Alta Rehab at Oak Brook

Inspectors wroteBased on observation, interview and record review, the facility failed to inform a resident's Healthcare Power of Attorney of the provision of atypical care requests. This applies to 1 of 3 residents (R1) reviewed for resident rights in a sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's foot was supported during wheelchair transport which resulted in a fracture of the lower leg. This past noncompliance occurred from October 27, 2025, through October 29, 2025. This applies to 1 of 3 residents (R1) reviewed for accidents in the sample of 6.

Inspectors wroteBased on the interview and record review, the facility failed to transfer a resident using a mechanical lift safely. This failure caused R1 to be dropped from mechanical lift resulting in an ankle fracture. This applies to one of three (R1) reviewed for falls in the sample of 7. This past non-compliance occurred from May 16, 2024, to June 2, 2024. Past noncompliance-no plan of correction required.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident representative was given accurate information regarding authorization to use an electronic monitoring device in the resident room, resulting in miscommunication and lack of informed consent related to resident rights. This applies to 1 of 3 residents (R1) reviewed for electronic monitoring device in the sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to ensure that grievances were identified, documented, and addressed in accordance with facility policy. This applies to 1 of 4 residents (R1) reviewed for grievances. The Findings Include: Review of the Electronic Medical Record (EMR) showed that R1, a [AGE] year-old male, was admitted to the facility on [DATE], from a hospital following a fall. R1's documented diagnoses included, but were not limited to: dementia, repeated falls, ataxia, muscle wasting, lack of coordination, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), cirrhosis, protein-calorie malnutrition, and depression. The Minimum Data Set (MDS) dated [DATE], identified R1 as having moderately impaired cognition and requiring substantial to maximum assistance with activities of daily living (ADLs). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide treatment for a skin tear as ordered by the physician. The facility also failed to reassess a worsening skin impairment, did not notify the physician of its changes to ensure timely and appropriate interventions, and lacked a care plan outlining specific interventions to manage multiple skin impairments. This applies to 1 of 4 residents (R1) reviewed for skin impairments. The Findings Include:The Electronic Medical record (EMR) showed that R1, a [AGE] year-old male admitted to the facility on [DATE], from a hospital following a fall. R1's diagnoses included, but were not limited to, dementia, repeated falls, ataxia, muscle wasting, lack of coordination, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), cirrhosis, protein-calorie malnutrition, and depression. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure supplements were given to residents with a history of significant weight loss as ordered by their physician. This failure resulted in R63 not receiving her nutritional supplements as ordered for her severe weight loss. This applies to 3 of 3 residents (R63, R12 & R73) reviewed for weight loss in the sample of 62.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents'' rooms were located at or above ground level which applies to 24 of 62 residents (R6, R12, R14, R15, R26, R29, R34, R41, R51, R53, R55, R63, R66, R70, R73, R78, R79, R81, R83, R85, R90. R113, R114, R115) reviewed for facility enviorment in a sample of 62.

Inspectors wroteBased on observation, interview and record review the facility failed to protect the resident's right to be free from verbal/mental abuse by staff. This applies to 1 of 62 residents (R14) reviewed for abuse in the sample of 62.

Inspectors wroteBased on observation interview and record review the facility failed to ensure transportation was arranged for a resident to a Urology appointment and failed to ensure a daily weight was performed. This failure applies to 2 of 2 residents (R30, R8) reviewed for care and services in the sample of 62.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner to 2 of 62 residents (R9, R42) reviewed for safety in the sample of 62.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received their prescribed tube feeding for 1 of 2 residents (R105) reviewed for tube feeding in the sample of 62.

