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Inspection visit

Health inspection

BEACON HILLCMS #1455221 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

145522 06/26/2025 Beacon Hill 2400 South Finley Road Lombard, IL 60148
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 were obtained in a timely manner to prevent residents from missing medication doses as ordered by the provider. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the area of missing medication doses in the sample of 4. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including lumbosacral spinal fusion, lumbar spine stenosis, anxiety, and breast cancer. R1's MDS (Minimum Data Set) dated June 13, 2025, showed R1 was cognitively intact. R1's Order Summary Report dated June 24, 2025, showed an order dated June 13, 2025, for Temazepam capsule 7.5 mg (milligrams), give one capsule by mouth at bedtime for insomnia. On June 23, 2025, at 2:46 PM, R1 said while she was residing at the facility, she was not able to sleep. R1 said she spoke with a provider and was told temazepam was ordered for her to sleep. R1 said she never received a dose of temazepam. R1's June 2025 MAR (Medication Administration Record) showed R1 did not receive temazepam as ordered on June 13 and June 14, 2025. A progress note dated June 13, 2025, at 10:17 PM, by V12 (RN/Registered Nurse) showed Temazepam capsule 7.5 mg, give one capsule by mouth at bedtime for insomnia. Not available. Order on progress. Physician and resident aware. A progress note dated June 14, 2025, at 9:47 PM, by V12 showed Temazepam capsule 7.5 mg, give one capsule by mouth at bedtime for insomnia. Not available. Order on progress. Physician aware. On June 25, 2025, at 1:21 PM, V12 said on June 13, 2025, R1 had an order for temazepam, but since the temazepam is a controlled substance, a script is required for pharmacy to fill the prescription. V12 continued to say V14 (Psychiatric Nurse Practitioner) is the provider who ordered the temazepam but V12 did not have a way to contact V14 regarding a script. V12 continued to say on June 13, V12 notified V17 (R1's Doctor) that a script was required in order for pharmacy to fill the temazepam order. V12 said she did not receive a script from V17. V12 continued to say she did not notify a Page 1 of 2 145522 145522 06/26/2025 Beacon Hill 2400 South Finley Road Lombard, IL 60148
F 0755 provider on June 14, 2025, when the temazepam was still unavailable. Level of Harm - Minimal harm or potential for actual harm On June 25, 2025, at 12:11 PM, V11 (Pharmacy Account Manager) said temazepam is not listed on R1's medication profile for the pharmacy. V11 said since the temazepam is not on R1's profile it means the pharmacy did not receive a script for the medication. Residents Affected - Few On June 25, 2025, at 1:56 PM, V1 (Administrator) said it should not have taken over 24 hours for R1's temazepam to be available to be administered. 145522 Page 2 of 2

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0755GeneralS&S Dpotential for harm

    F755 - Pharmacy Services

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

FAQ · About this visit

Common questions about this visit

What happened during the June 26, 2025 survey of BEACON HILL?

This was a inspection survey of BEACON HILL on June 26, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at BEACON HILL on June 26, 2025?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharm..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

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Next steps

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.