Alcott Rehabilitation Hospital

Inspectors wroteBased on interview and record review, the facility failed to maintain the rights exercised by the resident's representative (RP) for one of three sampled residents (Resident 1). For Resident 1, the facility failed to obtain consent from Resident 1's responsible party (RP) before cutting Resident 1's hair on 12/9/25. This deficient practice resulted in a violation of Resident 1's RP's right to make decisions on behalf of Resident 1. During a review of Resident 1's admission Record, indicated the facility admitted Resident 1 on 11/21/25 with diagnoses including dementia (a progressive state of decline in mental abilities) fracture of right femur (break in thigh bone), lack of coordination, and dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were dependent on staff for showers and feedings were provided those services for two of three sampled residents (Resident 1 and Resident 2).1. For Resident 1, who had a shower scheduled every Monday and Thursday, the facility failed to give Resident 1 shower on 11/24/25 (Monday), 11/27/25 (Thursday) and 12/1/25 (Monday). The facility also failed to notify Resident 1's responsible party (RP) when Resident 1 did not receive the showers on Resident 1's scheduled shower days. 2. For Resident 2, the facility failed to assist Resident 2 timely during breakfast on 12/23/25. Resident 2's breakfast tray was observed at the bedside table at 7:25 a.m. Resident 2 was not fed until 8:02 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control measures necessary to prevent the spread of infections by failing to:1. Ensure staff labeled laundry bins indicating if they were for clean or dirty items in the facility's laundry room.2. Discard and remove from the facility's storage room expired N95 (a disposable face mask that covers the user's nose and mouth which offers protection from small solid or liquid droplets found in the air) masks and expired Covid-19 (a respiratory illness that can spread from person to person) testing kits. These failures had the potential to place residents at increased risk of infection and cross-contamination (process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect).

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the residents' rights to dignity and respect for one of one sampled residents (Resident 110). By failing to utilize privacy curtains or closing the door while the resident was undressed from the waist down. This deficient practice left Resident 110 exposed to facility staff, residents, and visitors, leaving Resident 110 vulnerable to exploitation, humiliation, and safety concerns.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's medical records were updated to show documentation that advance directives (a legal document indicating resident preference on End-of-life treatment decisions) were discussed and written information were provided to the residents and/or responsible parties for one (1) of 1 sampled residents (Resident 84). This deficient practice had the potential to result in resident's healthcare wishes not being known or followed, placing the resident at risk of receiving unwanted or inappropriate treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately destroy or remove identifiable information on discarded medications for two (2) out of 2 sampled residents (Resident 87, 91). This deficient practice has the potential for unauthorized release of resident's personal information.

Inspectors wroteBased on observation, interview, and record review the facility failed ensure the Minimum Data Set (MDS, a standardized resident assessment tool) assessment for the Restorative Nursing Program (RNP, nursing interventions that aim to promote, maintain, and support a resident's ability to perform at their highest level) was accurately performed for two of three sampled residents (Resident 79 and Resident 86). These failures had the potential to result in adequate care for Resident 79 and Resident 86.

