West Suburban Nursing & Rehab Center

F 0551 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

in accordance with the revised requirements. Plans are expected to use the updated model enrollment form for enrollment requests received on or after January 1, 2025. Organizations may, at their option, implement any new requirement consistent with this guidance prior to the required implementation date. 10.1 Definitions: The following definitions relate to topics addressed in this guidance. Authorized Representative - An individual who is legally able to act on behalf of the beneficiary, as allowed by applicable state laws, in order to execute an enrollment or disenrollment request. A representative may be appointed by the individual (consistent with the standards under applicable law) or may be authorized under law without a specific or explicit appointment. 50 - Enrollment processing: The following should also be considered when processing an enrollment: .E. Signature and Date - The individual must sign the enrollment form or complete the enrollment request mechanism. If the individual is unable to do so, an authorized representative must sign the enrollment form or complete the enrollment request mechanism. If an authorized representative enrolls an individual, the authorized representative must attest to having the authority under State law to do so, and confirm that a copy of the proof of court-appointed legal guardian, durable power of attorney, or proof of other authorization required by State law that empowers the individual to effectuate an enrollment request on behalf of the applicant is available and can be presented upon request by the plan or CMS. On September 4, 2025 at 11:57 AM, V1 (Administrator) said the facility does not have a policy regarding obtaining consents. V1 provided the undated Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities brochure provided to every resident upon admission. The brochure shows, Your rights to participate in your own care: You have a right to complete information about your medical condition and treatment in a language that you can understand.

Your rights as a citizen and a facility resident: If a court of law has appointed a legal guardian for you, your guardian may exercise your rights for you. If you have named an agent under a Power of Attorney for Health Care, our agent may exercise your rights for you.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Suburban Nursing & Rehab Center

311 Edgewater Drive Bloomingdale, IL 60108

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0552 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Special Needs Plan). The Enrollment Form continues to show Resident R19's name, date of birth , gender, permanent address as the facility, and Resident R19's Medicare Number. Resident R19's signature is typed in a cursive font as

the signature on the Enrollment Form acknowledging Resident R19 read and understood the Enrollment Form. The Enrollment Form continues to show V15 (Agent) as the individual helping enrollee with completing this form only. On September 4, 2025 at 12:15 PM, V9 (Son of Resident R19) said, I did not know [Resident R19's] Medicare Advantage plan was changed. No one ever called me. I have Power of Attorney for [Resident R19]. I do not trust that my father could make a decision for changing his health plan. English is not his first language, and I would not be confident he understood what he was signing. He speaks Polish.The facility does not have the documentation to show Resident R19 has a Power of Attorney or Healthcare Surrogate form, or that V9 (Son of Resident R19) was contacted regarding Resident R19's Medicare Advantage plan. 3. On September 9, 2025, at 1052 AM, Resident R23 was sitting in a wheelchair in the hallway outside of his room. Resident R23 said, I signed some papers the other day, but

they didn't tell me it meant I was getting a new doctor and a new nurse practitioner. I didn't understand it. I want to go back, but I have to wait. They lied to us. Resident R23 became tearful and started crying out loud, saying

he has many health problems including Parkinson's disease and depression and this insurance change was causing him to feel sadder and more depressed. The EMR shows Resident R23 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including, degenerative disease of the basal ganglia, Parkinsonism, Type 2 diabetes, anxiety disorder, depression, repeated falls, abnormalities of gait and mobility, and Parkinson's disease. Resident R23's MDS dated [DATE REDACTED] shows Resident R23 is cognitively intact. Resident R23's Medicare Advantage Plan Enrollment Form dated August 19, 2025 shows, Select the plan you want to join: The box is checked next to: [outside insurance vendor] (HMO I-SNP). The Enrollment Form continues to show Resident R23's name, date of birth , gender, permanent address as the facility, and Resident R23's Medicare Number. Resident R23's signature is typed in a cursive font as the signature on the Enrollment Form acknowledging Resident R23 read and understood the Enrollment Form. The Enrollment Form continues to show V15 (Agent) as the individual helping enrollee with completing this form only. On September 3, 2025 at 9:41 AM, Resident R23 was sitting in the hallway in his wheelchair. Resident R23 said he was approached by V3 (SSD) to ask if Resident R23 wanted to hear a presentation regarding insurance. Resident R23 said he would gladly hear about it, but decided not to do it because he didn't like

