West Suburban Medical Ctr

Based on interview and record review, the facility failed to develop and implement an adequate plan for relocation and failed to provide written notification at least 60 days prior to closure to residents, resident representatives, and appropriate parties for eight of eight residents reviewed for facility closure (R1-R8).The facility closed abruptly without an approved closure plan or required notifications, resulting in uncoordinated and unsafe resident discharges.This deficient practice placed residents at risk for unsafe transfers, lack of continuity of care, and increased emotional distress. Findings include:On 3/31/26 at 2:41PM, V6 (President) said they notified the State Agency on Wednesday (3/25/26) via email that they will need to close the facility by Friday (3/27/26) due to financial concerns. V6 said they did not notify resident or representatives with any written documentation. V6 said they were updating State Agency daily on the discharge status of all residents throughout the week. V6 said case management verbally informed all residents at the facility. On 4/2/26 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that it was safe for one resident (R3) to self-administer medications and did not follow doctors order and facility policy prior to leaving inhaler medication at bedside. This failure affected one resident in a total sample of 15 residents. Findings include: R3 is a [AGE] year-old resident admitted to the facility on [DATE], with diagnoses including but not limited to Chronic obstructive pulmonary disease. Order dated 09/24/2024 documents: please assess patient for appropriateness of medications at bedside, if appropriate allow designated medications at bedside. Per protocol. Order dated 09/24/2024 documents: fluticasone-vilanterol 100mcg-25mcg/inhaler inhalation powder. Inhale 1 powder inhalation daily. Care plan dated 09/24/2024 documents: Deficient knowledge: medication related to cognitive impairment or lack of information for oral medications. Resident/Caregiver/support system self-administration assessment tool subacute…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop a person-centered care plan and interventions that meet the needs of a resident receiving dialysis treatment. This deficiency affects one (R65) of one resident in a sample of 15 reviewed for dialysis. Findings include: R65 is a [AGE] year old, female, admitted in the unit on 09/27/24, with diagnosis of End Stage Renal Disease. R65 goes to an outpatient dialysis center for hemodialysis three times a week. On 10/08/24 at 2:40 PM, R65 was observed in her room, sitting in bedside chair. R65 is alert, oriented, and verbal. R65 was asked regarding dialysis treatment. R65 replied, I go to dialysis Monday-Wednesday-Friday around 1-2 PM, for 3 and a half hours treatment. I go to outpatient dialysis center. R65's care plan read: Impaired fluid balance related to renal disease: Resident to go to Outpatient dialysis after scheduled therapy Hemodialysis - Monday, Wednesday, Friday schedule; fluid restriction. There were no other specific interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow its policy related to ensuring flowsheets and dialysis communication forms are placed in chart on a resident on dialysis treatment. This deficiency affects one (R65) of one resident in a sample of 15 reviewed for dialysis. Findings include: R65 is a [AGE] year-old, female, admitted in the skilled unit on 09/27/2,4 with diagnosis of End Stage Renal Disease. R65 goes to an outpatient dialysis center for hemodialysis three times a week. On 10/08/24 at 2:40 PM, R65 was observed in her room, sitting in bedside chair. R65 is alert, oriented, and verbal. R65 was asked regarding dialysis treatment. R65 replied, I go to dialysis Monday-Wednesday-Friday around 1-2 PM, for 3 and a half hours treatment. I go to outpatient dialysis center. No, I don't bring anything to the dialysis center. I leave here without anything and back here without anything. No forms or papers that I need to bring to or bring back from. On 10/08/24 at 1:10 PM, V2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow infection control policies regarding 1. hand hygiene while passing meal trays 2. Droplet Plus isolation precautions, and 3. Legionella (water contamination) prevention; and failed to have a policy which includes COVID prevention. These failures have the potential to affect all seven residents residing on the subacute rehabilitation unit. Findings include: 1. On 9/25/23 and 9/26/23, lunch was observed on the unit. Dietary staff were observed passing meals to residents in their rooms, and no hand hygiene was observed at any time during this process. While passing trays, items were manipulated on several resident's bedside tables in order to make room for the meals. Facility Hand Hygiene states; If hands are not visibly soiled, use an alcohol based hand-rub (ABHR) or wash hands with soap and water for routine decontamination in the following clinical situations: 1.5 After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. On 9/27/23 at 1:30PM, V5, Chief…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to maintain professional nursing standards of practice by not properly performing double nurse medication verification, in accordance with facility protocol, while administering cancer related medication and by preparing medications in advance of administering them. These failures applied to two (R6, R171) of eight residents reviewed for medication administration. Findings include: 1. On 9/27/23 at 9:45AM, V18, RN (Registered Nurse), was observed administering anastrozole 1 milligram tablet to R6. Upon signing the medication in the mobile scanner, R18 said the scanner prompted that a second nurse verification was needed to complete the administration, because the medication was a cancer related drug. V18 was followed on the unit until the other nurse on duty (V17) was located. V17 and V18 stood at the nurse's station and verified the medication in the mobile scanner. Shortly after this interaction, at 10:30AM, V17, RN, was interviewed about the facility's procedure requiring two nurse verification and said, The verification…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow their policy and procedures for providing assistance with activities of daily living by not ensuring resident nails were clean and cut, not ensuring a dependent resident's environment was clean and that he was was free of body odors, and failed to ensure a resident was raised out of bed for daily activities. These failures applied to five of five residents (R6, R7, R9, R18, and R68) reviewed for activities of daily living. Findings include: 1. On 09/26/23 at 11:27 AM, R6 stated her physician told her the podiatrist comes to the facility every 10 days. R6 stated she wanted her toenails cut. R6 had long unclean fingernails. R6 stated no one offered to cut her nails. R6's current subacute rehabilitation conference sheet documents she is dependent on and requires assistance with activities of daily living. 