Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to store food items in sanitary
conditions by having unlabeled and undated food items in dry storage and in a walk-in cooler, and ice
buildup on food items and the ceiling in the freezer.
This affects all 70 residents consuming food from the kitchen.
Findings include:
On 6/14/23 at 10:10 AM, V2 (Director of Nursing - DON) stated, We have 70 residents on the certified side.
Two are on gastrostomy tube (GT) feeding, but they are also on pleasure feeding. So, all 70 residents are
eating from the kitchen.
On 6/16/23 at 9:40 AM, during the initial kitchen tour with V5 (Assistant Dietary Manager), the dry kitchen
storage was observed with a partially used five-pound [NAME] Cracker Crumbs with no label or date.
On 6/16/23 at 9:45 AM, the kitchen walk-in cooler was observed with two apple pies with no label or date,
and two pounds of sliced ham dated 6/5/23 (11 days earlier), partially covered with plastic wrap.
On 6/16/23 at 9:45 AM, V5 stated, Sliced hams are good for seven days and should be fully covered . All
food items should be labeled and dated.
On 6/16/23 at 9:45 AM, the dietary freezer was observed with ice build-up on a five-pound salami, four
pizza crusts (no label/date), 90 portions of Turkey and Beef Patties, blueberry bagels, and angel food cake
mix. Observed freezer ceiling with ice that had formed throughout the freezer, and food was contained in
cardboard boxes that were saggy with ice/condensation. Dripping water was noted at the freezer entry door
from condensation that formed on the freezer ceiling.
On 06/13/23 at 09:48 AM, V5 added, Ice shouldn't be built up on the freezer, food items, and with the
ceiling.
The facility presented a policy on storing dry goods/foods (revised 5/20/2014) that showed: Opened
products are labeled, dated with the use-by date, and tightly covered to protect against contamination,
including from insects and rodents.
The facility presented a policy on refrigerated food prepared (revised 5/20/2014) that showed:
(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 4
Event ID:
145840
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
145840
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Tabor Hills Health Care Fac
1347 Crystal Court
Naperville, IL 60563
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 0812
Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by.
This includes leftovers. The discard/use-by date will be a maximum of six days after preparation.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145840
If continuation sheet
Page 2 of 4
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
145840
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Tabor Hills Health Care Fac
1347 Crystal Court
Naperville, IL 60563
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 implement infection control
measures to prevent cross-contamination from soiled linens, soiled gloves, incontinence wipes, and
resident trays. This applies to 11 of 23 residents (R4, R12, R17, R28, R42, R49, R52, R56, R60, R68, and
R278) reviewed for infection control.
Residents Affected - Some
Findings include:
1. On June 13, 2023, at 11:26 am, V7 CNA (Certified Nursing Assistant) placed a disposable incontinence
brief and pants on R278 while R278 was in a standing position, V7 threw R278's soiled under pad onto the
floor. R278 was assisted to her wheelchair. While still wearing soiled gloves, V7 walked out of R278's
bedroom to the clean linen cart in the hallway. V7 lifted the covering of the linen cart wearing the soiled
gloves and removed towels and a pillowcase. V7 returned to R278's room, removed the soiled gloves, and
used hand sanitizer.
R278's room contained three beds and R278 is assigned to bed #3; beds #1 and #2 were both made and
ready for new admissions. V7 moved R278's soiled linen and clothing she had previously placed on bed #2,
to bed #1, contaminating both beds. V7 picked up the soiled under pad from the floor and placed it on bed
#1. V7 collected R278's meal tray and the soiled linen placed on bed #1 and exited the room. V7 placed the
dirty meal tray on the clean linen cart before taking soiled linen into the soiled utility room.
On June 15, 2023, at 10:58 am, V2 DON (Director of Nursing) stated staff should be removing their gloves
and washing their hands after providing care to residents. Staff should not be going into a clean linen cart
and removing clean items with gloves they had worn while providing resident care. Staff should not be
placing soiled linen and used items on a clean bed. Staff should not place a meal tray that was in a
residents room on top of the clean linen cart. It is an infection control issue.
On June 15, 2023, at 12:18 pm V7 CNA stated she used the items on the cart for everyone down that
hallway (R4, R12, R17, R28, R42, R49, R56, R60, R68, and R278). R278 is in the room by herself, but the
other two beds are made and ready for new residents when they come. V7 stated she did not do hand
hygiene properly when observed on June 13th. V7 stated she should not have placed the meal tray on the
clean linen cart. V7 stated she did not clean the cart after she went through it. V7 stated housekeepers
clean the linen carts, but she did not know when.
On June 15, 2023, at 12:30 pm V8 Housekeeper stated housekeeping does not clean linen carts or their
covers.
2. On June 14,2023 at 08:51 AM, R52 needed to be transferred to the toilet. V4 (CNA- Certified Nurse
Assistant) came to the room and applied gloves without doing hand hygiene. V3 (CNA) was already in
R52's room. R52 was transferred to the toilet by V3 (CNA) and V4 (CNA). When R52 was done on the toilet,
V3 (CNA) took a wet wipe and wiped R52's buttocks. V3 (CNA) proceeded to wipe R52's perineum with the
same wet wipe without folding the wet wipe to use the clean side. Without changing gloves, V3 (CNA)
proceeded to put on R52's incontinent brief, pulled R52's pants up, assisted with transfer and put a clean
shirt on R52.
Interview with V2 (DON- Director of Nursing) on June 15,2023 at 10:43 AM, V2 stated during incontinence
care, staff are expected to wipe front to back for both male and female residents. V2 (DON)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145840
If continuation sheet
Page 3 of 4
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
145840
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/16/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Tabor Hills Health Care Fac
1347 Crystal Court
Naperville, IL 60563
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
stated wiping back and then front is not acceptable. V2 (DON) stated when using wet wipes, once a wipe is
dirty, staff can fold it and use the clean part or discard the wipe and get a new one. This practice should be
done to prevent infection. V2 (DON) stated before putting on gloves, staff are expected to wash their hands
or apply hand sanitizer. After providing incontinence care to a resident, staff are expected to take gloves off,
do hand hygiene and put on new gloves. Staff should change gloves from dirty to clean. Clean gloves
should be used after providing incontinent care before touching the resident and clean surfaces. This is
done to prevent infection.
Facility's undated Hand Hygiene Policy stated the following: . Standard: Proper hand hygiene techniques
are used for the prevention of transmission of infectious diseases.Policy: .Facility follows the World Health
Organization's Five Moments of Hand Hygiene model . After touching a resident (skin to skin).Hand
hygiene is performed before donning PPE, and after doffing PPE. Wearing PPE, especially gloves, is not a
substitute for performing hand hygiene. Hand Hygiene must be performed any time a staff member moves
from a dirty site to a clean site.
Facility's undated Perineal Skin Care Policy stated the following: . 9. Cleanse entire perineal area, moving
from front to back, while using a clean area of washcloth for each stroke. 10. Wash entire perineal area with
soapy washcloth or pre-moistened wipe, moving from front to back, while using a clean area of the
washcloth, new pre-moistened wipe, or clean washcloth for each stroke.11. Remove gloves, sanitize hands
and reglove.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145840
If continuation sheet
Page 4 of 4
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Back to topCitations
2 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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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 June 16, 2023 survey of TABOR HILLS HEALTH CARE FAC?
This was a inspection survey of TABOR HILLS HEALTH CARE FAC on June 16, 2023. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at TABOR HILLS HEALTH CARE FAC on June 16, 2023?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordanc..."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.