Inspectors wroteBased on interview and record review the facility failed to provide treatments and services to maintain or improve mobility (ability to move) and Range of Motion (ROM, full movement potential of a joint) for two of three sampled residents (Resident 79 and Resident 86). By failing to:1. Implement Resident 79's Restorative Nursing Program (RNP, nursing interventions that aim to promote, maintain, and support a resident's ability to perform at their highest level) for walking as indicated Resident 79's Care Plan (a plan of care that summarizes a resident's health conditions and the specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition) Report initiated 4/4/2025.2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the requirement for no more than four residents per room for one of 63 resident residential rooms (room [ROOM NUMBER]). This deficient practice had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents in room eight.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 24 out of 63 rooms (room [ROOM NUMBER], 6, 8, 12,19, 24, 26, 30, 32, 37, 39, 40, 41, 45, 46, 48, 50, 54, 56, 58, 59, 61, 62, and 63) met the required 80 square feet per resident regulation. This failure had the potential to result in the inadequate space necessary to provide safe nursing care and privacy for residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three of eight sampled staff (the Environmental Services Director [EVSD], Certified Nursing Assistant 2 [CNA 2] and Dietary Aide 1 [DA 1], maintained infection control practices (refers to policies and procedures used to minimize the risk of spreading infections) during a COVID-19 (a respiratory illness that can spread from person to person) outbreak (a rise in the number of cases of a disease) in the facility by failing to: 1. Ensure the EVSD performed hand hygiene (a general term that applies to hand washing, antiseptic hand wash, and alcohol-based hand rub) after throwing a cup in the trash for a resident (unidentified) in room A. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its policies and procedure on infection control to prevent the spread of coronavirus disease 2019 (COVID-19, a highly contagious infection affecting the respiratory system caused by a virus that can spread from person to person). By failing to: 1. Ensure all personnel wear N95 mask (disposable face mask that covers the user's nose and mouth which offers protection form small solid or liquid droplets found in the air) during the COVID-19 outbreak. 2. All staff perform COVID-19 test at beginning of their shift. 3. Pause resident activity during the COVID-19 outbreak. 4. Use dedicated shower room for COVID-19 positive residents only. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain infection control procedures when the facility did not screen family members and visitors for three day on signs and symptoms of Coronavirus (COVID-19, a contagious and infectious disease that is characterized by fever and cough and is capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) during a COVID-19 outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) in the facility. This deficient practice had the potential to result in the spread of COVID 19 to residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for one of five sampled residents (Resident 51) when Certified Nursing Assistant (CNA) 3 was observed standing over Resident 51 while feeding the resident lunch. This deficient practice had the potential to cause psychosocial harm to the Resident 51 and violated the resident's right to be treated with dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the person-centered care plan for one of three sampled residents (Resident 43), who suffered from depression. Resident 43's care plan did not include the resident's preferred activities. This deficient practice caused an increased risk of Resident 43 having meaningful activity to promote and enhance the resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to review, update, and/or revise the care plans for two of three sampled residents (Resident 71 and Resident 75). Resident 71 did not have current wound care treatment indicated for the Stage III sacral pressure ulcer and Resident 75's care plan did not include updated interventions for pressure injury prevention. These deficient practices had the potential to affect the provision of necessary care, treatment, and services for Resident 71 and Resident 75.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 75), who was assessed as a moderate risk to develop pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) was provided with a pillow or heel protectors (pressure relieving devices) to the left and right heels and repositioned every two hours and PRN (as needed), per the resident's care plan. This deficient practice placed Resident 75 at increased risk for developing pressure sores.

Inspectors wroteBased on interview and record review, the facility failed to provide services for one of two sampled residents (Residents 84) at risk for decline in range of motion (ROM, full movement potential of a joint) and mobility. Resident 84 did not receive Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments for passive range of motion (PROM, movement at a given joint with full assistance from another person) exercises and left knee extension splint, per the care plan. This deficient practice had the potential to cause further decline in functional mobility, ROM, and quality of life for Residents 84.

Inspectors wroteBased on interview and record review, the facility failed to provide an environment free from accident hazards to prevent avoidable accidents for one of two sampled residents (Resident 306), who was admitted to the facility with a history of falls and was at continued risk for falls, by failing to: -Accurately assess Resident 306's risk for falls dated 9/10/2024. -Evaluate and analyze fall risk hazards, implement individualized interventions to reduce risk of falling, and monitor for effectiveness of interventions. -Reevaluate and update individualized interventions to prevent recurrent falls after Resident 306 fell on 9/16 and 9/17/2024. -Ensure Resident 306 was not left without staff supervision in the facility patio. As a result, on 9/16/2024 Resident 306 stood up from the wheelchair in front of the nurse's station and fell. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one opened vial of Novolin R (a medication used to control blood sugar) was labeled with an open date per the manufacturer's requirements in one of two inspected medication carts (West Medication Cart.) The deficient practices of failing to store or label medications per the manufacturers' requirements increased the risk that residents could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to have a policy that addressed how to store and reheat resident's left-over food brought into the facility from outside kitchens / restaurants to ensure safe and sanitary food storage, handling, and consumption. This deficient practice had the potential to cause food borne illness in residents in the facility who were served the food brought by family or visitors.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the requirement for no more than four residents per room for one of 63 resident residential rooms (room [ROOM NUMBER]). This deficient practice had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents in room [ROOM NUMBER].