Inspectors wroteBased on observation, interview and record review the facility failed to have behavioral interventions in place for a resident with a diagnosis of dementia. This applies to 1 of 2 residents (R41) reviewed for dementia in the sample of 62.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure mechanical soft foods were served to a resident on a mechanical soft diet for 1 of 1 resident (R17) reviewed for mechanical soft diets in the sample of 62.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement enhanced barrier precautions (EBP) for residents with urinary catheters and pressure injuries for 3 of 62 residents (R2, R3, and R56) reviewed for infection control in the sample of 62.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for residents who required staff assistance for toileting, repositioning, and bathing. This applies to 16 of 16 residents (R1-R16) reviwed for ADL (Activities of Daily Living) care in a sample of 16.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was promptly assessed for injury following an incident during transfer with the mechanical lift machine. This applies to 1 of 3 residents (R1) reviewed for assessment, in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's leaking indwelling urinary catheter was changed in a timely manner, and a resident's indwelling urinary catheter was changed monthly as documented by the physician. This applies to 2 of 3 residents (R2, R4) reviewed for indwelling urinary catheters in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was transferred with two people while using a mechanical lift as shown in the facility's policy. This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders to administer antihypertensive and pain medications to a resident (R1) with diagnoses of hypertension, recent back surgery, and chronic back pain. This applies to 1 of 4 residents (R1) reviewed for significant medications in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide feeding assistance and timely incontinent care to dependent residents. This applies to 2 of 4 residents (R1 and R4) reviewed for activities of daily living (ADL) care in a sample of 4. The Findings Include: 1. R1 is a [AGE] year-old male admitted on [DATE] with an admitting diagnosis, including cervical spine myelopathy. The MDS (Minimum Data Set) assessment dated [DATE] documents that R1 has intact cognition. R1's Physician Order Sheet (POS) dated 10/17/24 documented that R1 is on a regular, thin-liquid diet, with one to one feeding. On 10/31/24 at 8:45 AM, R1 stated, I need feeding assistance; they just started feeding me yesterday. Before, I was like a dog, putting my face on a plate to eat what I could get like a dog. I don't have a good grip on my hand. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy ensure resident and family grievances are promptly resolved. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for assistance with ADLs (Activities of Daily Living) in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to develop resident-centered care plans. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for resident rights and policy and procedure in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly respond to call lights when a resident required assistance, failed to provide timely incontinence care, failed to provide feeding assistance as ordered by the physician, and failed to provide showers/bed baths as shown in the facility's policy. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for assistance with ADLs (Activities of Daily Living) in the sample of 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report, assess, and obtain treatment orders for a resident identified with a new wound before it became unstageable. This failure resulted in R61 receiving delayed wound care and deterioration of the wound. This applies to 1 of 3 residents (R61) reviewed for pressure ulcers in a sample of 23.

Inspectors wroteBased on observation, interview and record review, the facility failed to discard outdated food items and maintain the kitchen in a manner that prevent food borne illness. This applies to 108 of 109 residents serviced by the dietary services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to place residents' call lights within reach. This applies to 2 of 2 residents (R41, R58) assessed for accommodation of needs in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to reassess a resident for an appropriate-fitting device who had a hand wound; failed to ensure skin prevention interventions were implemented for a resident with a known behavior of scratching; and failed to check blood glucose levels prior to a resident eating or wipe the first drop of blood. This applies to 2 of 3 residents (R58, R61) reviewed for quality of care in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a resident's decrease in range of motion. This applies to 1of 3 residents (R36) reviewed for range of motion in a sample of 23.

Inspectors wroteBased on interview and record review the facility failed to act on the pharmacy MRR (Medication Regimen Review) and provide documentation monthly MMR. This applies to 2 of 5 (R44 and R52) residents reviewed for unnecessary medications and Monthly MMR in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prime an insulin pen prior to administration. This applies to 1 of 3 residents (R58) reviewed for significant medication error in a sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to provide dental services to a resident requesting and requiring dentures. This applies to 1 of 1 resident (R41) reviewed for dental services in a sample of 23.

