Inspection visit
Inspection
17 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 17 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to monitor residents' weight that have a history of weight
changes for two of three residents (R28, R25) reviewed for weight change in the sample of 12.
Residents Affected - Few
The findings include:
1. R28's admission Record shows he was admitted to the facility on [DATE] with diagnoses including
traumatic subdural hemorrhage, skull fracture, gastrostomy status, protein-calorie malnutrition, pneumonia,
history of falling, cognitive communication deficit, need for assistance with personal care, and dysphagia.
R28's Order Summary Report dated July 18, 2023 shows an order for, Weigh every Tuesday and record.
R28's Dietary Note dated March 8, 2023 shows he was seen at bedside by registered dietitian for
significant weight loss.
R28's Weights and Vitals Summary shows he was weighed on March 21, 2023, April 26, 2023, May 9,
2023, June 17, 2023, and July 8, 2023. R28 weighed 152.8 pounds on March 21, 2023 and on July 8, 2023
R28 weighed 147.8 pounds. (Five pound weight loss)
On July 19, 2023 at 8:59 AM, V2 DON (Director of Nursing) said R28 has a percutaneous gastrostomy tube
but he is also eating orally. V2 said the weights are to monitor R28 for weight loss or gain. V2 said that V12
Dietitian emails or texts V2 when the weekly weights are not being done. V2 said the CNAs (Certified
Nursing Assistants) weigh the residents and are to document the weights.
2. R25's admission Record shows he was admitted to the facility on [DATE] with diagnoses including
hemiplegia, epilepsy, aphasia, traumatic hemorrhage of left cerebrum with loss of consciousness, major
depressive disorder, need for assistance with personal care, abnormal weight gain, and localized edema.
R25's Order Summary Report dated July 18, 2023, shows an order for weekly weights every Thursday.
R25's Care Plan initiated on January 28, 2022 shows, The guest has nutritional problem or potential
nutritional problem related to comorbidities.
R25's Weights and Vitals Summary dated July 18, 2023 shows R25's weight was taken on May 11, 2023,
June 1, 2023, June 8, 2023, June 22, 2023, and July 8, 2023. On 5/11/23, R25 weighed 206.2 pounds and
on July 8, 2023, R25 weighed 199.6 pounds. (6.6 pound weight loss)
(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 7
Event ID:
146179
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
146179
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
New Summit Rehabilitation and Healthcare
1200 N Arlington Heights Rd
Arlington Heights, IL 60004
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 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
On July 19, 2023 at 9:14 AM, V12 Dietitian said R25 had a history of weight gain. V12 said R25's weekly
weights are to monitor him for weight change. V12 said residents weights are done to monitor residents for
weight loss, and to keep a closer eye on the residents. V12 said she emails V2 DON when she sees that
the weights are not being completed.
The facility's Weight Assessment and Intervention policy revised March 2022 shows, Resident weights are
monitored for undesirable or unintended weight loss or gain. Resident are weighed upon admission and at
intervals established by the interdisciplinary team. Weights are recorded in each unit's weight record chart
and in the individual's medical record.
Event ID:
Facility ID:
146179
If continuation sheet
Page 2 of 7
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
146179
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
New Summit Rehabilitation and Healthcare
1200 N Arlington Heights Rd
Arlington Heights, IL 60004
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to administer medications as ordered.
There were 29 opportunities with 5 errors resulting in a 17.24% error rate.
Residents Affected - Few
The findings include:
1. On July 17, 2023 at 9:14 AM, V10 Registered Nurse (RN) was giving R21's his scheduled morning
medication. She did not give R21 his scheduled senna-docusate (stool softener), thiamine (vitamin B-1)
and hydrocortisone cream (anti-itch cream). When V10 RN gave R21 his morning medications he had a
scheduled Lidoderm (pain patch) patch to his lower back. She had to remove his old Lidoderm patch to
apply the new one. The old Lidoderm patch was dated July 16, 2023 (the day before).