Inspectors wroteBased on observation and interview the facility failed to ensure 24 out of 63 rooms (Rooms 4, 6, 8, 12, 19, 24, 26, 30, 32, 37, 39, 40, 41, 45, 48, 50, 54, 56, 58, 59 61, 52, 62, and 63) met the required 80 square feet per resident. This deficient practice had the potential to result in inadequate space necessary to provide safe nursing care and privacy for residents.

Inspectors wroteBased on interview and record review, the facility failed to report a resident-to-resident altercation to the state survey agency (SSA) within 2 hours for two of three sampled residents (Resident 1 and Resident 2). This deficiency resulted in a delay of an onsite inspection by the Department of Public Health and had a potential for ongoing resident-to-resident altercations leading to resident harm.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide supervision to one of three sampled residents (Resident 1), who had history of falls, diagnosis of fractured thigh bone, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), received the care, treatment and services to prevent falls. The facility failed to: -Provide the correct level of assistance (two or more while eating) per the comprehensive assessment and the fluid imbalance care plan. - Implement a comprehensive person-centered fall care plan to include supervision of Resident 1 to prevent falls. [...]

Inspectors wroteBased on observation, interviews, and record review, facility failed to ensure one of one sampled residents (Resident 1) received adequate supervision and assistance to prevent a fall by failing to ensure bed siderails were up before leaving the resident's bedside. This deficient practice led Resident 1 falling from her bed on 11/23/2023 resulting in a laceration which required stitches.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility's policy and procedure (P&P) for Personal Protective Equipment are implemented by failing to: a. Ensure the Certified Nursing Assistant 1 and Certified Nursing Assistant 2 (CNA 2) wear the full personal protective equipment (PPE-a barrier precaution which includes the use of gloves, gown, mask, face shield, when anticipating coming in contact with blood, body fluids or other communicable toxins or agents) while providing care to four out of 10 sampled residents (Resident 5, 6, 7, 8's) room who are on transmission based precaution. b. Ensure the Certified Nursing Assistant 3 (CNA 3) wear a fit-tested NIOSH approved N95 or higher-level respiratory protection (mask that protect used by filtering out contaminants in the air) in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P) of incident reporting for unusual occurrence for one of seven sampled residents (Resident 1) by failing to report an unusual occurrence to the State Survey Agency and send a written report within 24 hours of Resident 1's death. This deficient practice resulted in a delay of an onsite inspection by the Department of Public Health and had potential to place other residents during an COVID-19 (an infectious disease that can cause respiratory illness in humans) outbreak.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Physician's Orders for Life Sustaining Treatment (POLST - a document that indicates what emergency treatment a resident wants the facility to provide if the resident's heart or lungs stop working) were accurate and/or complete for three of ten sampled residents (Resident 11, Resident 255, and Resident 256) as evidenced by observations of blank POLSTs signed by a physician in Resident 11's, Resident 255's and Resident 256's active chart. This deficient practice had the potential to result in Resident 11, Resident 255, and Resident 256 receiving medical treatment that would not honor the resident's wishes and decisions regarding end-of-life care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent the growth of microorganisms that could cause food borne illness as evidenced by: -Failing to label and date an opened bottle of white distilled vinegar and a half sandwich in two out of four refrigerators. -Failing to dispose of an open bag of tater tots and a can of granulated mushroom bullion which had past their use by date. These deficient practices had the potential to place residents in the facility at risk for food borne illness and/or contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy and dignity by leaving a resident uncovered without pants, with briefs (adult diaper) showing, and without use of privacy curtain for one of one sampled resident (Resident 306). This deficient practice had the potential for Resident 306 to experience loss of privacy and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report serious bodily injury to the state survey agency (SSA) within 24 hours for two of three sampled residents (Resident 18 and Resident 87). The facility failed to report: -Resident 18, an [AGE] year-old confused female, who sustained a left clavicle fracture (broken bone) after a fall on 8/22/2023. -Resident 87, an [AGE] year-old confused female who on 8/19/2023, had left wrist swelling and was then transferred to a general acute care hospital (GACH) and diagnosed with a wrist fracture (broken bone). Five days after the wrist fracture, on 8/24/2023, Resident 87 fell in her room and was unable to relate how she fell. These deficient practices resulted in a delay of onsite inspection from the SSA and caused an increased risk of injuries or potential abuse to Resident 18 and Resident 87.

