Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to provide Personal Privacy/Confidentiality for 1
of 3 residents (R2) reviewed for dignity and respect in the sample of 13.
Residents Affected - Few
Findings include:
R2's Face Sheet, not dated, documents, that R2 was readmitted to the facility on [DATE] with diagnosis of
Pressure ulcer of sacral region, unspecified stage listed as diagnosis.
R2's Care Plan, dated 10/10/2023, documents, Pressure Ulcer: Unstageable (Slough and/or eschar) to
Sacrum.
R2's Minimum Data Set, dated [DATE], documents that R2 is severely impaired cognitively and never/rarely
made decisions.
On 10/30/2023 at approximately 10:10 AM V16, LPN, stated, that she is the Nurse on the hall and also
helps with the wounds. V16 stated, that she does take pictures of wounds for treatment purposes. V16
stated, that she sends those pictures to V2, Director of Nurses, and V17, Wound Nurse (from outside
company).
On 10/30/2023 at approximately 11:00 AM. V2, Director of Nurses, stated that the facility does not take
pictures of wounds in the facility. V2 stated, that this is not a requirement of the Wound Nurse. V2 stated,
that they do not have a policy on taking photos of wounds, because this is not something that is done at
this facility. V2 stated, that he is not aware of staff taking pictures of residents and or resident wounds on
their personal phone.
On 10/30/2023 at approximately 11:30 AM V18, R2's daughter, stated that she was not aware of facility
staff taking pictures of R2's wound. V18 stated that she did not give permission for staff to take pictures of
residents wound on her coccyx.
On 10/30/2023 at 4:07 PM V15, R2's Daughter-in-law, stated that she came in to visit R2 in the afternoon.
R2 stated that R2 was soiled with bowel. V15 stated that she pulled the call light and waited for staff. V15
stated that she waited a little while and then went to the Nurse. V15 stated that she voiced her concerns to
the Nurse. V15 stated that she informed V16, Licensed Practical Nurse, that R2 was sitting in stool. V15
stated that she asked V16 how was R2's wound supposed to heal if R2 is sitting in stool for over 2 hours.
V15 stated that V16 informed V15 that R2's wound was improving. V15 stated that V16 then pulled out her
phone and showed V15 a picture of R2's coccyx wound when R2 was first admitted and the wound at a
later date. V15 stated, that V16 scrolled through her personal
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
146052
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alhambra Rehab & Healthcare
417 East Main Street, Box 310
Alhambra, IL 62001
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0583
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
photos of her family and children and then showed the photos of the wound on the coccyx. V15 stated that
anyone looking at her pictures would see R2's wound on her buttocks. V15 stated that R2 can't say
anything at this point, but that R2 would not like that. V15 stated that R2 would not have given the ok to take
pictures and keep them in their personal phone. V15 stated that if she gave the phone to someone to look
at her photos R2's coccyx wound would be seen. V15 stated that R2 would be embarrassed. V15 stated
that she asked V16 why she had pictures of R2's coccyx wound. V15 stated that V16 informed her that she
sends the pictures to her Director of Nurses. V15 stated now V2 has pictures of R2's coccyx wound and
rear end in his personal phone. V15 stated that I don't know if this is how things are done, but I do know
that R2 would not be ok with this.
On 10/31/2023 at 11:01 AM V17, APRN FNP-BC, stated, that she is the (Wound Management Company),
Wound Nurse. V17 stated that the normal process of new admits with wounds is the staff will describe the
wound to her and then review the current orders if any and then either continue the current order or change
it. V17 stated that this will treat the wound until she sees the wound on Tuesday. V17 stated that she did
receive a picture of R2's wound from V16. V17 stated that R2 was admitted from the hospital. V17 stated
per R2 the wound was worse than what was reported from the hospital. V17 stated that V16 sent V17 the
picture of the wound. V17 stated that the picture did not identify the area of the body. V17 stated that she
had to respond to V16 and ask where the wound was and who was the resident. V17 stated that V16 did
respond. V17 stated that she gave direction and orders for R2. V17 stated that this is not the normal way of
communicating. V17 stated that V16 was having a difficult time describing the wound and sent the picture.
V17 stated that she felt it was ok, because the location was unidentifiable. V17 stated that she would expect
that the picture be deleted immediately.
On 10/31/2023 at approximately 2:50 PM V16 stated, that she did take a picture of R2's wound on her
coccyx with her personal phone. V16 stated that she was notified of R2 had a stage 4 wound on her coccyx
the day before admission. V16 stated that she was aware of the wound. V16 stated that she had not had
any visual of the wound. V16 stated that in report from the hospital on the day of admission she was again
notified of the stage IV pressure ulcer to R2's coccyx. V16 stated that when R2 was admitted the wound
was different that she expected and did not know what to do. V16 stated that she notified the (V2) Director
of Nurses and they both looked at the wound. V16 stated that at that time she took a picture of the wound
and sent it to V17 for guidance. V16 stated that V2 was with her when she took the picture. V16 stated that
she deleted the picture immediately. When asked if she showed a picture of the wound to the family? V16
denied. V16 stated that she did not discuss with the family a picture of the wound. When asked how would
the family know that pictures were taken by V16 and visually seen them? V16 stated that she does not
know.
On 10/31/2023 at approximately 3:00 PM V2 stated that V16 did take the picture of R2's coccyx wound. V2
stated that he went down to the room. V2 stated that the facility does not have wounds of this caliber. V2
stated that upon admission (V2 ) and V16 looked at the wound. V2 stated that they were unsure if the
treatment was the correct one and did not know how to proceed with this wound treatment. V2 stated at that
time V16 took a picture of the wound, with V16's personal cell, and sent it to V17 cell. V2 stated that it was
easier to show her then try to describe what was being seen. V2 stated that he thought the photo was
deleted and would have expected it to be deleted. V2 stated that this is the not normal practice but felt this
was an extenuating circumstance. When asked what was the extenuating circumstance? V2 stated that the
wound was different than what was received in report. V2 stated that the expectation would be that the
Nurse would delete the photo and not keep it in her personal phone.
The Illinois Long Term Care Ombudsman Program Residents Rights for people in Long-Term Care
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146052
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146052
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alhambra Rehab & Healthcare
417 East Main Street, Box 310
Alhambra, IL 62001
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0583
Level of Harm - Minimal harm
or potential for actual harm
Facilities, dated 11/18, documents as Long-term care resident in Illinois, you retain the same rights as
every citizen of Illinois and the United States. It also documents, your facility must treat you with dignity and
respect and must care for you in a manner that promotes your quality of life. It continues, Your medical and
personal care are private. Facility must respect your privacy when you are being examined and given care.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146052
If continuation sheet
Page 3 of 3
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
FAQ · About this visit
Common questions about this visit
What happened during the November 2, 2023 survey of ALHAMBRA REHAB & HEALTHCARE?
This was a inspection survey of ALHAMBRA REHAB & HEALTHCARE on November 2, 2023. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALHAMBRA REHAB & HEALTHCARE on November 2, 2023?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Keep residents' personal and medical records private and confidential."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.