Inspection·October 26, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to follow its change in condition policy by not reporting the psychotropic medication adverse effect (drowsiness) to the provider. This applies to 1 of 6 residents reviewed (R1) for psychotropic medications/overdose/adverse effects in a sample of 6. The findings include: R1 was an [AGE] year-old female admitted on [DATE] with severe cognitive impairment per the Minimum Data Set (MDS) dated [DATE]. Record review on Physician Order sheet (POS) and Medication Administration Record (MAR) for 09/2023 document R1 was receiving Lasix 20 milligram (mg) daily, Mirtazapine 7.5 mg at bedtime, Sertraline 100 mg daily at 0900, Depakote 125 mg two times per day (0600 and 1800), Risperidone 2 mg two times per day (0800 and 2000, started on 5/18/23 and discontinued on 9/26/23), and Vistaril 25 mg two times per day (0900 and 1700). A review of the nursing Progress note dated 9/26/23, documented R1 was noted with a decline in condition, having episodes of lethargy. The documentation indicates the facility notified the Psychiatric Nurse Practitioner (Psych NP/V13), and the NP decreased the dose of the mood stabilizer and antipsychotic and ordered to continue to monitor the resident. Record review on POS documented the order for Risperidone was decreased on 9/26/23 from 2 mg to 1 mg twice daily. No other changes to R1's anti-psych medications. Record review on POS and MAR for 10/2023 document R1 was receiving Lasix 20 milligram (mg) daily, Mirtazapine 7.5 mg at bedtime (2100), Sertraline 100 mg daily at 0900, Depakote 125 mg two times per day (0600 and 1800), Risperidone 1 mg two times per day (0800 and 2000, started on 9/26/23 and discontinued on 10/07/23), and Vistaril 25 mg two times per day (0900 and 1700). A review of the nursing progress note dated 10/01/23 documents the facility held a Risperidone dose today due to sleepiness. Record review on MAR for 10/2023 document R1 was given Risperidone dose at 0800 and 2000 on 10/01/23. Record review on nursing progress note dated 10/02/23 and MAR for 10/2023 document R1 was drowsy, and the facility administered Risperidone dose along with other anti-depressants and mood stabilizers. (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: 145333 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 145333 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 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)