West Chicago Living and Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to provide pain medication to a resident in pain per physician orders. This applies to 1 of 3 residents (R4) reviewed for pain in a sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to keep R1 free from abuse. This applies to 1 of 3 (R1) residents reviewed for abuse.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were able to exercise their rights to retain personal items and failed to provide justification as to why those personal items were confiscated. This applies to 2 of 3 residents (R4 and R5) reviewed for resident rights in the sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to prevent the abuse of a facility resident. This applies to 1 of 4 residents (R7) reviewed for abuse in a sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to report resident allegations of abuse. This applies to 1 of 4 residents (R1) reviewed for abuse in the sample of 15.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide cool and comfortable room environments. This applies to 5 of 5 residents (R1, R2, R3, R5 and R17) reviewed for comfortable room environments in a sample of 17.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's privacy. This applies to 1 of 4 residents (R4) reviewed for privacy in a sample of 4.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the dishes are sanitized during dish washing procedure and failed to ensure that dented cans were separated from the in-use cans. This applies to all 88 residents that received foods prepared in the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their water management program for Legionella. This applies to all 88 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for antibiotic stewardship and have a standardized tool to identify infections in residents. This applies to all 88 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a substitute meal option with similar nutritional content as the main entrée for the lunch meal. This applies to 6 of 6 residents (R2, R10, R23, R34, R52, and R68) reviewed for dining in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to follow physician's order for ID (Infectious Disease) consultation. This applies to 1 of 1 resident (R59) reviewed for physician orders in the sample of 18.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident did not receive an unnecessary medication. This applies to 1 of 2 residents (R5) reviewed for antibiotic use in the sample of 18.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ground baked chicken to residents on mechanical soft diet. This applies to 2 of 3 residents (R1 and R79) reviewed mechanical soft diets in the sample of 18.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect R2's right to be free of abuse from another resident. This applies to 1 of 4 residents (R2) reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to have a system or any policies in place to identify services needed to meet the intimacy rights of mentally ill female residents of child-bearing age. This failure resulted in one female resident (R1) becoming pregnant by another resident and experiencing psycho-social harm when she was hospitalized and per the hospital Psychiatrist, is now in a catastrophic situation. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 6/21/2024 when R1 told staff that she had an interest in R2 (a male peer) and refused condoms and other forms of birth control. This applies to 1 of 10 residents (R1) reviewed for intimacy rights and has the potential to affect 6 other female residents (R12-R17) of child-bearing age living in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse. This applies to 1 of 3 residents (R9) reviewed for resident-to-resident physical abuse.

Inspectors wroteBased on interview and record review, the facility failed to have physician documentation to show the specific resident needs the facility could not meet for residents who were involuntarily discharged , and the efforts the facility made to meet those needs for a resident. The facility also failed to re-evaluate if a resident was able to be readmitted at the time of discharge from the hospital. This applies to 2 of 5 residents (R1 and R7) reviewed for discharges.

Inspectors wroteBased on interview and record review, the facility failed to inform and provide a resident with a notification of involuntary discharge. This applies to 1 of 5 residents (R1) reviewed for discharges.

Inspectors wroteBased on interview and record review, the facility failed to supervise a pregnant schizophrenic resident (R1) with a history of and known risk for elopement. This applies to 1 of 4 residents (R1) reviewed for safety.

Inspectors wroteBased on interview and record review, the facility failed to relinquish representative payee status back to a resident who requested to begin managing her own funds. This applies to 1 of 3 residents (R1) reviewed for resident rights in a sample of 3.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to use appropriate infection control practices for 3 COVID-19 positive residents (R15, R54, and R60), failed to have a system in place to monitor the measures in place to prevent the growth of Legionella and other opportunistic waterborne pathogens in the building water systems, and failed to store soiled linen properly. These failures have the potential to affect all residents at the facility. At the time of this survey, the facility's CMS 671 form (Long-Term Care Facility Application for Medicare and Medicaid) showed a census of 85 residents. 1. On 07/09/24 at 11:44 AM outside of R15's room there was a Stop Droplet plus precautions sign on R15's door and there were PPE (personal protective equipment) in the drawers outside her door. There was no eye protection inside the drawers as the sign showed needing. [...]