R21's Medication Administration Record (MAR) for July 2023 shows, Senna-Docusate sodium oral tablet
8.6-50 MG (milligram), give 2 tablet by mouth in the morning for constipation. Thiamine HCL (hydrochloric
acid) oral tablet 100 mg, give 1 tablet by mouth one time a day for supplement. Hydrocortisone external
cream 1%, apply to rt (right) lower back, rt (right) hip, leg topically every 12 hours for rash. Lidoderm patch
5% , apply to lower back topically in the morning for lower back on at 9AM (9:00 AM), off at 9PM (9:00 PM.
And remove per schedule [SIC (statement is correct)].
On July 17, 2023 at 1:24 PM, V10 RN stated, the Lidoderm patch was dated from the day before (July 16,
2023) and she forgot to put the hydrocortisone cream on. She did not realize she missed the
senna-docusate tablets and thiamine.
2. On July 17, 2023 at 9:47 AM, V10 RN was giving R93 her scheduled morning medications. R93's blood
pressure was 100/55. V10 RN omitted her lisinopril (blood pressure) medication because she felt her blood
pressure was too low.
R93's MAR for July 2023 shows, lisinopril 5 mg tablet, give 1 tablet by mouth one time a day for HTN
(hypertension (high blood pressure)). The physician order does not show parameters for when to give or not
give the medication.
On July 17, 2023 at 1:24 PM, V10 RN stated, she did not talk with the doctor (he was at the facility at the
time of medication administration) about holding R93's blood pressure medication.
The facility's administering medication policy last revised April 2019 shows, Policy Statement: Medications
are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation:
.4. Medications are administered in accordance with prescriber orders, including required time frame. 8. If a
dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as
having a potential adverse consequences for the resident or is suspected of being associated with adverse
consequences, the person preparing or administering the medication will contact the prescriber, the
resident's attending physician or the facility's medical director to discuss the concerns.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146179
If continuation sheet
Page 3 of 7
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
146179
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
New Summit Rehabilitation and Healthcare
1200 N Arlington Heights Rd
Arlington Heights, IL 60004
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 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review the facility failed to follow the recipes, to ensure the
nutritive value of pureed foods, for four of four residents (R18, R25, R28, R197) reviewed for pureed diets in
the sample of 12.
Residents Affected - Some
The findings include:
The facility's Diet Report dated July 17, 2023, showed R18, R25, R28, and R197 received a pureed diet.
The facility's menu dated July 18, 2023, showed a lunch menu that included tuna salad on a croissant.
The facility's pureed tuna salad on croissant recipe dated 2020, showed 1 cup of milk should be blended
with 4 sandwiches of tuna salad on a croissant to make 4 pureed servings.
On July 17, 2023, at 10:25 AM, V5 [NAME] added 4 servings of tuna salad and an unmeasured amount of
water to the food processor. No croissants were added to the food processor. V5 blended the tuna salad
and water. V5 [NAME] then divided the mixture into 4 separate servings, to be served at lunch, and placed
them in the cooler.
On July 17, 2023, at 11:48 AM, V6 Dietary Manager delivered pureed food trays to residents. V6 stated, (V5
Cook) did not puree the croissant with the tuna salad for lunch today. She should have. When I asked her
why she didn't, she said she forgot.
On July 17, 2023, at 12:04 PM, V6 Dietary Manager stated, Recipes should be followed. If water is added
instead of milk to a recipe, it can change the nutritional value of the food.
On July 18, 2023, at 9:10 AM, V5 [NAME] stated she should have followed the menu and recipe on July 17,
2023.