Inspectors wroteBased on interview and record review the facility failed to conduct a comprehensive admission assessment for elopement risk (leaving the facility without staff knowledge, presenting an imminent threat to the resident's health and safety) for one of one sampled resident (Resident 19). This deficient practice caused an increased risk of Resident 19's elopement and care plan goals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a care plan for at risk for falls for one of three sampled residents (Resident 87), who sustained a fall on 8/24/2023 and was unable to explain how the fall occurred. This deficient practice had the potential to place Resident 87 at risk for recurrent falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was provided a communication device with the language that the resident was able to understand for one of one sampled resident (Resident 98). This deficient practice prevented Resident 98 from communicating with the staff and had a potential to delay receiving appropriate care/treatment the resident needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the actual direct care staffing hours were posted daily in the facility for the month of October. As a result, the actual hours worked by the staff was not readily accessible to residents, family or visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 50) who received Remeron (an antidepressant) had a gradual dose reduction (GDR - the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) attempted. This deficient practice had the potential to result in the continued use of unnecessary medications causing adverse consequences.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to remove an expired morphine sulfate solution (opioid analgesic [a class of medication], indicated for the relief of moderate to severe pain) medication, from the Middle East medication cart 2, for one of one sampled resident (Resident 17). This deficient practice had the potential to cause medication errors by possibly administering an expired medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices as evidenced by: -Failing to label and date intravenous (IV - a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) tubing for Resident 6. -Failing to ensure Resident 81 had a date on the nasal cannula (device used to deliver supplemental oxygen placed directly on a resident' s nostrils) to ensure prompt weekly changing of the nasal cannula. These deficient practices had the potential to result in complications of intravenous and oxygen therapy, including the spread of diseases and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirement for no more than four residents per room for one of 24 sampled resident residential rooms (room [ROOM NUMBER]). This deficient practice had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents in room [ROOM NUMBER].

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the required room size of 80 square feet for 24 of 44 resident rooms. This deficient practice had the potential to result in continued inadequate space to provide the necessary safe nursing care and privacy for the residents.

Inspectors wroteBased on interview and record review, for one of three residents (Resident 1), the facility failed to protect Resident 1's right to be free from physical abuse by a Certified Nursing Attendant (CNA) in accordance with the facility's policy and procedures (P&P) titled Abuse, Neglect and Exploitation dated 12/19/2022. As a result, Resident 1 suffered a right femur (bone in the thigh) fracture (cracking or breaking of a bone) on 10/15/2023 and was transferred to a general acute care hospital (GACH) for further evaluation and management on 10/15/2023 at GACH at 5:15 PM. On 10/16/2023 Resident 1 had open reduction internal fixation (ORIF-surgical procedure that puts pieces of a broken bone into place using screws, plates, or rods that are used to hold the broken bone together) to repair the right femur fracture.