Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 New Summit Rehabilitation And Healthcare during CMS and state inspections, most recent first.
Two residents at risk for falls did not have required safety interventions in place. One resident, with mobility impairments and morbid obesity, was transferred without a gait belt and fell, resulting in a right ankle fracture that required surgery. Another resident with dementia was repeatedly observed in bed without fall mats in place and with the bed not in the lowest position, despite care plan and physician orders. Staff interviews and record review confirmed that these interventions were not consistently implemented.
Multiple residents did not receive care as ordered, including a resident who was moved after a fall before a nursing assessment was performed, a resident whose ace wrap orders for edema were not entered or applied after a podiatry visit, a resident with a cervical fracture who was not wearing a required neck collar during care, and a resident whose mirtazapine was discontinued due to lack of order clarification. These deficiencies resulted from failures to follow physician orders, clarify medication regimens, and adhere to assessment protocols.
Surveyors found that staff did not consistently monitor refrigerator temperatures or ensure perishable foods were properly dated and discarded, both in common areas and resident rooms. Opened thickened liquids and various food items were stored past recommended timeframes or without open dates, and some refrigerators lacked thermometers or operated above safe temperatures. Staff and family members were not consistently following or informed of food safety policies, leading to improper food storage and handling.
The facility did not consistently implement Enhanced Barrier Precautions and Contact Isolation for residents with wounds, G-tubes, and infections. Staff and a private caregiver failed to use required PPE, and staff did not change soiled gloves between tasks, leading to lapses in infection prevention and control.
A resident's MDS assessment was completed inaccurately, listing a discharge to an acute hospital when the resident was actually discharged home with family for home health care. The DON confirmed the error, and the CEO stated there was no specific assessment policy, with staff following the RAI procedure.
Two residents with pressure injuries did not receive required interventions: one was repeatedly found without a low air loss mattress and heel boots as ordered, and another was observed without a dressing on a stage 4 heel ulcer despite physician orders. These lapses occurred despite facility protocols and care plans specifying these interventions.
Two residents with indwelling urinary catheters did not receive proper catheter care, as one had a catheter bag positioned above the bladder during a transfer, causing urine backflow, and another had a catheter bag left on the floor during and after wound care. Facility policy requires catheter bags to be kept below the bladder and off the floor, but these protocols were not followed.
Two residents were not properly monitored during medication administration: one with severe cognitive impairment was found with partially dissolved pills in her mouth after a nurse failed to check for pocketing, and another was found with multiple medications at her bedside without orders or assessment for self-administration, contrary to facility policy and physician orders.
A high fall risk resident, an 85-year-old female with a post-surgical amputation, was found unable to reach her call light, which was wrapped around the bed rail on the opposite side of the bed. The CNA and DON confirmed that call lights should be within reach, as per the facility's policy. This deficiency was identified during a safety review of residents.
A facility failed to consistently perform and document treatment orders for a resident with a stage 3 sacral pressure injury. Despite having specific treatment orders, there were five instances where the treatment was not documented over a 23-day period. The Director of Nursing noted that the former wound nurse did not document treatments, contributing to the deficiency.
The facility failed to initiate Enhanced Barrier Precautions (EBP) for residents with an increased risk of contracting MDROs during high contact activities. Observations revealed that residents with invasive medical devices and chronic wounds did not have EBP signs or isolation carts with PPE outside their rooms. Staff did not wear gowns during high-contact care activities, despite the presence of chronic wounds and invasive medical devices, indicating a systemic failure to implement EBP as required.
A resident dependent on staff for showers and bathing did not receive necessary hygiene care for 18 days. Despite the facility's policy and the resident's ability to express his wishes, staff failed to provide scheduled showers, resulting in missed hygiene care on four out of five scheduled days.
A resident with multiple sclerosis and quadriplegia was found without a physician-ordered foam dressing on his sacrum, despite being at high risk for skin breakdown. The facility failed to document and perform the required dressing changes, leading to a deficiency in pressure ulcer care.
The facility failed to ensure proper catheter care for three residents, leading to deficiencies in infection control and resident dignity. Issues included kinked tubing, improper drainage bag placement, and lack of sanitation during catheter care.
A resident with chronic respiratory and heart conditions did not receive oxygen at the physician-prescribed rate, leading to labored breathing and wheezing. Staff confirmed the oxygen was turned off, contrary to the resident's needs and facility policy.
The facility failed to honor a resident's food preference by repeatedly serving eggs for breakfast despite the resident's aversion and claims of allergy. The dietary staff did not accommodate the resident's preference, even after being informed by the CNA and RD.
