Arc at Kankakee

In the surveyor’s words

From the most serious findings on record at Arc at Kankakee, in the surveyor’s own words.

• Immediate jeopardy, widespreadF678Nov 20, 2023

  Based on interview and record review the facility failed to initiate CPR (Cardiopulmonary Resuscitation) for a resident (R2) with full code status. The facility also failed to have a system in place to ensure that Advance Directives were accurate and complete (R1, R5, R11, R12). These failures resulted in R2 not receiving CPR as desired; and R1 being sent to the hospital, intubated, and later compassionately extubated at the hospital. These failures have the potential to affect all 22 residents residing in the facility. Findings include: These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was noted to begin on [DATE] when the facility failed to initiate CPR for R2. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 11:45 AM. […]

• Actual harm, isolatedF684Jul 8, 2026

  Based on observation, interview, and record review, the facility failed to provide professional standards of care for an arm injury/laceration. The facility failed to adequately assess the degree of the injury/laceration, thoroughly document the injury/laceration, and provide necessary wound care. R1 was sent to the emergency room for a large laceration with bone and tendon exposed to R1's left arm. This failure applies to 1 of 3 residents (R1) reviewed for quality of care. The findings include: R1's electronic medical records show R1's diagnoses including metabolic encephalopathy, dementia, Alzheimer's disease, lack of coordination, and hearing loss. R1 was admitted to the facility January 06, 2026. […]

• Actual harm, isolatedF580Nov 20, 2023

  Based on interview and record review the facility failed to notify the physician of a resident's change of condition. This applies to 1 of 12 residents (R2) reviewed for advanced directives in a sample of 14. This failure resulted in a potentially avoidable death when R2's change in condition was not addressed and R2 expired unexpectedly. Findings include: R2's Face Sheet dated [DATE] identified R2 as a [AGE] year-old admitted to the facility on [DATE] with diagnoses to include Rhabdomyolysis and DVT (Deep Vein Thrombosis). On [DATE] at 12:50 PM V12 (Certified Nursing Assistant/CNA) stated around 8:20 PM [DATE] R2 was moaning and groaning like she was in pain and was breathing abnormal when she was moved. […]

• Actual harm, isolatedF600Nov 20, 2023

  Based on interview and record review the facility failed to keep a resident free from neglect when they failed to notify the physician of a change in condition, provide medications as ordered, and initiate cardiopulmonary resuscitation. This applies to 1 of 12 residents (R2) reviewed for advanced directives in a sample of 14. This failure resulted in a potentially avoidable death when R2's change in condition was not addressed. R2 was later observed unresponsive and resuscitation and/or emergency interventions were not initiated. Findings include: R2's Face Sheet dated [DATE] identified R2 as a [AGE] year-old admitted to the facility on [DATE] with diagnoses to include Rhabdomyolysis and DVT (Deep Vein Thrombosis). […]

• No harm, potential for more than minimal, widespreadF812May 9, 2025

  Based on observation, interview, and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to 22 residents in the facility receiving dietary services. Findings include: On 05/06/25 at 10:30 AM, V6 (Dietary Manager) confirmed 22 residents in the facility receive food services from the kitchen. 1.) On 05/06/25 at 11:29 AM, V6 tested red sanitization bucket #3 at 500ppm (Parts Per Million). On 05/08/25 at 11:13 AM, V6 stated the red disinfecting bucket should be 200 to 400ppm. If the sanitizer level is too high could cause a chemical reaction to the skin. […]