the sound of it. Resident R23 said he has had the same insurance company his whole life and he did not want to change from that. Resident R23 said, Then when I said no, [V3] came back to my room and was asking me why I didn't want the new insurance. I felt like he was pressuring me to change to their preferred insurance, which seemed unethical and makes me not trust [V3] anymore. Resident R23's MDS dated [DATE REDACTED] shows Resident R23 is cognitively intact. On September 4, 2025 at 11:57 AM, V1 (Administrator) said the facility does not have a policy regarding obtaining consents. V1 provided the undated Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities brochure provided to every resident upon admission. The brochure shows, Your rights to participate in your own care: You have a right to complete information about your medical condition and treatment in a language that you can understand.

Your rights as a citizen and a facility resident: If a court of law has appointed a legal guardian for you, your guardian may exercise your rights for you. If you have named an agent under a Power of Attorney for Health Care, our agent may exercise your rights for you.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Suburban Nursing & Rehab Center

311 Edgewater Drive Bloomingdale, IL 60108

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

then the resident is considered to be a self-signer and that information cannot be validated against any medical record until the insurance plan is in place. V18 continued to say a sales agent would not know if a resident had any cognitive deficit and relies solely on the facility to ensure the residents the insurance agent is talking to are cognitively intact and able to understand and sign the paperwork. V18 said, there are financial incentives, and the outside insurance vendor does quality bonuses. We reward quality care. When [outside insurance vendor] contracts with anyone, there are metrics of quality. For example, if the [outside insurance vendor's] member (resident) has hypertension, and it is controlled in the building over time; I cannot speak of a dollar amount but is a shared savings program. The money does not come back to the residents. The money is dispersed to the ownership. On September 9, 2025 at 4:43 PM, V1 (Administrator) said, The [outside insurance vendor] asked us for a list of who is conversational, and we gave it to them. We weren't there to hear what they presented to the residents or who signed what. The facility's Abuse Prevention Program Policy revised 3/1/21 shows: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The following Procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party.VII. Prevention: The facility desires to prevent abuse, neglect, exploitation, misappropriation, and a crime against a resident by establishing a resident-sensitive and resident-secure environment. This will be accomplished by a comprehensive Quality Assurance Performance Improvement approach. As part of the social history evaluation and MDS assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Suburban Nursing & Rehab Center

311 Edgewater Drive Bloomingdale, IL 60108

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 (Resident R19) reviewed for appointments in the sample of 23. The findings include:On September 9, 2025 at 10:35 AM, Resident R19 was lying in bed in his room. Resident R19 said he went to see his neurologist about leg weakness a few months ago and the physician said Resident R19 should get a second opinion from another neurologist. Resident R19 said he is still waiting to see the neurologist and facility staff said it could be as long as February 2026 before the facility staff can find Resident R19 an appointment. Resident R19 said, Maybe I'll just give up and not go by the time they find me someone to go to. I can't wait this long. My legs won't work by that time. The EMR (Electronic Medical Record) shows Resident R19 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including, mononeuropathy of left lower limb, PVD (Peripheral Vascular Disease), hypertension, heart disease, spleen infarction, depression, anemia, spinal stenosis of the cervical region, post-laminectomy syndrome, low back pain, thoracic aortic aneurysm, anxiety disorder, adjustment disorder, and presence of prosthetic heart valve. Resident R19's MDS (Minimum Data Set) dated July 8, 2025 shows Resident R19 is cognitively intact, requires setup assistance with eating and lower body dressing, supervision with oral and personal hygiene, substantial/maximal assistance with showering and personal hygiene, and is dependent on facility staff for all other ADLs (Activities of Daily Living). Resident R19 is frequently incontinent of urine, and always incontinent of stool. The EMR shows the following order for Resident R19 dated June 18, 2025 at 12:13 PM and signed by V14 (Physician): Order summary: Neurologist order: 2nd opinion for spine consultation at tertiary care center. On September 4, 2025 at 12:57 PM, V8 (Scheduler) demonstrated how