Inspectors wroteBased on interview and record review, the facility failed to explain and obtain an appropriate arbitration agreement contract from a resident (R67) with impaired decision-making. This applies to 1 out of 5 (R67) residents in a sample of 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' rooms were located at or above ground level. This applies to 25 residents (R65, R59, R2, R55, R44, R81, R54, R52, R74, R18, R17, R26, R68, R67, R7, R33, R10, R51, R36, R40, R24, R61, R82, R50, and R354) reviewed for facility environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement strategies and equipment to prevent pressure injury. This applies to 1 resident (R2) of 3 residents observed for prevention and treatment of pressure injury. According to the MDS (minimum data set) for R2, R2 was admitted to the facility January 9, 2024 with advanced dementia and requires moderate assistance with bed mobility and substantial assistance with all transfers. The facility provided records of R2's pressure injuries which shows R2 has a pressure injury to the left heel, diagnosed on [DATE]. The wound is described as unstageable. The wound assessment performed by the Wound Doctor, dated April 10, 2024, shows the wound as worsening. The wound assessment performed by the Wound Doctor, dated April 17, 2024, shows the wound as improving. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents received adequate nutrition, thorough assessment and assistance with eating to prevent significant weight loss. This failure resulted in R1 experiencing a weight loss of 20.7 % in three months. This applies to 1 of 3 residents (R1) reviewed for weight loss in the sample of 4.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered by the physician and failed to follow the facility's policy for medication administration. This applies to 3 of 3 residents (R1, R2, and R3) reviewed for improper nursing care in the sample of 3.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident would be free from accident/hazards. This applies to 1 of 3 resident (R1) reviewed for accidents/hazards.

Inspectors wrote9. R24 has multiple diagnoses which includes encephalopathy, chronic obstructive pulmonary disease with exacerbation, chronic respiratory failure with hypoxia and type 2 diabetes mellitus, based on the face sheet. R24's admission MDS (minimum data set) dated May 1, 2023 shows that the resident is cognitively intact and requires extensive assistance with most of her ADLs (activities of daily living), including personal hygiene. On May 8, 2023 at 10:27 AM, R24 was in bed, alert, oriented and verbally responsive. R24 was observed with accumulation of facial hair on her chin area. R24 stated that she wants the staff to shave her chin hair. V10 (LPN/Licensed Practical Nurse) was present during the observation and was aware of R24's request to be shaven. R24's active care plan effective since April 22, 2023 shows that the resident requires assistance with personal hygiene. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents were not left exposed while in bed during the provision of incontinence care. The facility also failed to ensure that urinary catheter drainage bags are covered. This applies to 3 of 20 residents (R50, R192 and R193) reviewed for privacy in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to discontinue and intervene when a resident began to exhibit signs of coughing, throat clearing and increased secretions while being fed. The facility also failed to provide feeding supervision to a resident requiring supervision during eating. This applies to 2 of 2 residents (R33 and R39) reviewed for aspiration precautions in a sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the catheter tube and bag were not touching the floor and not positioned over the bladder. The facility also failed to provide urinary catheter care and failed to secured the catheter to the resident. This applies to 3 of the 4 residents (R53, R192, R193) observed for urinary catheter care in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to follow physician's order with regards to administration of continuous oxygen via nasal cannula. This applies to 1 of 1 resident (R11) reviewed for oxygen therapy in the sample of 20.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer medications as ordered by the physician. There were 25 opportunities with 6 errors resulting in a 24% error rate. This applies to 2 of 7 residents (R193 and R391) in the sample of 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve 2 Gram Sodium diets as ordered/planned to residents who had physician orders for the therapeutic diets. This applies to 3 of 3 residents (R27, R11 and R9) reviewed for therapeutic diets.

Inspectors wroteBased on observation and interview, the facility failed to ensure that all resident rooms in the lower level (Gardenview Units) are located at or above grade level. This affects 19 of 19 residents (R3, R4, R5, R15, R25, R27, R33, R34, R37, R40, R41, R46, R47, R55, R56, R60, R63, R68, R242) reviewed for rooms below grade level in sample of 20.