Inspection visit
Inspection
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.
F 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Not transfer or discharge a resident without an adequate reason; and must provide documentation and
convey specific information when a resident is transferred or discharged.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to provide documentation of a resident's AD (Advance
Directives) to the ALS (Advance Life Support) paramedics and the hospital during a hospital transfer.
This applies to 1 of 3 residents (R1) reviewed for facility-initiated transfer to the hospital and AD.
The findings include:
The EMR (Electronic Medical Record) showed that R1, a [AGE] year-old with diagnoses that includes acute
and chronic respiratory failure, fluid overload, congestive heart failure, dependence on oxygen supplement,
asthma, diabetes mellitust type 2, chronic kidney diase, end stage renal disease and dependence on renal
dialysis, anemia, cardiomyopathy, aortic valve stenosis, lack of coordination, osteoarthritis, and presence of
vascular implants and grafts, R1 was originally admitted to the facility on [DATE]. R1 was sent out to the
hospital via 911 on March 11,2025 and returned to facility on March 14, 2025.
The Social Service Notes dated February 28,2025 showed that R1, an African American female who
admitted to the facility .primary language is English. (R1's) speech is clear, and her hearing appears
adequate. (R1) is alert x3. (R1) is able to understand, as well as be understood Discussed advanced
directives. (R1) reported she did not have a POA (Power of Attorney); however, per nursing notes resident's
daughters provided POA paperwork and POLST (Practitioner Order Life Sustaining Treatment). (R1) did
confirm she would like to be DNR (Do Not Resuscitate).
The MDS (Minimum Data Set) assessment dated [DATE], showed that R1 was cognitively intact with BIMS
(Brief Interview Mental Status) score of 15/15.
The POLST form signed by R1 marked with a date of March 19,2019 showed R1's AD wishes as follows:
DNR (if patient with no pulse); When not in cardiopulmonary arrest and patient is breathingComfort-Focused Treatment: primary goal of maximizing comfort; Relieve pain and suffering through use of
medication, by any route, as needed, use oxygen, suctioning, and manual treatment of airway obstruction.
Do not use treatments Listed in Full and Selective Treatment unless consistent with comfort goal.
REQUEST TRANSPORT TO HOSPITAL ONLY IF COMFORT NEEDS CANNOT BE MET IN CURRENT
LOCATION.
The progress notes dated March 11,2025 showed that R1 was sent out to the hospital via 911 due to
shortness of breathing. R1 was admitted to hospital's ICU (Intensive Care Unit) with diagnoses of cardiac
overload.
(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 3
Event ID:
145901
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
145901
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lemont Nursing & Rehab Center
12450 Walker Road
Lemont, IL 60439
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 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
The hospital H&P (History and Physical) dated March 11,2025 showed that (R1) to ER (Emergency Room)
for worsening SOB (shortness of breathing) over the last 2 hours . Upon arrival, (R1) was in significant
amount of distress .admitted to ICU.
The EMR's SS (Social Service) progress note dated March 14, 2025, which was documented by V4 (Social
Serve Director) showed that V12 (R1's daughter/POA/Power of Attorney) had requested the facility for a
care plan meeting due to multiple concerns. One of the concerns was regarding R1's hospital transfer on
March 11,2025.
On March 25,2025 at 11:36 A.M., V4 said that on March 13,2025, she had received an email from V12. V4
added that the email was about V12 asking that a copy of R1's Advance Directives/POLST (Practitioner
Order Life Sustaining Treatment) Form be fax immediately to the hospital.
The facility provided the email correspondence between V12 and V4 dated March 13,2025. The email
showed that V12 asked V4 Please fax a copy of (R1's) DNR (Do Not Resuscitate form) to .(hospital)
.Pursuant to Illinois state law protocols, a copy of the DNR should have been provided to the transporter
(ambulance) as well as a copy to the receiving facility .Please confirm once completed.
The facility's concern form dated March 18,2025 showed that V12 was concern that DNR Form/POLST was
not sent with (R1) to the hospital.
On March 26,2025 at 4:55 P.M., V9 (LPN/Licensed practical Nurse) said that she sent R1 out to the hospital
on March 11,2025 sometime around 10:00 A.M. V9 said that R1 was sent out due to labored breathing, and
pulse oxygen level showed an alarming result of 72 % (normal 95). V9 said that she only provided
documentation to paramedics of R1's Face Sheet/ and Medication List. V9 added that she did not provide
R1's POLST documentation to the paramedics. V9 further said that she was informed by the nurse for the
next shift that a POLST copy should be provided to the paramedics who then will provide to the hospital
during resident's transfer. V9 said that she was also informed by V2 (Director of Nursing) after V12 had
complained that a copy of the POLST was not provided to the paramedics/and hospital. V9 said that she
was told that an in-service regarding appropriate documentation forms to be provided during transfer will be
given; however, had not receive the in-service up to the current time. V9 also said that she has been
working in the facility since July of 2024 and this was not the first time, she had sent a resident to the
hospital. V9 said she was not aware that a copy of documentation of AD/POLST was to be provided to
paramedics/hospital during transfer.
The EMS (Emergency Medical Services) transport report dated March 11, 2025, showed that 911 was
summoned by the facility on March 11,2025 at 8:30 A.M., paramedics were dispatched at 8:31 A.M., en
route at 8:33 A.M., with (R1) at 8:39 A.M., and at hospital at 9:08 A.M. The EMS transport report also
showed that R1 was in minor distress, with hyperventilation and fluctuation of oxygen saturation level,
remained alert and oriented times 4 spheres (name, time place, person). The report also showed NONE for
R1's Advance Directives.
On March 25,2025 at 1:30 P.M., V13 (EMS Director) had validated that according to the EMS transport
report for R1, none was checked for Advance Directives. V13 also sent a correspondence email dated
March 25,2025 that paramedics crew that transported R1 to the hospital were only provided documents
that included medication list and a face sheet.
On March 24,2025 at 3:45 P.M., V12 said that facility had not provided a copy of POLST/DNR/Advance
Directives to the paramedics and the hospital. V12 said she had sent an email to V4 once she had
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145901
If continuation sheet
Page 2 of 3
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
145901
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/27/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lemont Nursing & Rehab Center
12450 Walker Road
Lemont, IL 60439
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 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
found out POLST copy was not sent out with R1 at time of transfer. V12 also said that R1 did not coded en
route of transfer nor at the hospital. V12 also added it's the ramification of not sending a copy and (R1's)
wishes would not be implemented. She (R1) does want a DNR status.
On March 25,2025 at 12:30 P.M., R1 was observed sitting in her wheelchair in her room. R1 was alert and
oriented times 3. R1 said that she was sent out to the hospital a week or 2 weeks ago. R1 said her wish
was to remain a DNR status.
On March 26,2025, V1 (Administrator) explained the facility's policy and procedure regarding resident
transfer to the hospital. V1 said that their policy was to give forms that included face sheet and medication
list that was on the POS (Physician Order Sheet).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145901
If continuation sheet
Page 3 of 3
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Back to topCitations
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.
F622 - Transfer and discharge-
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
FAQ · About this visit
Common questions about this visit
What happened during the March 27, 2025 survey of LEMONT NURSING & REHAB CENTER?
This was a inspection survey of LEMONT NURSING & REHAB CENTER on March 27, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at LEMONT NURSING & REHAB CENTER on March 27, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific info..."
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
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.