Elmhurst Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Elmhurst Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF757Jan 28, 2025

  Based on record review and staff interview, it has been determined that the facility failed to ensure that residents are free from unnecessary medications for 1 of 2 residents reviewed who have cancer diagnoses, Resident ID #1. Findings are as follows: Review of a community reported complaint dated 1/17/2025 alleged that a cancer medication was given to the wrong resident for 14 days. During a surveyor interview on 1/21/2025 at 9:35 AM with Registered Nurse, Staff A, she indicated that she mistakenly transcribed Resident ID #2's Abiraterone Acetate into Resident ID #1's medical record. Staff A acknowledged that Resident ID #1 received Abiraterone Acetate 1000 mg daily from 12/21/2024 through 1/2/2025 in error, for a total of 13 days. […]

• Immediate jeopardy, patternF698Mar 24, 2023

  Based on record review and staff interview, it has been determined that the facility failed to ensure that residents who require dialysis receive such services consistent with professional standards of practice for 2 of 6 residents reviewed for dialysis, Resident ID #s 291 and 147. Findings are as follows: 1) Record review revealed that the resident ID #291 was admitted to the facility in March of 2023 and has diagnoses including, but not limited to, acute respiratory failure with hypoxia (when your lungs cannot release enough oxygen into your blood, which prevents your organs from properly functioning) and end stage renal disease (when your kidneys can no longer support your body's needs). […]

• Immediate jeopardy, patternF689Nov 2, 2021

  Based on record review, surveyor observation, staff and resident representative interview, it has been determined the facility failed to provide adequate supervision and assistance devices to prevent accidents for 5 of 6 residents reviewed for elopement behaviors, Resident ID #'s 1, 6, 7, 8 and 10. Findings are as follows: Review of the facility policy titled, Wandering and Elopements states in part, Policy heading .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation . 1. […]

• Immediate jeopardy, isolatedF689Apr 24, 2026

  Based on clinical record review and staff interview, the facility failed to provide adequate supervision and failed to ensure an effective elopement prevention system for 1 of 1 resident reviewed, Resident #1. The resident, who resides on a secured unit due to impaired safety awareness and a high risk for elopement, requires a wander guard device (a safety mechanism intended to monitor and prevent at-risk residents from exiting unsupervised). Despite this intervention, the facility failed to prevent unsafe exit-seeking behaviors. The resident was able to self-propel while in his/her wheelchair to a stairwell door, manipulate the handle until it released, and exited into the stairwell, resulting in him/her falling down approximately 10 stairs with the wheelchair positioned over him/her. […]

• Immediate jeopardy, isolatedF756Jan 28, 2025

  Based on record review and staff interview, it has been determined the facility failed to ensure that medication irregularities were identified by the pharmacist during the monthly drug regimen review for 2 of 4 residents reviewed, Resident ID #s 1 and 3. Findings are as follows: Review of the facility policy titled, Medication Regimen Review and Reporting revised 1/2023, revealed Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risk associated with medications. […]