Arlington Heights Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable to avoid duplicate testing and effort, which include incorporating the recommendation from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for two (Residents #1 and #2) of three residents reviewed for PASRR assessments. The facility failed to submit a completed request for Nursing Facility Specialized Services (NFSS) in the LTC Online Portal within 20 business days of Resident #1 and #2's IDT meetings held on 04/22/26. This failure could place residents at risk of not receiving specialized services and equipment to help ensure their needs are met.

Inspectors wroteBased on interview and record review, the facility failed to use the service of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 16 of 40 days (06/08/25, 07/05/2025, 07/06/25, 07/12/25, 07/19/25, 07/27/25, 08/09/25, 08/10/25, 08/31/25, 10/11/25, 10/12/25, 10/17/25, 10/18/25, 11/15/25, 12/06/25 and 12/07/25) reviewed during a look back period from 06/07/25 to 12/18/25 for weekend coverage. The facility failed to have RN coverage in the facility for eight consecutive hours on 06/08/25, 07/05/2025, 07/06/25, 07/12/25, 07/19/25, 07/27/25, 08/09/25, 08/10/25, 08/31/25, 10/11/25, 10/12/25, 10/17/25, 10/18/25, 11/15/25, 12/06/25 and 12/07/25. This failure could place residents at risk of not having their nursing and medical needs met and improper care.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents were screened for mental illness and coordinate with the State mental health authority the need for services for 1 of 4 residents (Resident #99) reviewed for PASARR screening. The facility failed to recognize that Resident #99's PL1 was inaccurate, which resulted in the resident not being referred to the local authority for a PE. The failure placed residents with mental illness at risk of not receiving services they were entitled to receive.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing, mental, and psychosocial needs for 2 of 20 residents (Residents #14 and #76) reviewed for care plans. 1. The facility failed to develop a care plan addressing Resident #14's nail care refusal.2. The facility failed to develop a care plan addressing Resident #76's right hand contracture. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 20 residents (Resident #33) reviewed for ADLs. The facility failed to ensure Resident #33 received showers/bed baths as scheduled for the months of November 2025 and December 2025. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 2 residents (Resident #114) reviewed for pressure ulcer treatment. The facility failed to ensure Resident #114 received wound care for his pressure ulcers on the weekend of 12/06/25-12/07/25. This failure could place the residents at risk of Infection and worsening wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 1 resident (Resident #116) reviewed for PICC lines.1. The facility failed to ensure the dressing on Resident #116's PICC line (used to deliver medications and other treatments directly to the large central veins near heart) was changed every seven days as ordered by the physician, which resulted in the resident's PICC line dressing not being changed on 12/06/25.2. LVN X failed to perform hand hygiene during medication administration through Resident #116's PICC line. The failures could affect residents by placing them at risk for infections and cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goal and preferences for 1 of 20 resident (Resident #116) reviewed for pharmacy services. The facility failed to ensure Resident #116's intravenous medication bag and tubing was labeled with date, time, and initials. These failures could place residents at risk for medication error, delay in medication administration and infection.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 20 residents (Resident #33) whose medications were reviewed for gradual dose reduction. The facility's Pharmacy Consultant recommended the physician should consider a gradual dose reduction for Resident #33's Amitriptyline (used to treat depression) on 08/29/25. The facility failed to ensure this was communicated to the resident's primary care physician regarding the recommendation. This failure could place residents receiving medications at risk for adverse consequences and could cause a decline in their physical, mental, and psychosocial condition.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that were complete in accordance with accepted professional standards and practices for 1 of 20 residents (Resident #10) whose clinical records were reviewed for accuracy. The Social Worker failed to document in Resident #10's clinical record when the resident's family/legal representative was invited to participate in the resident's quarterly care plan meetings. The failure placed residents at risk of not having their care and services accurately documented.