The facility's Liquids Used In Preparing Pureed Food policy dated 2021 showed, The healthcare community
serves food in a form designed to meet individual client's needs. Standardized recipes along with the
Guidelines for Pureed Preparation will be used in pureed food preparation .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146179
If continuation sheet
Page 4 of 7
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
146179
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
New Summit Rehabilitation and Healthcare
1200 N Arlington Heights Rd
Arlington Heights, IL 60004
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview and record review the facility failed ensure staff wore hairnets in the
kitchen. The facility failed to store dry foods in a manner to prevent contamination. The facility failed to
sanitize/wash dishware in a manner to prevent cross contamination. The facility failed to ensure food
storage areas were clean and free of debris. These failures have the potential to affect all 35 residents in
the facility.
The findings include:
The facility's Resident Census and Conditions of Residents form dated July 17, 2023, showed a resident
census of 35.
On July 17, 2023, at 9:00 AM, V4 Kitchen Aide was observed walking around the kitchen with no hairnet
on. V4 walked over to the dishwasher and removed clean dishes from the dishwasher. V4 did not wash her
hands or don gloves prior to removing the dishes from the dishwasher. V4 then began rinsing dirty dishes,
not wearing any gloves. V4 placed the dirty dishes in the dishwasher. At 9:05 AM, V4 removed the clean
dishes from the dishwasher, without washing her hands or donning gloves prior to handling the clean
dishes.
On July 17, 2023, at 9:10 AM, an open plastic bag of raisin bran cereal was noted on a prep table in the
kitchen.
On July 17, 2023, at 9:12 AM, pieces of fruit were frozen to the floor in the walk-in freezer. Multiple pieces
of plastic and cardboard were also noted on the floor in the walk-in freezer.
On July 17, 2023, at 12:04 PM, V6 Dietary Manager stated, Staff should always wear a hairnet in the
kitchen, so hair doesn't get in the food. We should have two people washing dishes. If we only have one
person running the dishwasher, they are to change gloves and wash their hands in between handling dirty
to clean dishes. All floors are to be swept daily.
The facility's Storage of Dry Goods/Foods policy dated 2021 showed, Dry foods and goods are handled so
that the integrity of the packaging is maintained until ready to use . Opened products are labeled, dated
with the use by date and tightly covered to protect against contamination from insects and rodents .
Opened products that have not been properly sealed and dated are discarded .
The facility's Cleaning Dishes/Dish Machine policy dated January 1, 2015, showed, The person loading
dirty dishes should not handle the clean dishes unless they change their apron and wash their hands
thoroughly before moving from dirty to clean dishes .
The facility's Employee Sanitary Practices policy dated January 1, 2015, showed, All kitchen employees will
practice standard sanitary procedures . All employee are restraint hair and wear clean uniforms .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146179
If continuation sheet
Page 5 of 7
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
146179
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
New Summit Rehabilitation and Healthcare
1200 N Arlington Heights Rd
Arlington Heights, IL 60004
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
2. The facility's list of COVID positive patients as of Monday July 17, 2023 shows, R29, R21, R95 & R44 are
positive for COVID and on contact/droplet isolation.
Residents Affected - Many
On July 17, 2023 at 9:14 AM, V10 Registered Nurse (RN) was passing morning medications to all the
residents on the COVID unit. V10 went into R21's room wearing a KN95 mask and no goggles. At 11:21
AM, V10 RN went into R95's room wearing a KN95 and no goggles. R21 and R95 are on contact/droplet
isolation for being positive for COVID.
On July 18, 2023 at 10:19 AM, V11 RN went into R21's room wearing a KN95.
On July 18, 2023 at 9:35 AM, V3 Infection Control Nurse stated, staff should be wearing an N95, goggles,
gown and gloves when going into a resident on isolation for COVID.
3. On July 17, 2023 at 8:54 AM, V10 RN tested R94 for COVID. V10 RN was wearing only a KN95 and
gloves. She did not have on an N95, goggles or gown. V10 RN brought the test card out to the nursing cart
at the nursing station and set it done on the cart to wait for the results.
On July 18, 2023 at 9:35 AM, V3 Infection Control Nurse stated, staff should be wearing an N95, gown,
goggles and gloves when testing residents. They should also leave the test card in the room and go back to
read it.
