Dupage Care Center

In the surveyor’s words

From the most serious findings on record at Dupage Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF880Aug 4, 2021

  Based on observation, interview, and record review, the facility failed to implement infection control policies and recommendations from the Center for Disease Control (CDC) regarding staff donning personnel protective equipment (PPE) when entering a Person Under Investigation (PUI) for Covid-19 resident room. The facility failed to have the required PPE for airborne/droplet isolation available outside the resident room to prevent possible exposure to Covid-19, for 4 of 4 residents (R150, R280, R281, and R282) reviewed for transmission based precautions (TBP) in the sample of 35. This failure has the potential to infect high risk residents with Covid-19 and spread the disease of Covid-19 to negative residents. […]

• Actual harm, isolatedF689Jun 20, 2024

  Based on record review and interview, the facility failed to ensure two staff assisted in transferring a resident safely while using a mechanical lift. This failure resulted in R2 falling from the mechanical lift to the floor, sustaining a right tibia fracture and an occipital contusion and transfer to the emergency department. This Applies to 1 of 5 residents (R2) reviewed for falls and accidents in a sample of 9. A care plan initiated on 10/30/2023 showed that R2 needs two staff members to assist with ADLs (Activities of Daily Living), including transfers from bed to wheelchair and vice versa. […]

• Actual harm, isolatedF684May 11, 2021

  Based on interview and record review, the facility failed to immediately assess and provide treatment to a resident with burn injuries after spilling coffee. This failure resulted in R1 (who is paraplegic) having a delay in treatment to his second degree [CONDITION(S)] requiring surgical debridement. This applies to 1 of 4 residents (R1) reviewed for incident/accidents in a sample of 11. Findings include: The review of R1's EHR (Electronic Health Record) shows R1 a [AGE] years old was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MDS (Minimum Data Set) dated 4/21/21 showed R1 required extensive assistance of one staff with bed mobility, transfer, and toilet use. The MDS shows R1 with impairment to one part of the upper extremities. […]

• No harm, potential for more than minimal, widespreadF812Aug 23, 2024

  Based on observation, interview, and record review, the facility failed to properly label/date/seal/store items, remove expired items, and perform hand hygiene while in the facility kitchen. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated [DATE] documents that the total census was 211 residents. On [DATE] at 1:16 PM, V39 (ADON/Assistant Director of Nursing) said there are 6 NPO (Nothing by Mouth) residents; all other residents eat from the facility kitchen. On [DATE] starting at 10:19 AM, V23 (Chef) was observed pureeing lunch items. […]

• No harm, potential for more than minimal, patternF550Sep 11, 2025

  Based on observations, interview and record review, the facility failed to provide residents their meal trays with others seated at the same table. This applies to 6 of 9 residents (R25, R62, R116, R153, R161, and R165) observed for dining in the sample of 35. The findings include: On September 8, 2025, at 12:09 PM during lunch meal observation on the first floor, 1 (one) North dining room, several residents were noted eating their meal when others on the same table had not received their meal tray. R160 was fed by V9 CNA (Certified Nursing Assistant) and had almost finished her meal, whereas R161 and R25 who were seated at the same table and had not received their meal trays. […]