West Suburban Nursing & Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to address a resident's grievances in a timely manner. This applies to 1 of 3 residents (R1) reviewed for grievances in a sample of 3.

Inspectors wroteBased on the interview and record review, the facility failed to schedule a follow up appointment with a recommended eye specialist for a resident experiencing blurry vision. This applies to 1 of 4 residents (R1) reviewed for appointments in a sample of 5. R1's face sheet showed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including type 1 diabetes with ketoacidosis, chronic kidney disease, lack of coordination, amputation of the left below-knee, anxiety, and depression. R1's MDS (Minimum Data Set) dated 03/15/2026 showed R1's cognition was intact and required supervision to touch-assistance for activities of daily living. On 05/01/2026 at 11:20 AM, R1 said the eye doctor saw him at the facility on 04/13/2026 and referred him to the retinal specialist. R1 said his right eye is blurred, and that when he closes his left eye, all he can see is a blur. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to safely transfer residents to prevent injury. This failure resulted in R2 falling and hitting her head, being admitted to the Intensive Care Unit for days to monitor a possible subarachnoid hemorrhage, and experiencing ongoing dizziness, headache, low back pain, and left hip pain with left leg spasms. This applies to 3 of 6 residents (R2, R6 and R7) reviewed for resident safety in a sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to provide bed hold information to residents who were transferred from the facility to hospitals. This applies to 2 of 3 residents (R1 and R3) reviewed for transfers in a sample of 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe shower chair equipment at the facility to prevent resident injuries. This applies to 3 of 6 residents (R2, R6, R7) reviewed for resident injuries in a sample of 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide toileting assistance to a resident dependent on staff for toileting. This applies to 2 of 5 residents (R1 and R7) reviewed for toileting assistance in a sample of 12.

Inspectors wroteBased on interview and record review, the facility failed to provide transportation services for a resident requiring an appointment with a medical specialist. This applies to 1 of 3 residents (R127) reviewed for social services in a sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were informed in a language and terminology they understood when a third-party vendor enrolled residents in a new Medicare Advantage plan at the facility. This situation resulted in R23 displaying psycho-social symptoms including emotional upset and crying when discussing the changes to his insurance he was not aware of. This applies to 3 of 17 residents (R1, R19, and R23) reviewed for changes to Medicare Advantage plans in the sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to ensure a resident received routine and emergency dental services in a timely manner. This failure resulted in R1 experiencing severe pain and requiring a tooth extraction. This applies to 1 of 3 residents (R1) reviewed for dental services in the sample of 23.

Inspectors wroteBased on interview and record review the failed to have documentation to show a resident's representative could legally make decisions regarding a resident's enrollment in a Medicare Advantage plan when a third-party vendor enrolled residents in a new Medicare Advantage plan at the facility. This applies to 8 of 17 residents (R6, R7, R10, R11, R12, R15, R16, and R18) reviewed for changes to Medicare Advantage plans in the sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the residents' right to be free from exploitation when the facility allowed an outside vendor to come into the facility and make unauthorized changes to cognitively impaired residents' Medicare Advantage plans. This applies to 3 of 17 residents (R5, R9, and R17) reviewed for changes to Medicare Advantage plans in the sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders to obtain an appointment for a neurology consult. This applies to 1 of 3 residents (R19) reviewed for appointments in the sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident requesting to see an audiologist, received assistance to make an appointment to see an audiologist. This applies to 1 of 3 residents (R1) reviewed for audiology services in the sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to assist a resident in discharge planning. This applies to 1 of 3 residents (R1) reviewed for discharge planning in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were supervised in the dining area to prevent a resident to resident incident resulting in a fall for 2 of 4 residents (R3, R4) reviewed for supervision in the sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to protect residents from facility abuse. This applies to 2 of 7 residents (R5 and R7) reviewed for abuse in a sample of 11.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide timely assistance with transfers to bed and showers as scheduled for residents who require staff assistance for transfers and bathing. This applies to 3 of 3 residents (R2, R3 and R8) reviewed for staffing in a sample of 11.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide timely assistance with transfers to bed and showers as scheduled for residents who require staff assistance for transfers and bathing. This applies to 3 of 3 residents (R2, R3 and R8) reviewed for staffing in a sample of 11.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food service pans, trays, and utensils were handled in a way to prevent cross-contamination. This applies to all 183 residents receiving food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired medications and failed to ensure the medication was refrigerated at the correct temperature for 9 of 35 residents (R175, R105, R152, R169, R46, R167, R156, R37 and R29) reviewed for medication storage in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pureed broccoli and pureed ham were free of particles and at a smooth consistency. This applies to 4 of 4 residents (R172, R179, R155, R129) reviewed for pureed diets in the sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from abuse for one of 35 residents (R146) reviewed for abuse in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to clarify orders following a missed appointment for a residents treatment of rheumatoid arthritis. This applies to 1 of 35 residents (R58) reviewed for quality of care in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 35 residents (R118) reviewed for vision aids received a pair of corrective eyeglasses, as prescribed, in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a protective dressing was in place for a resident with stage 3 sacral pressure ulcer. This applies to 1 of 9 residents (R152) reviewed for pressure ulcers in the sample of 35.

