/25 at 2:44 PM, R38's medication cart was reviewed and
showed a box for pioglitazone with a highlighted section showing to Take along with Metformin 850 MG.
R38's medication cart did not have a box of Metformin HCL (Hydrochloride) 850 MG tablets. On 8/20/25 at
3:22 PM, V6 said she thought the pioglitazone was combined with the metformin and thought she had
administered the combination medication. On 8/20/25 at 3:18 PM, V3 (ADON/Assistant Director of Nursing)
said she found R38's Metformin 850 MG tablets in the medication room. At 3:23 PM, V3 said the staff
probably put the medication in the medication storage room because they thought it was two boxes of the
same medication. The FDA (Food and Drug Administration) label for Breyna showed it should be
administered as 2 inhalations twice daily (morning and evening, approximately 12 hours apart), every day
by the orally inhaled route only. After inhalation, the patient should rinse the mouth with water without
swallowing. 2. On 8/20/25 at 8:51 AM, V6 prepared R6's Novolin insulin pen. V6 cleaned the tip of the pen,
attached the needle, and primed the pen with one unit of insulin. V6 then clicked the pen to 5 units of insulin
and administered it to the resident. R6's face sheet showed she was admitted to the facility with diagnoses
including Type 2 diabetes mellitus. R6's POS showed an order for Novolog flexpen U (Unit)-100 insulin
aspart 100 unit/mL (Milliliter) subcutaneous (5 units) insulin Pen starting 8/16/25. On 8/20/25 at 1:18 PM,
V5 (RN) said when administering medications, you had to follow the order in the computer. V5 said for
insulin pens, it needed to be primed with two units prior to administering the dose. V5 also said after
administering Breyna, the nurse should offer water to the resident to have them rinse their mouth and spit
out the water. On 8/21/25 at 1:55 PM, V8 (LPN/Licensed Practical Nurse) said insulin pens needed to be
primed with at least two units of insulin and to make sure to see the insulin shoot out. V8 said this was done
to make sure there were no bubbles in the needle to ensure the resident received the correct dose. V8 also
said after administration of the Breyna inhaler, the resident should rinse the mouth and spit the water out to
prevent thrush. V8 said the order for pioglitazone with metformin were two separate
Residents Affected - Few
(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 5
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
08/22/2025
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
pills and not a combination drug. On 8/21/25 at 9:42 AM, V2 (DON/Director of Nursing) said the insulin
pens needed to be primed with five to 10 units of insulin to ensure removal of the bubbles. V2 said one unit
of insulin was not sufficient to remove any bubbles. V2 also said after the use of the Breyna inhaler, the
nurse had to offer the resident water to swish and spit as it could cause candida in the mouth. The facility's
Administering Medications policy revised 4/2019 showed Medications are administered in accordance with
prescriber orders, including any required time frame. The individual administering the medication checks
the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right
method (route) of administration before giving the medication.
Event ID:
Facility ID:
145213
If continuation sheet
Page 2 of 5
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
08/22/2025
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 - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
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.
Based on observation, interview, and record review, the facility failed to remove expired medications. This
applies to 6 of 6 residents (R5, R6, R14, R24, R25, R43) reviewed for medication storage in a sample of
18.The findings include:On 8/21/25 at 9:18 AM, the medication storage room had the following items: R25's
Metoprolol Tartrate 50 MG (Milligrams) expired 12/31/24 with 30 pills remaining in the box., and R25's
Flecainide Acetate 50 MG expired 3/11/25 with 30 pills remaining in the box. R25's face sheet showed she
was admitted to the facility with diagnoses including cerebral infarction, paroxysmal atrial fibrillation, and
cerebrovascular disease. R24's Phenazopyridine 100 MG expired 2/4/25 with 15 pills remaining in the box.
