F 0626
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds
bed-hold policy.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation interviews and record reviews, the facility failed to readmit a resident after hospitalization. This
applies to 1 of 6 residents reviewed (R4) for involuntary discharge in a sample of 6.
The Findings include:
R4 is a [AGE] year-old female admitted on [DATE] with cognition intact as per the Minimum Data Set (MDS)
dated [DATE].
A record review on the health status note dated 6/17/24 documents that according to the facility, R4 left the
facility against medical advice (AMA) accompanied by daughter/power of attorney (V3).
Record review on health status note dated 6/15/24 documents that V3 voiced concerns about the resident
vomiting and not eating. The review also documented that the facility notified V6 (R4's attending physician)
and obtained orders for laboratory work and diagnostic tests, including urine culture and Kidney Ureter
Bladder (KUB) X-ray.
On 7/15/24 at 8:30 AM, V3 stated, R4 was not eating. They claim she was eating 75%, but that was not
true. She had nausea/vomiting and abdominal pain. R4's roommate's (R6) daughter (V5) witnessed these
incidents. The facility ordered a lab, urine culture, and KUB. But R4 continued to have nausea/vomiting and
throwing up and had abdominal pain. She was also losing her weight. On 6/17/24, I told V1 that I wanted R4
to transfer to a local hospital. They were not helpful and didn't even offer a wheelchair to get my mom into
my car. They gave me the paperwork needed for the hospital transfer. They didn't tell me or give me any
paperwork that time that R4 couldn't return. V3 added, When I was in the hospital, V2 (Director of
Nursing/DON) called me over the phone and said that R4 couldn't return as I was complaining too much
and that R4 was too complicated. I was so disappointed and shocked when she said that, so I hung up and
called the police. When the police called the facility, they said they couldn't accept her back as R4 was
discharged against medical advice (AMA). My mom stayed in the hospital for a few days, and the diagnostic
tests showed that she had a tumor, hernia, and ulcer. The emergency room doctor even hugs me, saying I
am my mom's best advocate.
On 7/15/24 at 9:00 AM, V5 stated, I visited my mom every day, and she was a roommate with R4. R4
wasn't eating her breakfast. She didn't like it and was drinking only coffee.
Record review on vitals document that R1 had a weight of 137.4 pounds (lbs) on 5/17/24 and 130.4 lbs on
6/17/24, yielding 5.1% weight loss in one month (critical weight loss if a weight loss).
(continued on next page)
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.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
145111
Printed: 05/15/2026
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
145111
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Elmhurst Extended Care Center
200 East Lake Street
Elmhurst, IL 60126
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 0626
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 7/15/24 at 9:20 AM, V2 (DON) stated, R4 was throwing up for 2-3 days and was complaining of
stomach pain. An in-house cardiologist saw her, and the medical director ordered blood work, urine culture,
and KUB. But R4 left the facility AMA before the urine culture, and KUB resulted.
On 7/15/24 at 9:15 AM, V6 (R4's attending physician) stated, I can't remember the facility calling me on
6/17/24 when R4's daughter wanted to transfer her to the hospital. They should have thoroughly
documented whether they contacted me and if there were any orders. Of course, if the daughter were
concerned about her mom's condition or wanted to take her mom to the hospital, I would order R4 to be
transferred to the local hospital. It is not a discharge against medical advice (AMA).
On 7/15/24 at 2:17 PM, V1 (Administrator) stated, We don't have any documentation to show that the
physician (MD) was notified when R4's daughter picked up her AMA. Our policy doesn't allow us to readmit
a resident once they leave AMA.
A record review of clinical progress notes and physician order sheet (POS) indicates that the facility didn't
contact MD when V3 picked up R4 on 6/17/24.
The facility presented policy on When to Call the Doctor - Protocol revised on 1/5/24 document:
I. The physicians caring for residents in the facility want to respond in an appropriate and timely manner to
acute changes in a resident's condition as indicated by the nursing staff and to ensure continuity of care.
A. The types of conditions which frequently arise are:
11. Family concerns
A record review of R4's face sheet documents shows that R4 had Medicaid as a primary payer.
The facility presented Bed Hold Policy and Procedure Manual (effective date 1/4/24) document:
1. Medicaid residents, when properly admitted , have a right to return to the facility to the first available bed
after a hospital transfer.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145111
If continuation sheet
Page 2 of 2
