Cycle 1
Health 2025-08-22 · Fire 2025-08-22
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Wheaton, IL
Wynscape Health & Rehab
5-star overall rating with 5-star inspections with 3 recent health deficiencies
2180 Manchester Road, Wheaton, IL
(630) 665-4330
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
209
Certified beds
Average residents
49
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Justliving Communities
Operator or chain grouping
Approved since
1969-11-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
2 facilities
Chain averages 5 overall / 5 health / 5 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.43
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.24
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.67
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
4.34
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
3.97
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
1.13
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.48
CMS adjusted RN staffing hours
Adjusted total hours
4.51
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,189
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.22% · Performance 21.49% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.57% · Performance 7.96% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.60
Baseline 94.00% · Performance 51.85% · Measure score 5.60 · Achievement 2.89 · Improvement 5.60
Adjusted total nurse staffing
2.88
Baseline 3.63 hours · Performance 3.90 hours · Measure score 2.88 · Achievement 2.88 · Improvement 0.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.52% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 164 · Observed rate 6.1% · Lower 95% interval 6.7% |
| Discharge to community | 67.07% |
50.57%
16.5 pts better
|
Better than the National Rate · Eligible stays 157 · Observed rate 64.97% · Lower 95% interval 59.79% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 91 · Denominator 91 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 91 |
| Discharge self-care score | 40.23% |
53.69%
13.5 pts worse
|
Numerator 35 · Denominator 87 |
| Discharge mobility score | 50.57% |
50.94%
0.4 pts worse
|
Numerator 44 · Denominator 87 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 91 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.97% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 7.55% · Lower 95% interval 4.71% |
| Staff COVID-19 vaccination coverage | 3.45% |
8.2%
4.7 pts worse
|
Numerator 3 · Denominator 87 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 52.87% |
56.45%
3.6 pts worse
|
Numerator 46 · Denominator 87 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 72 · Denominator 72 |
| Resident COVID-19 vaccinations up to date | 44.44% |
25.2%
19.2 pts better
|
Numerator 24 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.0
0.9 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.4 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.3
0.2 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.6%
10.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
50.3%
50.3 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
6.5%
4.4 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.2% · Q4 4.2% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.8% |
18.5%
2.3 pts worse
|
19.6%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 21.7% · Q3 20.8% · Q4 16.7% · 4Q avg 20.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.9% |
22.8%
4.1 pts worse
|
16.7%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · 4Q avg 26.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.0% |
17.2%
2.8 pts worse
|
16.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.3% |
15.0%
10.7 pts better
|
14.9%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 0.0% · Q3 4.5% · Q4 0.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.2% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.8% |
21.3%
17.5 pts better
|
19.8%
16 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 4.1% · Q3 0.0% · Q4 0.0% · 4Q avg 3.8% |
| Percentage of long-stay residents with pressure ulcers | 9.2% |
5.2%
4 pts worse
|
5.1%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 10.8% · Q3 6.2% · Q4 2.9% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
68.8%
30.2 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 100.0% · Q3 100.0% · Q4 99.1% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
14.0%
7.6 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 5.8% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.0% |
63.0%
36 pts better
|
79.7%
19.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
26.2%
2.8 pts better
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 19.4% · Expected 19.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-07 · Fire 2024-06-07
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-07-28 · Fire 2023-07-28
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-01-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-02-09
F · Potential for more than minimal harm
2024-06-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-27
D · Potential for more than minimal harm
2024-02-29
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-03-18
G · Actual harm
2023-11-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-04
E · Potential for more than minimal harm
2023-07-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-28
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-08-16
D · Potential for more than minimal harm
2023-07-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-28
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-08-16
Penalties and ownership
What sits behind the stars
Ownership
New England Life Plan Communities Corp
5% Or Greater Direct Ownership Interest · Organization
Ambler, Douglas
Operational/Managerial Control · Individual
Block, Emily
Operational/Managerial Control · Individual
Bradshaw, Lawrence
Corporate Officer · Individual
Brod, Kathryn
Corporate Director · Individual
Carpenter, Jeffrey
Corporate Director · Individual
Central Dupage Physician Group
Operational/Managerial Control · Organization
Life Care Services LLC
Operational/Managerial Control · Organization
Nelp - Wyndemere LLC
Operational/Managerial Control · Organization
Saad, Phillippe
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Dupage Care Center
Wheaton, IL
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Ahva Care Of Winfield
Winfield, IL
3-star overall rating with 4-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Wheaton Village Nrsg & Rhb Ctr
Wheaton, IL
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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