The facility's PPE (personal protective equipment) Requirement for Confirmed or suspected COVID cases
and during outbreak status within facility policy last revised June 5, 2023 shows, If a resident is suspected
or confirmed to have COVID, staff must wear an N95 respirator, eye protection, gown and gloves.
Based on observation, interview and record review the facility failed to ensure a COVID positive staff
member did not provide cares to facility residents. The facility failed to ensure staff wore the recommended
personal protective equipment (PPE) when caring for COVID positive residents and during facility testing for
COVID-19.These failures have the potential to affect all 35 residents in the facility.
The findings include:
1. V8 Certified Nursing Assistant's (CNA) COVID Point of Care Testing Result report dated July 14, 2023,
showed V8 tested positive for COVID-19. The report showed V8 was symptomatic with a complaint of
fatigue.
V8's July 2023 timecard showed V8 clocked into work at 7:12 AM on July 14, 2023 and clocked out of work
at 11:24 AM.
On July 17, 2023, at 10:07 AM, V3 Registered Nurse/Infection Preventionist (RN/IP) stated, The facility is
currently in (COVID-19) outbreak status. The outbreak started on July 3, 2023, when a resident tested
positive for COVID. As of last Friday (7/14/23), we have 4 positive residents in our facility. Last Friday, we
had a CNA (V8) report to work, and she turned up positive. She had been working on the unit where the
COVID outbreak started. We are currently testing residents and staff for COVID every 3 days while in
outbreak. Nurses are testing the residents. Staff are to self-test upon
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146179
If continuation sheet
Page 6 of 7
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
146179
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/19/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
New Summit Rehabilitation and Healthcare
1200 N Arlington Heights Rd
Arlington Heights, IL 60004
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 0880
entrance to building, prior to reporting to their assigned area .
Level of Harm - Minimal harm
or potential for actual harm
On July 18, 2023, at 9:35 AM, V3 RN/IP stated, On July 14, 2023, (V8 CNA) reported to work around 7:00
AM. For some reason, she didn't do a COVID test prior to starting her shift on the floor. She proceeded to
the floor to provide cares. Later that morning, (V8) said she felt tired so tested herself for COVID and her
test was positive. That was probably around noon. She was immediately sent home by the nursing
supervisor. We are in outbreak. Staff know they are to test upon arrival to work and prior to providing cares
.Myself and the department heads are responsible for making sure staff test prior to starting cares to make
sure if they are symptomatic, they don't pass COVID onto others. I don't know how (V8) got by without
being tested that day .
Residents Affected - Many
The facility's Infection Control Updated Outbreak Guidelines policy dated June 5, 2023, showed, Staff
COVID Screening . 2. Anyone with even mild symptoms of COVID-19 or close contact with someone
confirmed positive for COVID, regardless of vaccination status should receive a viral test for SARS-COV-2
ASAP .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146179
If continuation sheet
Page 7 of 7
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Back to topCitations
17 citations 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.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
- 0026GeneralS&S Fpotential for harm
Establish roles under a Waiver declared by secretary.
- 0035GeneralS&S Fpotential for harm
Provide family notifications of emergency plan.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0211GeneralS&S Epotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0311GeneralS&S Epotential for harm
Have an enclosure around a vertical opening shaft.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0345GeneralS&S Epotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0363GeneralS&S Epotential for harm
Install corridor and hallway doors that block smoke.
- 0364GeneralS&S Epotential for harm
Install properly constructed windows in hallway walls or doors.
- 0511GeneralS&S Epotential for harm
Have properly installed electrical wiring and gas equipment.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the July 19, 2023 survey of New Summit Rehabilitation and Healthcare?
This was a inspection survey of New Summit Rehabilitation and Healthcare on July 19, 2023. The surveyor cited 17 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at New Summit Rehabilitation and Healthcare on July 19, 2023?
Yes, 17 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide enough food/fluids to maintain a resident's health."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.