R24's face sheet showed she was admitted to the facility with diagnoses including pain in left leg and
generalized pain. R24's POS (Physician Order Sheet) showed an order for phenazopyridine 100 mg
starting 2/3/24 as needed three times daily. On 8/21/25 at 9:23 AM, V3 (ADON/Assistant Director of
Nursing) said the drawers in the medication room are for extra medications and they were checked once a
week. V3 said the expired medication should be returned to the pharmacy to be destroyed. On 8/21/25 at
9:50 AM, a medication cart was checked and had the following items: R6's Novolog Insulin pen without a
clear opened on date or expired on date. R6's face sheet showed she was admitted to the facility with
diagnoses including type 2 diabetes mellitus. R43's Benzonatate 200 MG expired 1/4/25 with 10 pills
remaining in the box. R43's face sheet showed he was admitted to the facility with diagnoses including
congestive heart failure, hypothyroidism, and dementia. R14's Ondansetron HCl (hydrochloride) 4 MG with
four tablets expired on 3/1/25 mixed in the same box with three tablets expired 2/2024. R14's face sheet
showed she was admitted to the facility with diagnoses including congestive heart failure, dizziness and
giddiness, and gastroesophageal reflux disease. R5's Hydralazine 50 MG expired on 4/11/24 with 33 pills
remaining in the box, and R5's Gabapentin 100 MG with 42 pills dated 10/19/24 and three pills dated
2/23/24. R5's face sheet showed she was admitted to the facility with diagnoses including hypertensive
heart disease, heart failure, low back pain, osteoarthritis, and hypertension. On 8/20/25 at 1:18 PM, V5
(RN/Registered Nurse) said she was unable to tell what the date was on R6's Novolog Insulin pen. V5 said
they need to know the correct date because the pen was only valid for 28 days. On 8/21/25 at 10:04 AM, V2
(DON/Director of Nursing) showed Novolog insulin pens should be labeled with the initials of the staff who
opened it, the opened-on date, and the expires-on date. On 8/21/25 at 1:55 PM, V8 (LPN/Licensed
Practical Nurse) said there should not be expired medication in the cart. V8 said the medications with
various expiration dates should not be mixed within the same box as they have different lot numbers, and it
would be difficult to track if there was a recall. V8 said the staff should not be storing expired medication in
the medication cart or the storage room. V8 said the pharmacy comes to the facility every afternoon and
the expired medication should be returned to the pharmacy. V8 said there was a potential to give expired
medication to residents if it was stored in the medication cart. The facility's Medication Labeling and
Storage policy dated 2/2023 showed If the facility has discontinued, outdated or deteriorated medications or
biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these
items.
Event ID:
Facility ID:
145213
If continuation sheet
Page 3 of 5
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
08/22/2025
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to follow infection control practices to
prevent the spread of infection.This applies to 2 of 2 residents (R35, R27) reviewed for infection control in a
sample of 18.The findings include:1. On 8/19/25 at 11:56 AM, V4 (Scheduler) was passing lunch trays.
R35's room was on contact isolation with signage on the door frame and an isolation cart with PPE
(Personal Protective Equipment) including gowns, gloves, and face masks outside the room door. At 11:56
AM, V4 pulled the tray cart in front of R35's room, pulled R35's meal tray out of the cart, and entered R35's
room without performing hand hygiene or wearing any PPE. V4 set R35's tray on the bedside table, moved
her belongings around, and rolled the tray table in front of R35. R35 requested creamer from V4 and V4 left
the room without performing hand hygiene and went to find creamer. Upon return at 11:59 AM, V4 entered
R35's room again without performing hand hygiene or applying any of the appropriate PPE prior to
re-entering R35's room. V4 handed R35 the creamer and removed the lid of her tray.
Residents Affected - Few
On 8/21/25 at 1:51 PM, V4 said for contact isolation rooms, the staff need to wear gowns and gloves. V4
said prior to entering the room, the staff need to use gel to clean hands and apply PPE, and before exiting
the room, to remove the PPE and wash hands.
On 8/21/25 at 1:55 PM, V8 (LPN/Licensed Practical Nurse) said for contact isolation residents, you have to
wash hands, wear gown, gloves before entering the room. V8 said even just to pass the meal trays, all the
PPE should be worn. V8 said the PPE was worn to protect the staff and to prevent the spreading of
whatever disease the resident had.
