Health inspection·May 8, 2023

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Based on observation, interview and record review, the facility failed to serve creamed corn to residents on mechanical soft diet and failed to serve nectar thick liquid to a resident with a diet order for the same. This applies to 3 of 9 residents reviewed for therapeutic diets in the sample of 9. The findings include: On 05/04/23 starting at 12:00 AM, the lunch meal service was observed in the facility 1st floor dining room. V17 (Assistant Dietary Manager) who was serving the meal, stated that mechanical soft diets will receive creamed corn instead of regular consistency corn for the lunch meal. Menu Daily Spreadsheet for Week 2 Thursday included roasted corn for the lunch meal and showed that mechanical soft diet will receive cream corn. On 05/04/23 at 12:12 PM, R1 was seated in the dining room for lunch and received two pieces of beef enchilada and regular consistency corn. R1 noted to be edentulous. When V12 (Certified Nursing Assistant) who was in the vicinity was asked whether R1 can have regular consistency corn, she stated, You are absolutely right, she shouldn't be eating regular corn. R1's diet order on (POS) Physician order Sheet included Mechanical Soft Diet (start date 4/24/23). On 05/04/23 at 12:19 PM, R8 received regular consistency corn with lunch meal. R8 noted to have poor dentition. R8 also received 4 oz/ounce cups of nectar thick consistency water and juice and an 8 oz cup regular consistency coffee. R8 was seen taking a few spoonsful of thickened water and adding it to his coffee. R8's meal ticket showed mechanical soft, nectar thick liquids. V12 was made aware of this and agreed he should have got creamed corn and thickened coffee. R8's face sheet showed diagnosis of dysphagia, oropharyngeal phase and POS included diet order of mechanical soft with nectar thick liquids (start date 06/08/21). On 05/04/23 at 12:24 PM, R9 also received regular consistency corn when his meal ticket showed mechanical soft diet. R9 was edentulous and did not touch the corn and stated he is unable to chew it. V1 (Administrator) who was in the area was made aware of it. R9's POS included diet order of mechanical soft diet (start date 05/01/23) On 05/05/23 at 11:35 AM, V16 (Dietitian) stated that residents on mechanical soft diet should have (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 2 Event ID: 145715 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 145715 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Wheaton Village Nrsg & Rhb Ctr 1325 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)