Alton Memorial Rehab & Therapy

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision of a dependent resident during care to prevent a resident from falling out of bed for 1 of 3 (R3) residents reviewed for accidents in a sample of 6. This failure resulted in R3 falling from bed causing a left hip fracture requiring surgical intervention.

Inspectors wroteBased on observation, interview and record review the facility failed to follow fall policy and procedures, and staff failed to use a gait belt when transferring a resident, for 1 (R2) of 3 residents reviewed for accidents. This failure resulted in a cognitively impaired resident (R2) being transferred to the emergency room after hitting her head. R2 had to get an EKG, blood work, head CT and chest x-ray. Using the reasonable person approach, this failure caused pain, discomfort and invasive interventions during an emergency room visit. Findings Include: R2's Resident Profile Report (Care Plan) dated 11/26/2025, documents R2 was at risk for falls and requires assistance with transfers and ambulation. The care plan states, Please ensure my bed is at an appropriate height at all times and call light is within reach. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to notify the provider of a fall with injury for 1 (R2) of 3 residents reviewed for accidents.

Inspectors wroteBased on interview and record review, the Facility failed to ensure food was palatable for 4 of 4 residents (R4, R12, R32, R44) reviewed for nutritional services in the sample of 25.1- R4's Undated Face Sheet documents R4 was admitted to the facility on [DATE]. R4's Minimum Data Set (MDS) dated [DATE] documents R4 is cognitively intact and is independent with eating. R4's Physician Order dated 3/27/2025 documents R4 has a Regular Diet. On 12/2/2025 at 11:35 AM R4 stated the food in the facility is terrible and tastes like s***. R4 stated residents have brought up the food issue regarding taste and temperature every month at resident council and the facility has failed to change things. R4 stated she eats in her room and every meal tray she receives is cold. R4 stated the food is well done and hard, the pasta is gummy, and everything is tasteless. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure respectful handling and safeguarding of 2 (R3,R4) of 2 residents' personal clothing in the sample of 25. The loss of the resident's clothing demonstrates a failure to honor the resident's right to dignity and respect for personal belongings.

Inspectors wroteBased on record review and interview that facility failed to evaluate and revise the care plan for 1 of 1 (R22) residents reviewed for care plans in a sample of 25. R22's Undated Face Sheet documents R22 was re-admitted to the facility on [DATE] and has a medical diagnosis of Hypertensive Disorder, Osteoporosis, Focal to Bilateral Tonic-Clonic Epileptic Seizures. R22's Minimum Date Set (MDS) dated [DATE] documents R22 is moderately cognitively impaired and needs partial/moderate assistance with sitting to standing, chair/bed to chair transfers, and toilet transfers. R22's Care Plan Last Reviewed 10/17/25 documents (R22) is at risk for falls. I require assistance with transfers and ambulation. Please ensure my bed is at an appropriate height at all times. Please ensure my call light is within reach when I am in my room. 8/28/25: call don't fall sign in bathroom; labs. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement current progressive interventions to prevent falls for 1 of 6 (R22) residents reviewed for falls in a sample of 25. R22's Undated Face Sheet documents R22 was re-admitted to the facility on [DATE] and has a medial diagnosis of Hypertensive Disorder, Osteoporosis, Focal to Bilateral Tonic-Clonic Epileptic Seizures. R22's Minimum Date Set (MDS) dated [DATE] documents R22 is moderately cognitively impaired and needs partial/moderate assistance with sitting to standing, chair/bed to chair transfers, and toilet transfers. R22's Care Plan Last Reviewed 10/17/25 documents (R22) is at risk for falls. I require assistance with transfers and ambulation. Please ensure my bed is at an appropriate height at all times. Please ensure my call light is within reach when I am in my room. 8/28/25: [...]

Inspectors wroteBased on observation, interview, and record review, the Facility failed to follow physician prescribed therapeutic supplement order for 1 of 1 residents (R33) reviewed for nutritional services in the sample of 25.

