West Suburban Nursing & Rehab Center

September 4, 2025 at 12:15 PM, V9 (Son of R19) said, I did not know [R19's] Medicare Advantage

father could make a decision for changing his health plan.

English is not his first language, and I

have the documentation to show R19 has a Power of Attorney or Healthcare Surrogate form, or that V9 (Son of R19) was contacted regarding R19's Medicare Advantage plan. 3. On September 9, 2025, at 1052 AM, R23 was sitting in a wheelchair in the hallway outside of his room. 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. 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 R23 was admitted to the facility on [DATE] 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. R23's MDS dated [DATE] shows R23 is cognitively intact. 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 R23's name, date of birth , gender, permanent address as the facility, and R23's Medicare Number. R23's signature is typed in a cursive font as the signature on the Enrollment Form acknowledging 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, R23 was sitting in the hallway in his wheelchair. R23 said he was approached by V3 (SSD) to ask if R23 wanted to hear a presentation regarding insurance. R23 said he would gladly hear about it, but decided not to do it because he didn't like the sound of it. R23 said he has had the same insurance company his whole life and he did not want to change from that. 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. R23's MDS dated [DATE] shows 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.

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West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108

Prevention Program Policy revised 3/1/21 shows: It is the policy of this facility to prohibit and

employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected

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.

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West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108

a neurology consult.

This applies to 1 of 3 residents (R19) reviewed for appointments in the sample of

he went to see his neurologist about leg weakness a few months ago and the physician said R19 should get a second opinion from another neurologist. 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 R19 an appointment. 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 R19 was admitted to the facility on [DATE] 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. R19's MDS (Minimum Data Set) dated July 8, 2025 shows 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). R19 is frequently incontinent of urine, and always incontinent of stool.

The EMR shows the following order for 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 R19 to see the neurologist. 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 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.

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West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108

received assistance to make an appointment to see an audiologist.

This applies to 1 of 3 residents

at 12:36 PM, R1 was sitting in his room. R1 said he has been having a difficult time hearing and has been asking to see an audiologist for a long time. 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 R1 was admitted to the facility on [DATE] 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. R1's MDS (Minimum Data Set) dated June 19, 2025 shows 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). 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 R1 on May 16, 2025 but did not submit 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 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 [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,

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

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West Suburban Nursing & Rehab Center 311 Edgewater Drive Bloomingdale, IL 60108

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.