she makes appointments for residents and sets up transportation to and from the appointments. V8 opened

the facility's appointment calendar on the computer for the period of September 4, 2025 through February 28, 2026. V8 was unable to show a scheduled appointment for Resident R19 to see the neurologist. Resident R19 did not have

a system in place to keep track of resident appointments, and went through many papers in her office, including sticky notes, scratch paper, and binders full of notebook paper, and was unable to find the appointment scheduled for Resident R19. V8 said, Maybe the paper is in my backpack out in my car. The facility's policy dated 5/14/23 shows: Guidelines for Resident Appointments Outside the Facility shows: Purpose: While the facility has in-house physician visits to residents per policy and State/Federal regulatory mandates, there are times when the resident may need to be seen outside of the facility by a provider that does not physically travel to the nursing home. Procedure: Procedure: Upon receiving a physician's order for a situation or event that will require the resident to need transport services, the nurse who processes the order will notify the staff member who coordinates transport orders so that appropriate transport can be scheduled. The transport will be secured according to medical necessity-such as a medical emergency or

an acutely ill resident requiring an ambulance, while a routine non-emergency situation could require the transport services of a local or facility provider. The nursing staff will be aware of the appointments that require residents to be transported from the facility. There will be a calendar/log to inform them of this.

Residents who will be transporting on a given day/date will have their personal care done and their medications given in accordance with the time they will be away from the facility for the appointment.

Dialysis residents will have a meal sent with them as indicated. If for any reason an ordered/scheduled appointment is missed, it will be re-scheduled as appropriate, unless there has been some change, and the order is cancelled. All parties to include the ordering physician, transport provider, resident and resident's responsible party/POA (Power of Attorney) will be notified of the re-scheduling or the cancellation of an appointment.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Suburban Nursing & Rehab Center

311 Edgewater Drive Bloomingdale, IL 60108

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685

Assist a resident in gaining access to vision and hearing services.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 (Resident R1) reviewed for audiology services in the sample of 23. The findings include:On September 2, 2025, at 12:36 PM, Resident R1 was sitting in his room. Resident R1 said he has been having a difficult time hearing and has been asking to see an audiologist for a long time. Resident R1 continued to say he would be happy to go out in the community if he could see an audiologist sooner, but facility staff have not assisted him with making an appointment to see

an audiologist. The EMR (Electronic Medical Record) shows Resident R1 was admitted to the facility on [DATE REDACTED] with multiple diagnoses including, COPD (Chronic Obstructive Pulmonary Disease), dementia, generalized anxiety disorder, hypertension, anemia, insomnia, history of skin cancer, major depressive disorder, epilepsy, cognitive communication deficit, lack of coordination, leukemia, toxic encephalopathy, urine retention, bipolar disorder, and psychosis. Resident R1's MDS (Minimum Data Set) dated June 19, 2025 shows Resident R1 has moderate cognitive impairment, is independent with bed mobility, requires setup assistance with eating, and supervision with all other ADLs (Activities of Daily Living). Resident R1 is always continent of bowel and bladder.

The facility's Concern Form dated May 16, 2025 completed by V7 (Ombudsman) shows multiple concerns including, Needs to be seen by an audiologist. Has been asking since January 2025 and hasn't seen one.

On September 8, 2025, at 3:37 PM, V7 (Ombudsman) said she completed the grievance form for Resident R1 on May 16, 2025 but did not submit Resident R1's grievances to V1 (Administrator) until May 19, 2025 at 8:45 AM via email. V7 provided documentation to show V1 received her grievance on behalf of Resident R1 on May 19, 2025 at 11:25 AM. V7 continued to say she spoke to V11 (RN-Registered Nurse) regarding referrals to the audiologist in mid-June 2025. On June 16, 2025 at 1:59 PM, V11 (RN) documented, Writer called [V12] (Insurance Case Manager) to fax doctor list for urologist, eye doctor, dental, audiologist doctor. He said he will fax the doctor list for urologist, eye doctor, dental, audiologist doctor. Will f/u (Follow up). Writer provided

the fax number for the facility. On September 9, 2025 at 11:05 AM, V11 (RN) said, I notified the social worker back in June that [Resident R1] needed to see an audiologist. I used the communication tool in our EMR to communicate with him. I can tell you the exact date I communicated the request to see the dentist and audiologist to [V5] (SSD-Social Services Director). It was June 16, 2025. I can tell by looking at my documentation in the medical record. V11 continued to show the process of using the communication feature in the EMR and also showed her nursing progress note dated June 16, 2025. The facility does not have documentation to show facility staff followed up on the list of providers from Resident R1's insurance company.