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately staff the dietary department to ensure meals were served in a timely manner for 1 of 5 residents (R9) reviewed for food and nutrition services in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to ensure all abuse investigations were reported to the designated representative and to other officials in accordance with State law, including State Survey Agency within five working days of the incident for 1 of 7 residents (R2) reviewed for reporting in the sample of 10.

Inspectors wroteBased on interview and record review the Facility failed to ensure all abuse allegation were thoroughly investigated for 1 of 5 residents (R2) reviewed for investigation of abuse in the sample of 10.

Inspectors wroteBased on interview and record review the facility failed to provide timely and complete incontinent care for 5 of 5 residents (R13, R23, R24, R31, R33) reviewed for incontinent care in a sample of 33. This failure resulted in R23 laying in urine all night, feeling dirty, like a fool and embarrassed.

Inspectors wroteBased on interview, record review, and observation the facility failed to ensure residents are free from significant medication errors for 1 of 6 (R195) residents reviewed for medication administration in a sample of 33. A delay of 6 days in getting the antibiotic started to treat UTI as ordered by the Physician Assistant caused R195 to become confused, have abdominal pain, increased leg pain, and missed some therapy sessions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications and ensure expired medications were discarded when appropriate. This has the potential to affect all 45 residents living in the facility.

Inspectors wroteBased on observation, and interview the facility failed to ensure a resident was treated with dignity and had needs met timely for 1 of 3 (R23) residents in a sample 33 observed for dignity.

Inspectors wroteBased on record review and interview, the facility failed to complete the periodical comprehensive Minimum Data Set Assessments in the required time frame for 3 of 3 (R16, R23, R28) residents reviewed for resident assessments in a sample of 33.

Inspectors wroteBased on record review, and interview, facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner promotes each resident's rights, physical, mental, and psychosocial well-being. This failure has the potential to affect all 33 residents residing in the facility. R23's Care Plan, not dated, documents R23 is occasionally incontinent of urine of bladder and continent of bowel. Please provide frequent toileting and peri care after each incontinent episode, requires extensive assist with ADL's (activities of daily living), R23's Minimum Data Set, dated 8/20, documents R23 is alert and oriented x4 occasionally incontinent of urine and requires assistance from staff for toileting. On 10/7/2024 at approximately 9:00 AM, observed V5, CNA, provide R23 incontinent care. R23 was incontinent of urine. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a safe transfer for 1 of 3 residents (R2) reviewed for falls in the sample of 13. This failure resulted in R2 sustaining a large, abrasion/laceration on her right calf while being transferring without the use of a gait belt and needing wound care.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure Dietary Staff wear appropriate hair and beard nets, failed to perform proper hand hygiene and/or wear gloves, and failed to check temperatures of food, including all diets (regular diets, special diets, and pureed foods) prior to serving to residents, to prevent contamination and foodborne illness. This failure has the potential to affect all 52 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications and label tuberculin vials and insulin pens. This has the potential to affect all 40 residents living in the facility.

Inspectors wroteBased on interview and record review, the facility failed to organize and have a monthly Resident Council Meeting for 7 of 7 residents (R1, R5, R6, R13, R18, R19, R214), reviewed for Resident Council meetings in the sample of 33.

Inspectors wroteBased on observation, interview and record review the facility failed to provide an ongoing program of activities for 6 of 6 residents (R1, R5, R6, R13, R18 and R19) reviewed for activities in a sample of 33.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide complete incontinent care for 6 of 6 (R1, R4, R5, R25, R205, R212) residents reviewed for incontinent care in a sample of 33.

Inspectors wroteBased on observation, interview, and record review, the facility failed to change and date the oxygen tubing and humidification water bottles on the oxygen concentrators and failed to store needed equipment in a safe and sanitary manner for 6 of 6 (R1,R17, R35, R37, R204, R255) residents reviewed for respiratory care in a sample of 33.

Inspectors wroteBased on observation interview and record review the facility failed to perform proper hand hygiene and glove changes per current standards of practice and failed to secure a catheter bag off the floor for 5 of 5 (R1, R20, R104, R209, R213) residents reviewed for infection control in a sample of 33.