Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Suburban Medical Ctr during CMS and state inspections, most recent first.
A resident with a history of stroke, aphasia, hemiplegia, seizure disorder, and significant communication and cognitive impairments, whose preferred language was Vietnamese and who required an interpreter, was transferred from the unit to a local county hospital ED without written notice of transfer/discharge to the resident or the state guardian. Staff had long known the resident had no insurance, no family, and a state guardian, and that prior placement attempts had failed due to financial and identity issues. As the unit prepared to close, staff contacted a hospital transfer center, which declined admission for lack of acute need, yet the facility still arranged a private ambulance transfer to the ED based on reported verbal direction from county officials, without documented discharge planning, referrals, a discharge care plan, or a written notice specifying the reason, effective date, and destination of the transfer.
The facility abruptly closed without an approved closure plan or the required 60-day written notice to residents, their representatives, and appropriate agencies. Leadership notified the State Agency by email only a few days before stopping admissions and discharging all in-house patients, relying on verbal communication from case management to inform residents. A guardian reported learning of the closure from media coverage rather than from the facility and received no written notice. Despite a written policy requiring advance notice, regulatory coordination, and individualized, documented discharge/transfer planning with early counseling of patients and representatives, the facility did not produce any written notifications, closure documentation, or accessible records demonstrating that these procedures were followed.
A resident with COPD was found with an inhaler at their bedside without proper assessment for self-administration. The resident was unsure about the medication usage, and the self-administration assessment tool was incomplete. A nurse admitted to not following the correct procedure, and the DON confirmed the policy was not adhered to.
A facility failed to create a person-centered care plan for a resident with End Stage Renal Disease undergoing dialysis. The care plan lacked specific interventions for monitoring, fluid restriction, and access care. The DON stated that care plans depend on doctors' orders and are developed by admitting nurses, but no individualized plan was in place. The facility could not provide a care plan policy during the survey.
A facility failed to follow its policy for documenting dialysis care for a resident with End Stage Renal Disease. The resident, who receives hemodialysis three times a week, did not have the required dialysis communication forms and flowsheets in her chart. Interviews with the DON and Director of Nursing Operations confirmed the absence of these documents, despite the facility's policy mandating their inclusion.
Failure to Provide Required Written Notice Prior to Resident Transfer to Emergency Room
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of transfer/discharge, including the reason, effective date, and location, to a resident and/or the resident’s representative prior to transfer to a hospital emergency room. The resident had resided on the same unit for many years, with documentation inconsistencies regarding admission dates and no clear initial admission record available from the facility. The resident’s MDS documented that the preferred language was Vietnamese, that an interpreter was required, and that the resident was rarely or never understood and rarely or never understood others, with a cognitive pattern score indicating the resident was rarely/never understood. The resident’s diagnoses included stroke, aphasia, cerebrovascular accident, hemiplegia, and seizure disorder, and the MDS indicated that active discharge planning for return to the community was not occurring and no referral had been made to a local contact agency. Social work and nursing documentation over time showed that the resident could not be effectively interviewed, had a state guardian, no family, and no insurance coverage or established identity or immigration status, which had prevented successful placement efforts. Staff interviews confirmed that the resident had been on the unit for many years, had a state guardian, and that there was no current discharge plan, with only a tentative idea of sending the resident to a local county hospital due to lack of an accepting facility related to payment source. As the facility’s closure approached, the unit manager and social worker reported attempting to contact a local hospital transfer center, which declined to accept the resident due to no acute care need and indicated the resident would be better served at a SNF. Despite this, the facility proceeded with arranging a transfer to a local county hospital emergency room. On the day of transfer, the state guardian reported learning of the unit’s impending closure from the news and then calling the facility, later being informed that the facility had nowhere for the resident to go and needed help with placement. The ambulance crew arrived with reported orders from a county official to take the resident to the local county emergency room, but could not provide documentation of this order. The administrator confirmed that the ambulance crew was given a face sheet, medication list, and electronic medical record data for the transfer. Progress notes documented that the resident was discharged to the county hospital emergency room due to the hospital closing, and a late entry case management note stated that the resident was transferred after approval from local hospital administration, with a message left for the state guardian. Review of social work transition planning notes over the prior year and progress notes from the days before discharge showed no documentation of referrals, discharge planning, discharge assessments, discharge summary, or orders other than the plan to send the resident to the emergency room, and there was no discharge planning care plan documented, nor any written notice of transfer/discharge provided to the resident or guardian as required by facility policy and regulations.