Inspectors wrote2. R152's face sheet shows he is a [AGE] year-old male with diagnoses including orthopedic aftercare following surgical amputation, acquired absence of right leg above knee amputee, type 2 diabetes, PVD (peripheral vascular disease), end stage renal disease, dependence on renal dialysis, hypertensive heart disease. On 10/28/24 at 9:49 AM, R152 was observed lying in bed, his oatmeal spilled over his bed sheets. R152 pressed his call light for assistance. R152 said it takes a while for staff to answer his call light. At 9:58 AM, this surveyor looked outside of R152's room, his call light was not alarming. R152 pressed his call light again and the light did not alarm outside of his room. This surveyor pressed the call light from bed 1, it alarmed outside. V17 (Certified Nursing Assistant-CNA) entered the room and was notified R152's call light was not working. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a urinary catheter collection bag and tubing was positioned in a manner to prevent infection for 2 of 5 residents (R30 and R49) reviewed for urinary catheters in the sample of 35.

Inspectors wroteBased on interview and record review the facility failed to ensure the Health Care Worker Registry was checked prior to hire to determine work eligibility for Certified Nursing Assistants (CNAs). This failure has the potential to affect all 183 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident's code status was assessed and accurately documented in the medical record upon readmission to the facility. This applies to 1 of 35 residents (R37) reviewed for advanced directives in the sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure wound treatments were completed and wound interventions were in place for residents with non-pressure wounds and failed to schedule transportation for a residents physician appointments for 3 of 35 (R24) (102) (R116) reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with dysphagia was supervised during meals. The facility also failed to ensure a resident's call light was placed within his reach. This applies to 2 of 35 residents (R57, R28) reviewed for safety and supervision in the sample of 35. 1. On 12/5/23 at 8:48 AM R57 was sitting up in bed in his room at the end of the hall, feeding himself breakfast. R57 had food particles all over his face, chest, and bedding. R57 stated he did not need any help and confirmed he was able to feed himself. No staff was present in R57's room or in the hallway. On 12/6/23 at 9:00 AM R57 was again seen feeding himself breakfast. R57 had scrambled eggs on his chest and chin and some on the floor next to his bed. V12 (CNA) was in another resident's room in the middle of the hall assisting that resident to eat. [...]

Inspectors wroteBased on interview and record review the facility failed to monitor and record weights for a resident at risk for weight loss for 1 of 9 residents (R146) reviewed for weight loss in the sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure unqualified staff did not operate a resident's enteral (tube) feeding pump for 1 of 6 residents (R154) reviewed for tube feeding management in the sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene and change gloves during incontinence care to prevent cross contamination for 1 of 35 residents (R163) reviewed for infection control in the sample of 35.

Inspectors wroteBased on the interview and record review, the facility failed to follow its change in condition policy by not reporting the psychotropic medication adverse effect (drowsiness) to the provider. This applies to 1 of 6 residents reviewed (R1) for psychotropic medications/overdose/adverse effects in a sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat residents in a dignified manner by not sitting down to feed residents for two of 34 residents (R45, R105) reviewed for dignity in the sample of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the call light system was within reach for a resident when needing assist of staff for 1 resident (R42) reviewed for call lights within reach in a sample of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide ADL (Activities of Daily Living) assistance for two of nine residents (R106, R21) who require extensive assistance with ADL care in the sample of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely transfer and reposition a resident for two of six residents (R144, R21) reviewed for safety in the sample of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident at risk for weight loss received double portions as ordered for 1 of 34 residents (R373) reviewed for therapeutic diets in the sample of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene and change gloves in a manner to prevent cross contamination for three of 34 residents (R21, R32, R106) reviewed for infection control in the sample of 34.