Inspectors wroteBased on observations and interviews, the facility failed to ensure each bed had suspended ceiling curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for 3 of 21 residents (Residents #74, #95, and #99) reviewed for privacy curtains. The facility failed to ensure Residents #74, #95, and #99 were ensured full visual privacy. This could place the residents at risk of lower self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1, who had dementia, was provided with adequate supervision to prevent her from eloping from the facility on 08/08/25. The resident was found half a block away from the facility. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 08/08/25 and ended on 08/08/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents who require supervision at risk of harm, severe injury, and possible death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #3 did not physically abuse Resident #2. On 07/17/25, Residents #2 and #3 physically attacked each other and Resident #2 suffered scratches to her left cheek and lip. The noncompliance was identified as PNC. The noncompliance began on 07/17/25 and ended on 07/17/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a care plan for Resident #1's Foley catheter. This failure placed resident at risk of not receiving appropriate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who enters the facility with an indwelling catheter receives appropriate treatment and services for 1 of 3 (Resident #1) reviewed for catheters. The facility failed to obtain physician orders to address the treatment and services that were to be provided to care for Resident #1's Foley catheter. The failure placed residents at risk for catheter complications and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that an alleged violation involving abuse was reported immediately but not later than 2 hours after the allegation was made to the Administrator of the facility for 1 of 3 residents (Resident #1) reviewed for abuse. LVN A failed to immediately report an abuse allegation to the Administrator, who was the facility's abuse coordinator, when she overheard CNA B verbally abusing Resident #1 in early May 2025. This failure could have caused residents to experience abuse by staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 3 of 10 residents (Residents #2, #3, and #4) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #2, #3, and #4 were free of abuse from Resident #1. Resident #1 hit Resident #2 and #3 with her doll in the face and head when she was upset and punched Resident #4 in the stomach after she approached her boyfriend. An Immediate Jeopardy (IJ) was identified on 02/11/25 at 3:47 PM. The IJ template was provided to the facility on 2/11/25 at 4:00 PM. While the IJ was removed on 02/13/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with respect, dignity, and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident #5) reviewed for resident rights. The facility failed to treat Resident #5 with dignity when staff failed to assist the resident with colostomy care, resulting in it leaking and causing her to feel embarrassed in front of her roommate. This failure could cause the resident embarrassment and a decreased sense of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #5) reviewed for ostomy care. The facility failed to assist Resident #5 with colostomy care resulting in her colostomy leaking. This failure could place the resident at risk of skin irritation and breakdown from exposure to fecal matter.

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination and the PASARR evaluation report for 8 (Residents #2, #3, #15, #23, #29, #39, #62, #71) of 10 residents reviewed for PASARR assessments. The facility failed to submit a Nursing Facility Specialized Services (NFSS) form request by the specific deadline for Residents #2, #3, #15, #23, #29, #39, #62, and #71. This failure could place residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require.

Inspectors wroteBased on observation, interview, record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 6 residents (Residents #13 and Resident #63) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #13's care plan was revised to include her pleasure feedings. 2. The facility failed to ensure Resident #63's care plan was revised to include his dialysis treatment. This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Residents #25) of five residents reviewed for ADL care. The facility failed to provide Resident #25 assistance with timely incontinence care. The failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 (Resident #81) of 2 residents reviewed for intravenous fluids. The facility failed to ensure Resident #81's intravenous medication bag and tubing were labeled with the date, time, and initials. The facility failed to ensure Resident #81 received timely PICC line (used to deliver medications and other treatments directly to the large central veins near heart) dressing change. Resident #81 went without a dressing change for 8 days. The failures could affect residents by placing them at risk for infections and cross-contamination and at risk for medication error, and delay in medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on 1 of 4 medication carts (100 Hall medication aide cart) and 2 of 2 residents (Residents#36 and #57) reviewed for pharmacy services. The facility failed to ensure the 100 Hall medication aide medication cart contained accurate narcotic logs for Residents #36 and #57. These failures could place residents at risk for medication error, drug diversion, and delay in medication administration.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure an environment that was free of accident hazards and that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to ensure Resident #1 was provided with adequate supervision and free of potential harm when he eloped from the facility on 07/30/2024 without staff knowledge. The facility was informed of the elopement by a family member who reported the resident was found 8 miles from the facility. The facility failed to ensure staff rounded often to ensure all Resident #1 was in the facility prior to leaving at the end of their shift or upon starting their shift on 07/30/2024. A past non-compliance Immediate Jeopardy (IJ) situation was identified on 08/02/2024 at 1:40 PM. