F 0575
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy
groups and a statement that the resident may file a complaint with the State Survey Agency.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to display in a public and accessible location, the
[NAME] and [NAME] Retaliation Hotline poster informing residents of their right to explore or decline
community transition, and their right to be free from retaliation. The facility also failed to submit a monthly
list of voluntary and involuntary discharge residents to the [NAME] and [NAME] program. This failure has
the potential to affect all 42-residents residing in the facility.
Findings Include:
On 6/26/24 at 11:00am, the first-floor bulletin board observation was conducted with surveyor, V1
(Administrator) and V3(Admissions) for the [NAME] and [NAME] Retaliation poster. All parties verified that
there was no visible poster of the mentioned advocacy group in the facility.
On 6/26/24 at 11:30am, the dining and activity rooms were observed. There was no signage of [NAME] and
[NAME] poster posted in these rooms.
On 6/26/24 at 12:30pm V1 (Administrator), V3(Admissions) and V8 (Social Services) stated that they were
not aware of a poster/signage that needs to be posted and visible to residents and family members in the
facility. V1 stated I didn't know about this poster, but I will post it now on the facility's bulletin's board.
On 6/26/24 at 1:00pm, V1 and V8 both stated that they are not aware that they must submit a monthly list of
voluntary and involuntary discharge residents to the [NAME] and [NAME] program. V8 stated that an email
is sent to the agency when residents request to be transferred into the community. There is no monthly list
of residents on the program that is sent out.
Facility document titled; Health Care Council of Illinois reads: Resident admission Packet revised 12/2023.
Statement of Resident Right.
5. The facility must post in a form and manner accessible and understandable to resident and resident
representative:
(i) A list of names addresses and telephone number of all pertinent state agencies and advocacy groups
such as the state Survey Agency, the State licensure office, adult Protective Services where law provides
for jurisdiction in long term care facility, the office of the State Long-Term Care on
(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:
146013
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
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
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)
F 0575
Ombudsman program, the protection and advocacy network, home and community-based services
programs .
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 2 of 4
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
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
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)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to follow the Wound Care Plan by not
implementing effective interventions to prevent further alteration in skin integrity. This failure affected 1
resident (R44) of 3 residents reviewed for wounds in a total sample of 15.
Residents Affected - Few
Findings Include:
On 6-25-24 at 8:03 AM, R44 was noted laying on a low air loss mattress with the mattress setting at static.
On 6-27-24 at 11:00 AM, R44 was noted laying on a low air loss mattress with mattress set at static and
verified with V11 (Assistant Director of Nursing/ADON).
On 6-27-24 at 11:00 AM, V11 (ADON) said the low air loss mattress helps with wound healing by
alternating pressure relief. V11 said the alternating pressure setting is based on the resident's weight. V11
said static setting is when all chambers are full and there is no alternating pressure relief for the resident.
V11 said it is the nurse's responsibility to check the settings on the air mattress.
On 6-27-24 at 11:28 AM, V2 (Director of Nursing) said the low air loss mattress can promote wound healing
by alternating pressure relief for the resident. V2 said staff will use the static setting when changing position
or providing care for a resident. V1 said static setting on the air mattress does not deliver the intended
benefit of the air mattress.
R44's wound care plan documents: Pressure reducing/relieving mattress and wheel chair (w/c) cushions as
needed.
Pressure Ulcer Prevention Protocol (no date) documents: Procedure: 4.C. Use of Pressure Reducing
Devices, such as pressure reducing mattresses, mattress overlays, w/c cushioning devices, if needed.
Manufacturer's Instructions (no date) documents: 2. Therapy Modes: A. Static - Redistribute body mass
over a greater surface area at a constant low pressure. All of the air cells are equally inflated at lower
pressures when compared to the respective comfort level in alternating mode. B. Alternate Pressure- 1 in 2
alternating cell cycle achieves period pressure relief. There are four selectable cycle time available.
Caregivers can select one of the four cycle times based upon patient comfort and desired outcome.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 3 of 4
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
146013
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/28/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Berkeley Nursing & Rehab Center
6909 West North Avenue
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on observation, interview, and record review the facility failed to follow the Medication Policy by not
labeling medication bottles with the opened date. This failure affected 3 residents (R24, R34, and R18) of
15 residents reviewed for medications.
Findings Include:
On 6-26-24 at 1:10 PM surveyor found R24's Ketoconazole Shampoo 2%, R34's levocarnitine Oral
Solution, and R18's liquid Ondansetron were opened without any opened date on the label.
On 6-26-24 at 1:13 PM, V10 (Licensed Practical Nurse/LPN) said the opened date is important because
staff can tell when it expires and how long the medication can last. V10 said the opened date lets staff know
when to discard.
On 6-26-24 at 1:45 PM, V9 (LPN) said when accessing medications she would label with the opened date
and note the expiration date.
On 6-26-24 at 9:00 AM, V2 (Director of Nursing) said nurses are responsible for labeling medication with
the opened date. V2 said the opened date of medications is important to determine how long the
medication can be used. V2 said the nurses will also honor the medication expiration date on the
medication as well.
Medication Policy (no date) documents: Procedure: 1. Each prescribe medication medication label includes:
h. Date medication dispensed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146013
If continuation sheet
Page 4 of 4