Failure to Implement Fall Prevention and Safe Transfer Interventions
Penalty
Summary
The facility failed to implement appropriate fall prevention interventions and ensure safe transfer practices for two residents identified as being at risk for falls. One resident, who had diagnoses including cellulitis, unsteadiness of feet, abnormal gait, reduced mobility, and morbid obesity, required partial to moderate assistance for transfers. On the day of the incident, a CNA assisted the resident to the bathroom and instructed her to hold the grab bar and stand. As the resident attempted to stand, she lost her balance and fell. The CNA did not use a gait belt during the transfer, contrary to facility policy and the resident's care requirements. The resident sustained a right ankle fracture, which was later confirmed by X-ray and required surgical intervention. Interviews with staff and the DON confirmed that a gait belt should have been used and that the injury likely resulted from the fall. Another resident with impaired cognition, dementia, and a moderate risk for falls was observed in bed with fall mats stacked against the wall rather than positioned next to the bed as required by her care plan and physician orders. The bed was also not in its lowest position, further increasing the risk of injury from a potential fall. Multiple observations confirmed that the fall mats were not in place during different times, and staff interviews indicated awareness that the mats should be next to the bed when the resident is in it. Record review showed that both residents had documented fall risks and specific interventions ordered and care planned, such as the use of gait belts for transfers and placement of fall mats and low bed positioning. Despite these documented interventions, staff failed to consistently implement them, resulting in a fall with injury for one resident and unsafe conditions for another.
Failure to Follow Physician Orders and Assessment Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for several residents. In one instance, a resident who experienced a fall in the bathroom was assisted off the floor and placed in a wheelchair by CNAs before a nurse was notified or an assessment was performed. The Director of Nursing confirmed that facility policy requires a nurse to assess a resident before moving them after a fall, and follow-up assessments were not documented in the medical record for the required period following the incident. The resident later complained of increased pain, and an X-ray revealed an acute fracture, indicating that the necessary post-fall monitoring and documentation were not completed as per policy. Another resident returned from a podiatry appointment with ace wraps applied to both lower extremities for edema control, but the new order for ace wraps was not entered into the facility’s electronic system. The resident reported that nursing staff did not reapply the ace wraps after dressing changes, and the wound care nurse confirmed that the order was not entered due to a communication issue. The Director of Nursing stated that it is the floor nurse’s responsibility to enter new orders from outside appointments, but this was not done, resulting in the resident not receiving the prescribed treatment. Additional deficiencies included a resident with a cervical vertebral fracture who was ordered to wear a soft cervical collar at all times, but was observed without the collar secured during care, leading to complaints of neck pain during repositioning. Another resident’s medication order for mirtazapine was not properly clarified upon admission, resulting in the medication being discontinued for several weeks despite ongoing indications for its use. The facility’s policy requires clarification of medication orders, especially when stop dates are unclear, but this was not followed, leading to an interruption in the resident’s prescribed medication regimen.
Failure to Monitor and Date Perishable Foods in Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to properly monitor and maintain both resident and common area refrigerators, and did not ensure that perishable foods were appropriately dated and discarded according to professional standards and manufacturer recommendations. Specifically, opened boxes of thickened liquids in the bistro area refrigerators were found with only the date of receipt, not the date they were opened, and remained in the refrigerators well past the recommended 6-7 day discard period. The Dietary Manager confirmed that staff are expected to label boxes with the date opened and discard them after 6 days, but there was no formal policy in place, only manufacturer guidance. Additionally, the Diet Type Report indicated that several residents required thickened liquids, making proper handling critical for their care. Further deficiencies were noted in resident room refrigerators, where some units lacked thermometers and were found operating above the recommended temperature range of 33-41°F. Perishable food items, including yogurt, hot dogs, and lunch meat, were stored without proper dating, and residents or their families were not consistently informed or required to label or check in food brought from home. Staff interviews confirmed that the same food safety rules apply to resident refrigerators as to the kitchen, including the need for dating and timely disposal of perishable items. The facility's own policy required labeling and dating of perishable foods, but this was not consistently followed, as evidenced by undated and potentially expired food items found during the survey.
