F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings include:
1). The EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], and discharged
from the facility on [DATE], at the local hospital, where R1 expired. R1 had multiple diagnoses including
bipolar disorder, chronic obstructive pulmonary disease, asthma, heart failure, type 2 diabetes,
spondylolisthesis lumbosacral region and morbid obesity.
R1's MDS (Minimum Data Set) dated [DATE], showed R1 to be cognitively intact, and required extensive
assistance with ADLs (Activities of Daily Living) including bed mobility, transfer, dressing, toileting, personal
hygiene and required total assistance with bathing and limited assistance with mobility while using a
wheelchair.
On [DATE]. 2023, at 1:03 PM, V7 (RN-Registered Nurse) stated she was R1's nurse on [DATE] at 3:00 AM
when R1 was found unresponsive, CPR (Cardiopulmonary Resuscitation) had been initiated and R1 was
transferred to the local hospital. V7 stated she did not contact V9 (R1's mother/POA/ Power of Attorney) to
notify her of R1's transfer to the hospital. V7 also stated she was R1's nurse on [DATE], at 1:20 AM, when
R1 had a fall that required transfer to the local hospital for a CT (computer tomography) scan of his head.
V7 stated she could not recall if she contacted V9 regarding the fall incident and transfer to the hospital.
R1's progress notes, written by V7, of [DATE], regarding the fall incident and transfer and the progress note
of [DATE], describing R1's change in condition and transfer to the hospital did not include notification to V9.
On [DATE], at 3:00 PM, V2 (DON) stated R1 had a room change on [DATE], due to his roommate's request
due to odors caused by R1. There is no documentation to include R1's agreement to the move, or
notification to either R1 or V9 (R1's representative) regarding the room change. V2 also stated R1 and R8
had exchanged rooms to accommodate room change requests.
On [DATE], at 2:00 PM, V9 stated she was not informed by the facility of R1's transfer to the hospital or his
change in condition. V9 further stated during the summer she was not informed of her son's fall or transfer
to the hospital. V9 stated her last conversation with R1 was on [DATE], when R1
(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
12/26/2023
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)
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
complained to her that his room had been changed, R1 did not understand why his room was changed and
he did not like the roommates in his new room.
2). R8's MDS (Minimum Data Set) dated [DATE], showed R8 was cognitively intact and required extensive
assistance with ADLs including bed mobility, transfer, toileting, dressing and personal hygiene, and mobility
while using wheelchair, and limited assistance with eating. The EMR showed R8 was admitted to the facility
on [DATE], and had multiple diagnoses including Chronic obstructive pulmonary disease, dementia, type 2
diabetes, schizophrenia, and chronic kidney disease.
R8's progress notes showed R8 developed a cough, and an X-ray of his chest was ordered and completed
on [DATE]. The next progress note was written on [DATE], by R8's physician. R8's admission record has an
emergency contact person listed. There is no documentation that either R8 or the emergency contact was
informed of either his illness or the room change that the census report showed occurred on [DATE].
On [DATE], at 2:15 PM, V2 (DON) stated there should be documentation when a resident agrees to a room
change or when resident representatives are notified of condition changes or transfer to the hospital.
The facility's policy Notification of Change in Condition Policy dated [DATE], showed under Standards: A
licensed nurse shall promptly inform the resident, consults with the resident's physician and if known, notify
the resident's legal representative or an interested family member of - a. An accident involving the resident
in which there is a potential or an actual injury b. a significant change in the resident's physical,
.deterioration .in either life threatening conditions or clinical complications c. a need to alter treatment and
d. a decision to transfer or discharge the resident facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145715
If continuation sheet
Page 2 of 2
