Inspection·October 10, 2024

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that it was safe for one resident (R3) to self-administer medications and did not follow doctors order and facility policy prior to leaving inhaler medication at bedside. This failure affected one resident in a total sample of 15 residents. Residents Affected - Few Findings include: R3 is a [AGE] year-old resident admitted to the facility on [DATE], with diagnoses including but not limited to Chronic obstructive pulmonary disease. Order dated 09/24/2024 documents: please assess patient for appropriateness of medications at bedside, if appropriate allow designated medications at bedside. Per protocol. Order dated 09/24/2024 documents: fluticasone-vilanterol 100mcg-25mcg/inhaler inhalation powder. Inhale 1 powder inhalation daily. Care plan dated 09/24/2024 documents: Deficient knowledge: medication related to cognitive impairment or lack of information for oral medications. Resident/Caregiver/support system self-administration assessment tool subacute rehabilitation form dated 09/24/2024 shows 6 questions not answered. This document had a total of 6 questions. This document also stated: Inability to answer yes to all of the above requires removal of medications from bedside. Above form is signed by two nurses one of which was V5. In the area that stated medication name it documents none/Breo Inhaler. On 10/07/2024 at 10:38 AM, R3 had inhaler at bedside sitting on bedside table within reach. Inhaler was Breo ellipta 100mcg/25 mcg (fluticasone-vilanterol). R3 stated, I am not sure when to take it. They tell me when I should take it. I don't believe in all of them medicines. On 10/08/2024 at 2:40 PM, V5, Registered Nurse RN (Registered Nurse), stated, I signed the self-administration assessment tool sheet last week for (R3). I should not have signed the same assessment tool from admission. I should have done a whole new sheet and put the date and time. I could not find the Breo Ellipta so I ordered one and seen there were no medications on the assessment tool, so I added the Breo Ellipta. I did not get a chance to ask all questions. Usually this is done on admission. V5 stated, 09/24/2024 was the first day the Breo Ellipta was ordered. On 10/08/2024 at 2:43 PM, V2, Director of Nursing DON (Director of Nursing), stated, My expectation for all nurses regarding self administration assessment tool is that they fill out the paperwork (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 4 Event ID: 145743 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 145743 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE West Suburban Medical Ctr 3 Erie Court Oak Park, IL 60302 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)