Failure to Implement and Maintain Infection Control Precautions
Penalty
Summary
The facility failed to implement and maintain appropriate infection prevention and control measures for multiple residents requiring Enhanced Barrier Precautions (EBP) and Contact Isolation. One resident with multiple wounds was not placed on EBP upon re-admission from the hospital, despite having an order for EBP and documented unstageable and stage 3 pressure injuries. The resident's room did not have the required EBP signage or personal protective equipment (PPE) available until it was noticed during a chart review, resulting in a delay in initiating necessary precautions. Another resident with a gastrostomy tube (G-tube) was not provided with EBP signage or PPE at the room entrance. Staff providing care to this resident did not consistently use the required gown and gloves during high-contact activities, such as medication administration via the G-tube and incontinence care. Additionally, a certified nursing assistant (CNA) failed to change soiled gloves before handling the resident's personal items and before continuing with clean care tasks, increasing the risk of cross-contamination. A resident on Contact Isolation for a Clostridium difficile infection had a private caregiver who was not informed of the isolation status and was not educated on the need to wear PPE while in the room. The caregiver provided direct care without wearing a gown or gloves until educated later in the day. Another instance involved a CNA providing incontinence care to a resident on supplemental oxygen, where the CNA failed to change soiled gloves before handling clean items and transferring the resident, contrary to facility policy and infection control standards.
Inaccurate MDS Assessment for Discharge Status
Penalty
Summary
The facility failed to ensure an accurate assessment was completed for one resident. The Minimum Data Set (MDS) for this resident indicated a discharge status of transfer to a short-term general hospital, while the resident's progress notes documented that the resident was actually discharged home with a family member to receive home health care. During interviews, the Director of Nursing confirmed that the MDS was completed in error and that the resident was not hospitalized, as supported by the progress notes. The Chief Executive Officer stated that the facility does not have a specific policy on assessments and relies on the Resident Assessment Instrument (RAI) procedure for timely and accurate MDS submissions.
Failure to Implement Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
A deficiency occurred when a resident was admitted with a deep tissue injury (DTI) to the left buttock, blanchable redness to the coccyx and right buttock, and blanchable redness to both heels. Physician orders and facility protocols required the use of a low air loss mattress and heel boots to prevent further skin breakdown. Despite the mattress being delivered on the day of admission, the resident was observed on multiple occasions lying on a standard mattress instead of the prescribed low air loss mattress. Additionally, the resident was repeatedly found in bed without heel boots, with their heels resting directly on the mattress, contrary to the care plan and physician orders. The DON confirmed that such interventions are necessary for residents with wounds or at high risk for skin breakdown. Another deficiency was identified when a second resident with a stage 4 pressure injury to the left heel, who had physician orders for medi-honey and a dry dressing, was observed without a dressing on the wound during a wound assessment. The wound care nurse confirmed that the resident should have had a dressing in place and that dressing changes were ordered three times a week and as needed. The facility's policy required identification and implementation of treatment interventions for pressure injuries, which was not followed in this instance.
Failure to Maintain Proper Positioning of Indwelling Urinary Catheter Bags
Penalty
Summary
The facility failed to ensure proper care and handling of indwelling urinary catheter bags for two residents. In the first instance, a resident with an indwelling urinary catheter was being transferred from bed to a shower chair using a mechanical lift. During the transfer, two CNAs attached the catheter bag to the sling strap of the lift, positioning it above the resident's bladder. This resulted in visible backflow of cloudy yellow urine into the resident's bladder. The resident's care plan and the facility's urinary catheter care policy both specify that catheter bags should be kept below the level of the bladder at all times to prevent backflow. In the second instance, another resident's indwelling urinary catheter bag was observed lying on the floor next to the bed while the resident was in bed. The bag remained on the floor during and after a wound care procedure performed by a wound care nurse and nurse practitioner, and was still on the floor later that morning. The facility's catheter care policy states that catheter bags should be kept off the floor. These observations were confirmed by the DON, who acknowledged that the catheter bags were not handled according to policy.
Failure to Ensure Proper Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure proper medication administration and monitoring for two residents. In one instance, a female resident with severe cognitive impairment and a diagnosis of dementia was observed with partially dissolved pills falling from her mouth nearly two hours after the morning medication pass. The registered nurse who administered the medication stated that they believed the resident had swallowed all her pills but did not check for pocketing after administration. Both the LPN and the VP of Operations confirmed that nurses are expected to ensure residents have swallowed their medications as part of the administration process. The facility's policy requires medications to be administered safely, timely, and as prescribed. In another case, a resident was found with multiple bottles of medications, including nasal sprays and eye drops, at her bedside over consecutive days. The LPN and DON both stated that residents must have an order and be assessed for the ability to self-administer medications and keep them at the bedside, which had not been done for this resident. The resident's physician orders did not include permission for self-administration or bedside storage of these medications, and there was no order for one of the medications present. The facility's policy specifies that self-administration must be approved and assessed by the attending physician and treatment team.
