Alta Rehab at Oak Brook

In the surveyor’s words

From the most serious findings on record at Alta Rehab at Oak Brook, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 14, 2025

  Based 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.The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis, spastic hemiplegia affecting the right dominant side. Paraplegia, fracture of both the right and left femurs with surgical repair, diabetes mellitus, dementia, and left tibia fracture added October 27, 2025. […]

• Actual harm, isolatedF689Nov 5, 2025

  Based 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.The findings include:On 10/31/2025 at 11:30 AM, V10 (R1's family) said R1 was dropped from the mechanical lift on 05/16/2024 due to only one staff member attempting the transfer and without properly applying the sling. V10 stated the fall broke R1's ankle. V10 said R1 was transferred to the hospital the next day. […]

• Actual harm, isolatedF692Aug 6, 2025

  Based 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. The findings include: 1.R63's face sheet shows, she was admitted on [DATE] with diagnoses to include: muscle wasting and atrophy, protein-calorie malnutrition, dementia, anoxic brain damage, liver disease, underweight and altered mental status. R63's weights and vitals summary printed on 8/5/25 shows, her weight on admission was 100.2 pounds (lbs). […]

• Actual harm, isolatedF686Jul 19, 2024

  Based 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. The findings include: The EMR (Electronic Medical Record) showed R61 admitted to the facility on [DATE]. R61's EMR showed multiple diagnoses including encephalopathy, malnutrition, intervertebral disc degeneration of the lumbar region, history of malignant neoplasm of the prostate, dementia, anxiety, pain, ataxia, and left foot drop. […]

• Actual harm, isolatedF692Apr 11, 2024

  Based 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. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including dementia, presence of left artificial hip, malignant neoplasm of the prostrate, and pressure ulcer of the sacrum. […]