West Suburban Medical CTR

In the surveyor’s words

From the most serious findings on record at West Suburban Medical CTR, in the surveyor’s own words.

• Actual harm, isolatedF627Apr 2, 2026

  Based on observation, interview, and record review, the facility failed to provide written notice of transfer/discharge to the resident and/or resident representative, including the reason, effective date, and location of transfer, for one of eight residents reviewed for discharge (R2).This failure resulted in R2, who has aphasia and resided on the same unit for over six years, being transferred to a local hospital emergency room without prior notification or opportunity for preparation.This deficient practice has the potential to cause R2 to experience fear, anxiety, and confusion related to unexpected transfer.Findings includeR2's face sheet documents an admission date 3/25/24. Under insurance it documents self-pay. No contacts listed. […]

• No harm, potential for more than minimal, widespreadF845Apr 2, 2026

  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. […]

• No harm, potential for more than minimal, widespreadF658Aug 25, 2022

  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. […]

• No harm, potential for more than minimal, widespreadF761Jun 4, 2021

  Based on observation, interview and record review, the facility failed to follow their policy for handling outdated Intravenous Fluid (IVF) supplies by failuring to remove expired IVF from the unit stock. This has the potential to affect all 18 residents residing in the facility. Findings include: On [DATE] at 10:47am, checked Medication room with V3 Registerd Nurse. Observed four IVF of [MEDICATION(S)] with 0.9% Normal Saline 1 liter with an expiration date of [DATE]. V3 stated pharmacy usually checks the IVFs. She only checks the IVF stock if she has to use it. V3 added, expired IVF should be reported to pharmacy. She was not aware of expired IVF in the medication room. […]

• No harm, potential for more than minimal, patternF880Sep 28, 2023

  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. […]