Call Light Inaccessibility for High Fall Risk Resident
Penalty
Summary
The facility failed to ensure a call light was within reach for a high fall risk resident, identified as R1, who was part of a sample of 16 residents reviewed for safety. R1 is an 85-year-old female resident admitted to the facility with a post-surgical amputation and reduced mobility, requiring assistance with personal care and transfers. On the date of observation, R1 was found sitting in her wheelchair with the call light wrapped around the bed rail on the opposite side of the bed, approximately 2-3 feet away, making it inaccessible. R1 confirmed she could not reach the call light and demonstrated her inability to do so. A Certified Nursing Assistant (CNA) acknowledged that call lights should be within reach before leaving a resident's room, and the Director of Nursing (DON) confirmed that call lights should be accessible to residents. The facility's Call Light Policy, dated September 2022, mandates that call lights be accessible to residents when in bed, on the toilet, in the shower, or on the floor.
Failure to Document and Perform Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that treatment orders were consistently performed for a resident with a stage 3 sacral pressure injury. The resident, a female with a complex medical history including spinal stenosis, quadriplegia, and reduced mobility, had a documented stage 3 pressure wound on her sacrum. The wound was noted to have moderate serous drainage and varied in size over time, indicating ongoing issues with healing. Despite having specific treatment orders documented in the Medication Administration Record (M.A.R.) for cleansing and dressing the wound, there were five instances out of 23 days where there was no documentation that the treatment was provided. The Director of Nursing acknowledged that the former wound nurse was not documenting wound treatments, which was a contributing factor to the deficiency. The facility's Wound Care Policy, which outlines the necessity of recording the type of wound care given, the date and time, and the name and title of the individual performing the care, was not adhered to. This lack of documentation and adherence to the wound care policy led to a failure in promoting wound healing for the resident.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to initiate Enhanced Barrier Precautions (EBP) for residents with an increased risk of contracting a Multi-drug Resistant Organism (MDRO) during high contact activities. This deficiency was observed in 8 of 10 residents reviewed for infection control and 7 residents outside the sample. During a facility-wide tour, it was noted that residents with invasive medical devices and/or chronic wounds did not have EBP signs on their doors, nor did they have isolation carts with PPE outside their rooms. Specific instances included residents with conditions such as below-the-knee amputation, PICC lines, G-tubes, and indwelling catheters, where staff did not don gowns during high-contact care activities, despite the presence of chronic wounds and invasive medical devices. One resident with a below-the-knee amputation and a history of infections was observed receiving IV antibiotics through a PICC line without the staff wearing gowns. Another resident with a G-tube was administered medications by a nurse who did not wear a gown, despite frequent contact with the resident's bed. Additionally, a resident with an indwelling catheter received incontinence and catheter care from staff who did not wear gowns. These observations were consistent across multiple residents with similar conditions, indicating a systemic failure to implement EBP as required. The facility's Infection Control Nurse and Director of Nursing acknowledged the availability of PPE and the policy for EBP but admitted to not realizing that residents with chronic wounds and invasive medical devices needed to be on EBP. The facility's policy and the Centers for Medicare & Medicaid Services' guidelines clearly state that EBP should be used for residents with wounds and/or indwelling medical devices to prevent the spread of MDROs. The lack of adherence to these guidelines led to the observed deficiencies in infection control practices at the facility.
Failure to Provide Scheduled Showers to Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident, who is totally dependent on staff for showers and bathing, received the necessary hygiene care. The resident, diagnosed with multiple sclerosis and quadriplegia, reported not being offered a shower since admission 18 days prior. Observations confirmed the resident's hair was greasy and uncombed, and the resident stated that staff had only wiped him down with peri wipes once or twice. The resident's bath schedule indicated missed showers or bed baths on four out of five scheduled days, and the resident and his wife confirmed that he never refused showers or bed baths, contradicting the facility's records. Interviews with staff, including a Certified Nurse Aide and a Registered Nurse, confirmed that the resident should be receiving showers at least twice a week and that the resident had no memory problems and could express his wishes. The Director of Nurses emphasized the importance of regular showers for infection prevention, dignity, wound prevention, and overall health. The facility's policy on Activities of Daily Living, revised in March 2018, mandates appropriate care and services for residents unable to carry out ADLs independently, including hygiene care. Despite this policy, the resident did not receive the necessary hygiene care as required.