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as was possible for 1 of 1 doorway in the south hallway of Zone 3 in between the vending machines and the doorway to the smoking courtyard reviewed for accidents and hazards. The facility failed to ensure residents who accessed the south hallway of Zone 3 in between the vending machines and the doorway to the smoking courtyard was free of hazards, when a large puddle of water was observed on July 5, 2024. The facility failed to ensure the south hallway of Zone 3 in between the vending machines and the doorway to the smoking courtyard was free of slip/fall hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of four residents observed for infection control. The facility failed to prevent Resident #1's indwelling urinary Foley catheter device from contact with the floor. This failure could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plans for 3 (Residents #1, #2, and #3) of 5 residents reviewed for comprehensive care plans in that: The MDS Coordinators failed to individualize the care plans, to include interventions, for Residents #1, #2, and #3. This failure could place the residents at risk of receiving the individualized care they required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living, receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #1) of 3 residents reviewed for ADLs. The facility failed to ensure Resident #1 was not left in a soiled brief for an extended period of time on 04/04/24. This failure could place the resident at risk for skin breakdown.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and assure only authorized personnel had access to the keys for 1 (Resident #2) of 1 resident reviewed for pharmacy services, in that: The facility failed to ensure that Resident #2's albuterol inhaler, one bottle of levocetirizine (allergy medication) 5 mg, eleven pills Slow Fe (iron) tablets, and two yeast plus tablets were stored in a secured place. This failure could place all residents on the 300 Hall North at risk of drug diversion or misuse of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for one (Resident #3) of five resident rooms reviewed for accidents and hazards. The facility failed to ensure the closet doors in Resident #3's room were maintained in a safe and functional manner. This failure could place residents at risk of accidents or injury.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #1) of 3 residents reviewed for accurate medical records in that: LVN A failed to complete the initial admission assessment documentation on Resident #1 when she admitted to the facility on [DATE]. LVN A failed to document on the MAR/TAR indicating what medication Resident #1 admitted with and whether any of the medications were administered during Resident #1's short stay in the facility. This deficient practice could result in misinformation about professional care provided.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for two (Resident #1 and Resident #2) of four residents reviewed for and pharmacy services. 1. The facility failed to follow physician orders and provide Resident #1's treatment to her newly amputated leg sutures and incision site on 12/25/23, 12/27/23, 01/01/24 and 01/03/24. 2. The facility failed to follow physician orders and provide Resident #2 her analgesic topical pain medications of Diclofenac Sodium External Gel on 01/05/23 and a Lidocaine Patch on 01/02/24, 01/03/24 and 01/05/23. The failure could place residents at risk for increased pain, infection and physical discomfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for one (Resident #1) of three reviewed for quality of care. The facility failed to maintain ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for Residents #1. The failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, maintained medical records on each resident that were complate and accurately documented for one (Resident #1) of four residents reviewed for quality of care. The facility failed to provide wound care to Resident #1's coccyx on 12/25/23, 12/26/23, 12/27/23, 12/30/23 and 01/01/24 through 01/04/24 and document when it was provided. The facility failure placed residents at risk of continued pain, discomfort, infection and a worsening of their wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for eight (Rooms #302, #303, #305, #306, #307, #308, #309) of ten rooms reviewed for infection control. CNA A failed to use hand hygiene while passing lunch trays on the 300 hall Rooms #302, #303, #305, #306, #307, #308, #309. These failures could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on interview and record review, it was determined the facility failed to inform the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in mental or physical condition of a resident who has mental illness or intellectual disability for one (Resident #1) of one resident reviewed. The facility failed to notify Resident #1's state mental health agency or intellectual disability agency of a significant change for Resident #1 when he expired on [DATE]. This failure could affect residents in the facility that are PASRR positive for their mental health agency or state intellectual disability agency not being notified of a significant change for residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting appropriate to their needs for 6 (Residents #8, #10, #34, #38, #40, and #76) of 8 residents reviewed for PASARR compliance. The facility failed to follow up on Residents #8, #10, #34, #38, #40, and #76, who were PASARR Level I positive and refer them to the local authority for further evaluation to determine their need for specialized services. This failure placed the residents at risk of not receiving the full extent of services available to them and/or alternative living accommodations.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #82) of 18 residents reviewed for quality of care. The facility failed to ensure Resident #82 received dressing changes to his lower legs as scheduled. This failure placed the resident at risk of infection and decreased feelings of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status based on the residents' comprehensive assessments for 4 (Residents #90, #91, #204, and #206) of 18 residents reviewed for nutrition. The facility failed to obtain Resident #90, #91, #204, #206 weights at admission per facility policy. This failure placed the resident at risk of infection and decreased feelings of self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good nutrition for 2 (Residents #37 and #81) of 18 residents reviewed for ADL's. 1. The facility failed to ensure Resident #37 was getting assistance with feeding. 2. The facility failed to ensure Resident #81 was bathed as scheduled. This failure had the potential to affect residents by placing them at risk for poor nutrition and a decline in their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders and the comprehenxive person-centered care plan for 1 (Resident #97) of 1 resident reviewed for parenteral fluids. The facility failed to ensure Resident #97's PICC line dressing remained intact. This failure placed the resident at risk of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for one (Resident #37) of five residents reviewed for therapeutic diets. The facility failed to provide Resident #37 a pureed diet as prescribed by the physician. The failure placed residents at risk for aspiration and weight loss.