Wheaton Village NRSG & RHB CTR

In the surveyor’s words

From the most serious findings on record at Wheaton Village NRSG & RHB CTR, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 12, 2026

  Based on interviews and record review, the facility failed to provide adequate supervision during meals for a resident identified as being at high risk for choking. This failure resulted in a choking episode that required emergency intervention, hospitalization, and placement of a tracheostomy tube to establish and maintain the resident's airway. This applies to 1 of 1 resident (R6) reviewed for a choking incident.The Findings Include:Review of the Electronic Medical Record (EMR) showed that R6, a [AGE] year-old resident, was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF697Nov 2, 2023

  Based on observation, interview and record review, the facility failed to comprehensively assess/evaluate and inform the physician of the residents complaint of pain to help manage existing pain and/or prevent pain. This applies to 2 of 6 residents (R38 and R105) reviewed for pain management in the sample of 29. This failure resulted in R38 verbalizing complaint of worsening pain for two consecutive days (10/30/23 and 10/31/23). R38's frequent pain level of eight, documented in the resident's October 2023 medication flowsheet pain scale. The findings include: 1. […]

• No harm, potential for more than minimal, widespreadF812Nov 1, 2024

  Based on observation, interview, and record review, the facility failed to properly label/date/store/discard items, ensure the dishwasher was functioning, dispose of garbage, and maintain proper levels of chlorine in the dishwasher and quaternary in sanitizer buckets. 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 110 residents. On [DATE] at 11:16 AM, V4 (Dietary Manager) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. […]

• No harm, potential for more than minimal, widespreadF803Nov 2, 2023

  Based on observation, interview, and record review, the facility failed to serve food portion sizes to residents as planned on the facility menu. This applies to all 111 residents receiving oral diets at the facility The Long-Term Care Facility Application for Medicare and Medicaid form, dated 10/31/23, shows the facility census was 111 residents. Facility Order Report by Category, dated 9/30/23 to 10/3023, shows 19 residents had diet orders of mechanical soft or pureed diets and all other residents had diet orders of Regular/No Added Salt/No Added Sweets or Double Portions. […]

• No harm, potential for more than minimal, widespreadF812Nov 2, 2023

  Based on observation, interview, and record review, the facility failed to safely store refrigerated potentially hazardous foods and failed to maintain kitchen equipment, floors, and walls in clean and sanitary conditions. This applies to all residents receiving oral diets in the facility. The findings include: The Long-Term Care Facility Application for Medicare and Medicaid form, dated 10/31/23, shows the facility census was 111 residents. Facility Order Report by Category, dated 9/30/23 to 10/3023, shows 19 residents had diet orders of mechanical soft or pureed diets and all other residents had diet orders of Regular/No Added Salt/No Added Sweets. Facility document, dated 10/30/23, shows the facility had zero residents who had physician orders of NPO (Nothing by Mouth). 1. […]