Bria Of Westmont
BRIA OF WESTMONT in WESTMONT, IL — inspection on September 12, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure medications for newly admitted residents were available for timely administration.
This applies to 1 of 3 residents (R1) reviewed for pharmacy services.The findings include:R1's Face Sheet showed he was admitted to the facility on [DATE]. R1's admission nursing progress note was timed at 12:30 PM. On 9/10/2025 at 11:00 AM, V2 DON (Director of Nursing) stated there are two pharmacy deliveries daily, one in the afternoon around 3:00-5:00 PM, and one in the morning between 3:00-6:00 AM.R1's September 2025 Active Physician Orders as of 9/10/2025 showed orders for Carvedilol twice daily for hypertensive heart disease with heart failure, and Entresto twice daily for hypertensive heart disease with heart failure. R1's September Medication Administration Record (MAR) showed both medications were scheduled for administration at 9:00 AM and 5:00 PM.On 9/10/2025 at 11:58 AM, V5 (Pharmacy Technician) stated most of R1's medications were delivered at 4:30 AM on 9/5/2025. V5 stated the only medication that was not delivered was R1's Entresto. R1's September 2025 MAR showed 9 for his 5:00 PM dose of carvedilol on 9/4/2025.
The corresponding eMAR Medication Administration progress note from 9/4/2025 at 10:31 PM showed carvedilol. unavailable.
The same MAR showed 9 for R1's 5:00 PM of Entresto on September 5, 2025. No corresponding eMAR Medication Administration note was written.On 9/10/2025 at 1:17 PM, V2 (DON) stated if the medication is not available in the stat-safe (emergency prescription medication storage), it can be ordered STAT from the pharmacy. V2 stated staff should check the stat-safe and if they can't get it, they should contact her or the pharmacy. V2 stated if a medication is given late, staff should contact the MD.R1's September 2025 MAR showed R1's 9/4/2025 Entresto dose scheduled for 5:00 PM was administered and the Administration Details report showed it was signed off as administered at 10:20 PM.
The facility's 12/2024 Medication Orders policy showed Procedures. D.
The prescriber is contacted by nursing for direction when delivery of a medication will be delayed, or the medication is not or will not be available.
The policy continues F. 3).
Emergency/STAT Medication Order (Medication NOT Contained in Emergency Medication Supply) a.
Emergency/STAT order is placed with the provider pharmacy and the medication is scheduled to be given as soon as received or within two hours, whichever is sooner.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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