A list of the most recent deficiencies for Complete Care at Wheaton. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-12 | 2021-04-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-12 | 2021-04-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-12 | 2021-04-24 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-03-12 | 2021-04-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-03-12 | 2021-04-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-03-12 | 2021-04-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-03-12 | 2021-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-12 | 2021-04-24 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-03-12 | 2021-04-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-03-12 | 2021-04-24 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-03-12 | 2021-04-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-12 | 2021-04-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-12 | 2021-04-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-03-12 | 2021-04-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-12 | 2021-04-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-12 | 2021-04-24 | Y |
| Meet other general requirements. | Fire Safety | 2021-03-10 | 2021-04-03 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-03-10 | 2021-04-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-03-10 | 2021-04-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-31 | 2019-08-12 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-05-31 | 2019-08-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-05-31 | 2019-08-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-05-31 | 2019-08-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-05-31 | 2019-08-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-05-31 | 2019-08-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-05-31 | 2019-08-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-05-31 | 2019-08-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-05-31 | 2019-08-12 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-05-31 | 2019-08-12 | N |
| Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. | Health | 2019-05-31 | 2019-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-31 | 2019-08-12 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-06-03 | 2019-06-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-03 | 2019-06-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-25 | 2018-06-25 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-05-25 | 2018-06-25 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-05-25 | 2018-06-25 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-05-25 | 2018-06-25 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-05-25 | 2018-06-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-25 | 2018-06-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-25 | 2018-06-25 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-05-25 | 2018-06-25 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-05-25 | 2018-06-25 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-05-25 | 2018-06-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-25 | 2018-06-25 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-05-25 | 2018-06-25 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-05-25 | 2018-06-25 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-05-25 | 2018-06-25 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2018-05-25 | 2018-06-25 | N |
| 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. | Health | 2018-05-25 | 2018-06-25 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-05-25 | 2018-06-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-25 | 2018-06-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-06-04 | Not Fixed | N |