As of September 2, 2025, the facility did not have documentation to show Resident R1 was assisted with making an appointment to see an audiologist or had seen an audiologist.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Suburban Nursing & Rehab Center

311 Edgewater Drive Bloomingdale, IL 60108

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

26, 2024, shows V13 (Dentist) documented Resident R1 received a dental exam and needed extractions of teeth number 8 and 9, asap (as soon as possible). The facility does not have documentation to show Resident R1 was seen by the dentist following the dental exam on April 26, 2024, or that Resident R1 refused to have the two teeth extracted as recommended by V13. The Dental Consult form dated August 27, 2025 shows Resident R1 received a dental exam by V13, and Resident R1 had red, puffy tissue, lost a filling in tooth number 19, and had continuing pain.

V13 ordered an antibiotic for Resident R1 and recommended an extraction of the tooth at the next visit. The Dental Consult form dated August 30, 2025 shows Resident R1 had an extraction of tooth number 19, and recommended extractions of two teeth, number 9 and 10 at the next visit. On September 9, 2025 at 9:28 AM, V13 (Dentist) provided a timeline of his dental visits with Resident R1, beginning on August 27, 2025. V13 said he visits the facility weekly. V13 said he sees residents routinely who are signed up for the dental program, and will see any resident in the facility, upon request, including residents who are not enrolled in the dental program. V13 said the last time he examined Resident R1 prior to August 27, 2025 was on April 26, 2024, when V13 recommended extraction of two different teeth (8 and 9). V13 said, when he examined Resident R1 on August 27, 2025, Resident R1 had a lot of pain, swelling, and infection present due to a lost filling in tooth number 19. V13 was not able to extract the tooth on August 27, 2025 due to the swelling and infection and prescribed antibiotics with the plan to return to the facility in a few days to extract the tooth. V13 said he returned on August 30, 2025 to extract tooth number 19, and returned to the facility on August 31, 2025 for a post-operative follow-up and found Resident R1 was experiencing a condition called dry socket. V13 said he again returned to the facility on September 2, and 7, 2025 due to Resident R1 experiencing pain, and again on September 8, 2025 due to pain. V13 said if Resident R1 had received prompt dental care when he voiced concerns regarding the lost filling, the tooth pain and infectious process Resident R1 experienced could have been prevented. The facility's undated policy entitled Dental Services shows: Policy: it is the policy of the facility to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This includes meeting any need for dental/denture care to include routine as well as emergency indicated services. Procedure: 1. A licensed nurse will conduct a comprehensive, accurate, standardized assessment of each resident's functional capacity to include dental status. Note: Dental condition status refers to the condition of the teeth, gums, and other structures of the oral cavity that may affect the resident's nutritional status, communication abilities or quality of life. The assessment should include the need for and use of dentures or other dental appliance(s). 2. These assessments will be conducted initially upon admission, quarterly, annually, and when there is a significant change in the resident's condition that affects the oral cavity.6. The assessing nurse will physically inspect the resident's mouth (oral cavity) for any abnormalities. 7. The assessing nurse will monitor for: .Darkness on a tooth (likely decay) or broken natural teeth, bleeding or loose teeth, mouth, or facial pain - discomfort or pain when chewing. Note: Negative findings will be immediately addressed. The attending physician will be notified as well as the facility's dental provider. The DON (Director of Nursing), MDS (Minimum Data Set) Coordinator, and SSD will also be notified as well as the resident or their responsible party. 8. SSD will work with the resident, family, physician, and the dental provider to coordinate timely care. This includes arranging transportation and staff accompaniment as needed.

Event ID:

Facility ID:

If continuation sheet