Abrupt Facility Closure Without Required 60-Day Written Notice or Coordinated Relocation Plan
Penalty
Summary
The facility failed to develop and implement an adequate plan for relocation and failed to provide written notification at least 60 days prior to closure to residents, resident representatives, and appropriate parties. The facility president reported that the State Agency was notified by email only two days before the closure due to financial concerns, and that residents were informed verbally by case management without any written documentation. All residents were discharged by the stated closure date, and the surveyor was not provided with any written letters or notifications related to the closure, despite requesting such documentation. A state guardian for one resident stated she did not receive written notification and only learned of the closure from the news before calling the facility to confirm. The facility’s own policy required that any temporary suspension, reduction, conversion, or permanent closure of a hospital unit be conducted in a safe, legally compliant manner with advance notice to the Hospital and Facilities Review Board, the Illinois Department of Health, and other impacted agencies, and that for a permanent hospital closure at least 60 days’ notice be provided. The policy also required early, documented counseling of patients and legally authorized representatives regarding transfer plans and anticipated discharge dates. During the survey, there was no access to resident computer records and no policies or procedures specific to unit/facility closure were provided beyond the undated policy reviewed. The abrupt closure occurred without an approved closure plan, without the required written notifications, and without documented individualized discharge or transfer planning as outlined in the facility’s own procedures.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure the safety of a resident in self-administering medications, specifically an inhaler, without following the necessary protocols. The resident, who has a diagnosis of Chronic Obstructive Pulmonary Disease, was found with an inhaler at their bedside, despite not being assessed properly for self-administration. The resident expressed uncertainty about when to use the inhaler, indicating a lack of understanding and knowledge about their medication regimen. The self-administration assessment tool, which should have been completed to determine the resident's capability to manage their medication, was inadequately filled out, with all six questions left unanswered. A registered nurse admitted to signing the assessment tool without completing it and acknowledged that the process was not followed correctly. The Director of Nursing confirmed that the expectation was for all nurses to complete the assessment properly and adhere to the policy, which was not done in this case.
Failure to Develop Individualized Dialysis Care Plan
Penalty
Summary
The facility failed to develop a person-centered care plan and interventions for a resident with End Stage Renal Disease who receives dialysis treatment. The resident, a female admitted on 09/27/24, attends an outpatient dialysis center three times a week. The care plan for this resident only included a general statement about impaired fluid balance related to renal disease and a schedule for outpatient dialysis, with no specific interventions regarding monitoring, fluid restriction amounts, or access care. The Director of Nursing indicated that care plans depend on doctors' orders and are developed by admitting nurses, but acknowledged that there is no individualized written plan. The facility was unable to present a policy regarding care plans during the survey period.
Failure to Document Dialysis Care for Resident
Penalty
Summary
The facility failed to adhere to its policy regarding the documentation and communication of dialysis care for a resident with End Stage Renal Disease. The resident, a [AGE] year-old female, was admitted to the skilled unit and required hemodialysis treatment three times a week at an outpatient dialysis center. Despite the facility's policy mandating that dialysis communication forms and flowsheets be placed in the resident's chart, these documents were not present. The resident confirmed that she did not bring any forms to or from the dialysis center. Interviews with the Director of Nursing and the Director of Nursing Operations revealed that the facility did not receive or maintain the necessary dialysis communication forms and flowsheets in the resident's chart. The facility's policy, dated August 2023, clearly outlined the requirement for these documents to be included in the resident's chart post-dialysis. However, the staff acknowledged that these documents were neither uploaded into the system nor available in the resident's chart, indicating a lapse in following the established protocol for ensuring proper documentation and communication of dialysis care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At The Boulevard | 0.7 mi | ★★★★★ | 7 | 0 |
| Austin Oasis, The | 1.5 mi | ★★★★★ | 10 | 0 |
| Oak Park Oasis | 1.5 mi | ★★★★★ | 7 | 0 |
| Ryze West | 1.5 mi | ★★★★★ | 3 | 0 |
| Berkeley Nursing & Rehab Center | 1.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.