On 8/21/25 at 9:42 AM, V2 (DON/Director of Nursing) said for residents with contact isolation, the signage
needs to be placed outside the room door with an isolation bin. V2 said prior to entering the room, the staff
need to wear gowns and gloves as it was strict isolation, and everything needed to be worn.
R35's face sheet showed she was admitted to the facility with diagnoses including congestive heart failure,
cognitive communication, and urinary tract infection. R35's POS (Physician Order Sheet) dated August 21,
2025 shows an order for Isolation- Contact Precautions Notes: For ESBL (Extended-spectrum
beta-lactamase) in urine. R35's care plan dated August 21, 2025 showed Problem: [R35] has an infectionUTI (Urinary Tract Infection) (ESBL in urine) with interventions including Infection precautions per physician
order. Use PPE, gown, and gloves at all times. Maintain contact isolation precautions at all times. Placed
isolation signage outside [resident] door. Educated resident and family regarding contact isolation
precautions and use of PPE.
The facility's Contact Precautions policy revised 3/12/25 showed In addition to wearing gloves as outlined
under Standard Precautions, clean, nonsterile gloves will be worn when providing direct care (changing
clothing, toileting, bathing, dressing changes, etc.) to residents with MDROs (Multi Drug Resistant
Organisms). Gloves should also be worn when handling items potentially contaminated by MDROs. This
may include items such as bedside tables, over-bed tables, bed rails, bathroom fixtures, television and bed
controls, suction, and oxygen tubing. Wearing gloves is not a substitute for hand washing. Gloves will be
removed and discarded before leaving the resident's room, hands will immediately be washed with soap
and water or an alcohol based hand rub will be used. Gowns should also be worn when body contact with
environmental surfaces and items in the room that may be contaminated is anticipated.The gown will be
removed and appropriately discarded before leaving the room. After gown removal, staff should ensure that
clothing does not contact potentially contaminated environmental
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145213
If continuation sheet
Page 4 of 5
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
08/22/2025
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 0880
surfaces to avoid transfer of microorganisms to other residents or environments.
Level of Harm - Minimal harm
or potential for actual harm
2. On 08/20/2025 at 11:51 AM, V10 CNA (Certified Nursing Assistant) put on PPE of face shield, gown and
gloves in addition to the surgical mask he was already wearing. V10 CNA went into R35's contact isolation
room, assisted her to reposition items on her over bed table, and delivered her meal tray. V10 removed all
the PPE he was wearing and stepped out of R35's room without performing hand hygiene. V10 removed a
new surgical mask from the PPE cart, re-entered R35's room and applied the surgical mask, exited R35's
room, and used hand sanitizer.
Residents Affected - Few
V10 CNA then moved the meal cart down the hall to deliver R27's meal tray. V10 put on a gown, face shield
and gloves. V10 did not perform any hand hygiene. V10 assisted R27 in positioning the overbed table and
delivered the meal tray. V10 removed his PPE except for the surgical mask and did not perform any hand
hygiene. V10 moved the meal cart further down the hall.
V10 stated he is required to perform hand hygiene before and after removing PPE. V10 stated he had
missed opportunities for hand hygiene during the meal delivery. V10 did not say why it was important to do
hand hygiene before and after removing PPE.
On 08/21/2025 at 1:15 PM, V2 DON (Director of Nursing) stated R35 is on Contact isolation for ESBL
(Extended Spectrum Beta Lactamases) in her Urine. V2 stated R27 is on Enhanced Barrier Precautions
related to a wound she has. V2 DON stated staff entering and exiting resident's room should perform hand
hygiene before and after care and before and after applying and removing PPE. Touching the clean PPE
cart with soiled hands is an infection control issue and contaminates the clean PPE and increases the
spread of infections.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145213
If continuation sheet
Page 5 of 5
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
3 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.
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the August 22, 2025 survey of WYNSCAPE HEALTH & REHAB?
This was a inspection survey of WYNSCAPE HEALTH & REHAB on August 22, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at WYNSCAPE HEALTH & REHAB on August 22, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure medication error rates are not 5 percent or greater."
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.