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Deficiency Records for Downers Grove Rehab and Nursing
A list of the most recent deficiencies for Downers Grove Rehab and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Downers Grove Rehab and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-04-30 | 2024-05-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-04-30 | 2024-05-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-04 | 2024-05-08 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-03-25 | 2024-04-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-25 | 2024-04-16 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-25 | 2024-04-16 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-02-13 | 2024-03-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-13 | 2024-03-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2024-02-13 | 2024-03-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-13 | 2024-03-12 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2024-02-13 | 2024-03-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-13 | 2024-03-12 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-02-13 | 2024-03-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-13 | 2024-02-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-02-02 | 2024-02-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-02 | 2024-02-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-02 | 2024-02-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-02 | 2024-02-27 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-02-02 | 2024-02-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-02 | 2024-02-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-02 | 2024-02-27 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-02 | 2024-02-27 | N |
| 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. | Health | 2024-02-02 | 2024-02-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-02-13 | 2024-02-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-13 | 2024-02-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-13 | 2024-02-23 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-13 | 2024-02-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-13 | 2024-02-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-02-13 | 2024-02-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-13 | 2024-02-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-01-18 | 2024-02-14 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-13 | 2024-02-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-23 | 2023-09-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-23 | 2023-09-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-23 | 2023-09-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-06 | 2023-05-12 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-20 | 2023-05-12 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-04-20 | 2023-05-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-20 | 2023-05-12 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-04-20 | 2023-05-12 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-14 | 2023-05-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-07 | 2023-05-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-07 | 2023-05-04 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Develop a communication plan. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-03-14 | 2023-04-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-17 | 2023-03-24 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-17 | 2023-03-24 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-17 | 2023-03-24 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-17 | 2023-03-24 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-03-17 | 2023-03-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-01 | 2023-03-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-03-01 | 2023-03-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-01 | 2023-03-24 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-03-01 | 2023-03-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-01 | 2023-03-24 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-03-01 | 2023-03-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-03-01 | 2023-03-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-01 | 2023-03-24 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-01 | 2023-03-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-03-01 | 2023-03-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-03-01 | 2023-03-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-01 | 2023-03-24 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-03-01 | 2023-03-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-27 | 2023-02-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-27 | 2023-02-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-12-29 | 2022-12-31 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-12-17 | 2022-12-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-16 | 2022-12-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-16 | 2022-12-29 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-16 | 2022-12-29 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-12-16 | 2022-12-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-02 | 2022-11-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-02 | 2022-11-17 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-10-19 | 2022-10-24 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-03 | 2022-10-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-11 | 2022-07-21 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-14 | 2021-12-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-14 | 2021-12-15 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-12-14 | 2021-12-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-12-14 | 2021-12-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-14 | 2021-12-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-12-14 | 2021-12-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-09 | 2021-12-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-09 | 2021-12-10 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-09 | 2021-12-10 | N |
| 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. | Health | 2021-12-09 | 2021-12-10 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-12-09 | 2021-12-10 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-12-09 | 2021-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-09 | 2021-12-10 | N |
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