2. On 09/25/23 at 1:11 AM, R7 had a sock on his left hand, right hand was heavily contracted, his toe nails were long, thick, and yellow, R7 had a strong body odor, and R7's skin was red on his right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their fall prevention policy and procedures by not ensuring a chair alarm intervention was in place as required for a resident at risk for falls resulting in an unwitnessed fall. This failure applied to one of one resident (R9) reviewed for accidents/falls. Findings include: R9 is an [AGE] year-old female with a diagnosis history of Partial Paralysis due to Stroke, who was admitted to the facility 09/08/2023. On 09/25/23 at 1:28 PM, R9 was sitting in her room in her wheelchair. V15 (Family) was visiting R9. V15 stated R9 had a fall last Tuesday or so, at around 3PM. V15 stated the facility has known R9 is a fall risk since she was admitted and has provided her with a chair alarm since her admission. V15 stated during the incident, R9 was sleep in her chair. V15 stated R9 moves around a lot because in her mind she can still move. V15 stated R9 fell on her bottom. R9's physician progress note, dated 09/19/2023, documents per V15 (Family Member),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were six medication errors out of 25 medication opportunities, resulting in a 24% medication error rate. This failure affected two of five residents observed during medication administration. Findings include: On 09/26/23 at 12:25PM, V7, RN (Registered Nurse), was observed for insulin administration for R9. V7 said the blood glucose was taken around 11:30AM, prior to lunch. V7 could not provide the exact blood glucose result, but said according to the result, R9 should have gotten some insulin according to a sliding scale as ordered by the Physician. V7 said before insulin was given to R9, she needed to be monitored for how much food was eaten. Later at 12:45PM, V7 said since R9 only ate 25% of her meal, she would be withholding the insulin, and this did not require notification of any provider, because she knows the blood sugar will decrease if given. According to results review in the electronic health record, blood glucose was not documented as…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow their vaccine policy and procedures for flu and pneumonia vaccination by not ensuring a vaccine eligible long term care resident was offered and educated on or receiving a flu or pneumonia vaccination. This failure applied to one (R7) of five residents reviewed for vaccinations. Findings include: R7 is a [AGE] year-old male, with a diagnoses history of Coronary Vascular Accident, Aphasia, Seizures, and Depression who has been residing at the facility for the past 5 years per nursing. On 09/27/23 at 12:40 PM, V16 (Infection Preventionist) stated she began working on the unit as the Infection Preventionist at the end of July, and has been working in that role a little over 2 months. V16 stated it wasn't documented R7 received any flu vaccines. V16 stated she educates the nurses on vaccines, and they handle ensuring residents are offered and educated on vaccines. V16 stated if the patient wants the vaccines, they would sign a consent, or if they…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to follow their COVID-19 policy and procedures for COVID vaccination, by not ensuring a vaccine eligible long term care resident was offered and educated on or received a COVID vaccination. This failure applied to one (R7) of five residents reviewed for COVID vaccination. Findings include: R7 is a [AGE] year-old male with a diagnoses history of Coronary Vascular Accident, Aphasia, Seizures, and Depression, who has been residing at the facility for the past 5 years, per nursing. On 09/27/23 at 12:40 PM, V16 (Infection Preventionist) stated she began working on the unit as the Infection Preventionist at the end of July, and has been working in that role a little over 2 months. V16 stated R7 received a COVID 19 vaccine 03/16/2021, which is likely an initial dose, based on when the vaccines became available in December 2020. V16 stated she is unable to find any other COVID vaccine information for R7. V16 stated the facility does not have a COVID policy. V16…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to have an active order for oxygen administration for one resident (R9) prior to administration; failed to follow facility policy and accepted standards of care related to medication administration by not pulling residents' medications at the time of administration; and failed to safely secure controlled class drug medications. These failures apply to nine of nine (R8, R9, R10, R11, R109, R158, R159, R161, R209) residents reviewed for medication administration and storage, and has the potential to affect all 22 residents currently on the unit. Findings include: On 08/23/2022 at 10:03am, observed a closed binder laid on top of V3's (Registered Nurse) mobile nursing cart. V3 (Registered Nurse) took a small cup of packaged medications from the top of her mobile cart, walked away from cart, and headed down the opposite end of hallway. Mobile cart with binder on top of cart was left unsecured, plugged into an outlet near opposite end of hallway, and not under constant surveillance by V3. At 10:07am, V3 (Registered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow their policy to ensure residents had Advanced Directives in place. This failure applied to six (R6, R7, R108, R109, R110, and R159) of six residents reviewed for advanced directives. Findings include: R159's record review indicated no Advanced Directive in place. Noted resident to have an admission date of 08/19/2022. R7's record review indicated no Advanced Directive in place. Noted resident to have an admission date of 10/23/2020. On 08/23/22 at 2:17pm, the facility provided no documentation showing R6 was given a copy of the state law on Advanced Directives, or has Advanced Directives in place. On 08/23/22 at 2:17pm, the facility provided documentation R108 was given a copy of the state law on Advanced Directives in 08/2022. Did not provide documentation showing R108 has Advanced Directives in place. On 08/23/22 at 2:17pm, the facility provided no documentation showing R109 was given a copy of the state law on Advanced Directives, or has Advanced Directives in place. On 08/23/22 at 2:17pm, the facility provided…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.