Inspectors wroteBased on observations interviews and record reviews the facility failed to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. This has the potential to affect all residents at the facility. At the time of this survey, the facility's CMS 671 form (Long-Term Care Facility Application for Medicare and Medicaid) showed a census of 85 residents.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide a safe comfortable and homelike environment for 3 residents (R8, R31, and R76) in a sample of 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to invite residents to their quarterly care plan meetings and have an active care plan for a medical diagnosis. This applies to 6 of 6 residents (R8, R25, R64, R65, R76, and R83) reviewed for care plans in the sample of 21.

Inspectors wroteBased on observation, interview and record review the facility failed to waste compromised medications and label a medication with the opened on and use by date. This applies to medications for 4 residents (R6, R29, R36 and R74) in the facility of 85 residents.

Inspectors wroteBased on interview and record review the facility failed to enter a physician's order that reflects the resident chosen code status of DNR (Do Not Resuscitate). This applies to 1 of 10 residents (R10) reviewed for advanced directives in a sample size of 21.

Inspectors wroteBased on interview and record review, the facility failed to make an appointment for a resident experiencing urinary urgency symptoms. This applies to 1 of 1 resident (R83) reviewed for quality of care in a sample of 21.

Inspectors wroteBased on observation and interview the facility failed to provide foot care for one resident R51 in a sample of 21 residents.

Inspectors wroteBased on interview and record review the facility failed to provide physician visits to 1 resident (R6) in a sample of 21 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide Alcoholics Anonymous meetings for a resident with alcohol dependence and failed to provide scheduled one on one meetings with a resident's therapist as ordered. This applies to 2 of 2 residents (R83 and R52) reviewed for behavioral health services in a sample of 21.

Inspectors wroteBased on observation and interviews, the facility failed to post the daily staffing. This affects all 85 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to follow its policy to administer scheduled medications as ordered. This applies to 1 of 3 residents (R1) reviewed for medication administration services and quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure maintenance and housekeeping services were provided to ensure repair of broken furniture and light fixtures, repair of floor tiles in the resident dining area and cleaning of the walls in hallways and resident rooms. This applies to all 90 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical abuse from another resident. This applies to 1 of 3 residents (R1) reviewed for physical abuse in a sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services when it failed to administer a resident's monthly injection for 23 days after it was dispensed after a one-day delay in delivery. This applies to 1 of 4 residents (R4) reviewed for medications in a sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's (R1) right to be free from sexual abuse from another resident (R2) with known history of sexual behaviors. This failure resulted in R1 being sexually abused by R2. This applies to 1 of 6 residents (R1) reviewed for sexual abuse in the sample of 6. This resulted in Immediate Jeopardy. The Immediate Jeopardy began on January 5, 2024, when the incident between R1 and R2 occured. The facility failed to use increased interventions of supervision when they identified R2 as hypersexual to ensure R1's safety. This failure resulted in R1 being sexually abused. V1 (Administrator), V2 (Director of Nursing), V3 (Assistant Director of Nursing) and V13 (Human Resource) were notified of the Immediate Jeopardy on January 23, 2024, at 4:27 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to review and revise a resident's (R2) plan of care, after the resident exhibited hypersexual behaviors. This failure resulted in R2 sexually abusing R1 on January 5, 2024, resulting in R2's arrest by the local police and charged with two counts of domestic battery. This applies to 1 of 4 residents (R2) reviewed for behavioral care plans in the sample of 6.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide a safe and sanitary environment for residents. This applies to 41 residents (R1-R3, R9-R34, R35-R46) reviewed for a sanitary environment.

Inspectors wroteBased on interview and record review the facility failed to implement the abuse policy by not doing a resident criminal background check within 24 hours of admission for 1 of 3 residents (R1) reviewed for abuse in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a multi-dose vial of tuberculin solution was labeled with an open date. This failure has the potential to affect all 93 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to have an assessment of the water system to identify where waterborne pathogens could grow and spread. This failure applies to all 93 residents in the facility reviewed for infection control. The facility also failed to ensure staff changed gloves and performed hand hygiene and failed to ensure a resident washed their hands after toileting to prevent cross contamination for 1 of 19 residents (R2) reviewed for infection control in a sample of 19.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a homelike environment by having gray duct tape securing the linoleum flooring on the B wing for 3 residents (R23, R63, R69) in a sample of 19 residents and 1 unsampled resident (R12) reviewed for homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment orders were carried out for 1 of 19 residents (R82) reviewed for quality of care in the sample of 19.