Failure to Ensure Physician-Ordered Dressing for Resident at Risk for Skin Breakdown
Penalty
Summary
The facility failed to ensure a physician-ordered dressing was in place for a resident at risk for skin breakdown. The resident, who has multiple sclerosis, quadriplegia, and other conditions, was observed without the required foam dressing on his sacrum, which had a grapefruit-sized, circular reddened area. The resident mentioned that the dressing had not been applied recently, although it was supposed to be changed every Tuesday, Thursday, and Saturday. The Director of Nurses confirmed the resident's high risk for skin breakdown and the necessity of the foam dressing but could not provide documentation of the dressing changes being done as ordered. The resident's care plan and pressure ulcer risk assessment indicated a moderate risk for developing pressure ulcers, and the facility's policy required documentation and reporting of wound treatments. However, during an observation, the resident was found without the foam dressing, and there was no record of the dressing changes being performed. This lack of adherence to the physician's orders and facility policy contributed to the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Deficiencies in Catheter Care and Infection Control
Penalty
Summary
The facility failed to ensure proper catheter care for three residents, leading to deficiencies in infection control and resident dignity. One resident was observed with kinked and occluded catheter tubing under her leg, and she was unaware of the reason for having a catheter. The Director of Nursing (DON) confirmed that such kinks could cause urinary retention and increase the risk of infection. The resident's care plan indicated the need to check for kinks, but this was not adhered to during the observation. Another resident was found with a catheter drainage bag laying on his bed, which was against infection control protocols. The resident's catheter bag was also visible from the hallway, despite a dignity bag being available. The DON confirmed that the drainage bag should always be below the bladder and covered to prevent backflow and maintain dignity. The resident's urinalysis report showed signs of infection, and he was subsequently treated for a urinary tract infection. A third resident had a drainage bag hanging on the bed railing, visible from the hallway, and the catheter stat lock was not properly secured. During catheter care, the CNA did not sanitize the tubing after it touched a non-sterile surface. The DON stated that stat locks should be secure to prevent kinking and pulling, and drainage bags should remain below the bladder. The facility's policies on catheter care and dignity were not followed, leading to potential infection risks and compromised resident dignity.
Failure to Administer Oxygen at Prescribed Rate
Penalty
Summary
The facility failed to ensure that oxygen was administered at the physician-prescribed rate for a resident with chronic obstructive pulmonary disease, chronic diastolic heart failure, and other conditions. The resident had a physician order for oxygen at 2 liters per minute to maintain oxygen saturation above 92%. However, during observations, the resident's oxygen was found to be set at zero liters per minute, despite the resident wearing the nasal cannula and experiencing labored breathing and wheezing. The resident was unsure if the oxygen was running, and a nurse confirmed that the oxygen was not on, attributing it to the therapy department turning it off earlier in the morning. The nurse acknowledged that the resident needed the oxygen continuously to prevent desaturation and breathing issues. Further interviews with staff, including another RN and the Director of Nurses, emphasized the importance of administering oxygen at the prescribed level to prevent hypoxia, shortness of breath, and respiratory distress. The facility's policy on oxygen administration also stated that the proper flow of oxygen should be ensured for resident safety. The failure to administer oxygen as ordered led to the resident experiencing labored breathing and potential health risks due to inadequate oxygen levels.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preference and find an appropriate alternative for a resident who dislikes and claims to be allergic to eggs. On multiple occasions, the resident received eggs for breakfast despite informing staff of her aversion. The resident expressed that the smell of eggs made her sick to her stomach, and she resorted to eating oatmeal instead. A CNA confirmed that the resident did not like eggs and mentioned that other residents also did not want eggs. Despite notifying the kitchen, the dietary staff did not accommodate the resident's preference. The Registered Dietician (RD) stated that she meets with all new residents to discuss their dietary preferences and records these in her progress notes, which are then communicated to the dietary manager. The RD confirmed that she had discussed alternatives to eggs with the resident and informed the kitchen, but she needed to follow up on the matter. The facility's menu showed that eggs were served for breakfast on most days, and the resident's nutrition form and care plan indicated her dislike for eggs. The facility's Food Preference policy mandates that food preferences should be honored, but this was not adhered to in this case.
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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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Nursing homes near Arlington Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lutheran Home For The Aged | 0.7 mi | ★★★★★ | 23 | 0 |
| Moorings Of Arlington Heights | 2.3 mi | ★★★★★ | 0 | 0 |
| Bella Terra Wheeling | 3 mi | ★★★★★ | 0 | 0 |
| Pearl Of Rolling Meadows,the | 3 mi | ★★★★★ | 5 | 0 |
| Eden Vista Prospect Heights | 3 mi | ★★★★★ | 8 | 0 |
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