Alta Rehab at Wauconda

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 11, 2024

  Based on interview and record review, the facility failed to ensure a resident was positioned in a safe manner for one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in R1 experiencing a fall which required sutures and resulted in R1 obtaining a small subdural hematoma. The findings include: R1's Face Sheet shows he was admitted to the facility on [DATE], with diagnoses including alcohol abuse, fall from bed, mood disorder, vascular dementia, generalized anxiety disorder, Parkinson's disease, and malnutrition. R1's Fall Risk assessment dated [DATE], shows that R1 is at risk for falls. […]

• Actual harm, isolatedF686Jul 26, 2023

  Based on observation, interview, and record review the facility failed to ensure pressure reducing interventions were in place for residents with pressure injuries for 2 of 8 residents (R106, R183) reviewed for pressure injuries in the sample of 28. This failure resulted in R106's coccyx excoriation progressing to an unstageable pressure injury and R183's Stage 3 coccyx pressure injury advancing to an unstageable pressure injury. The findings include: 1. On 07/24/23 at 10:34 AM, R106 was in her room, sitting up in her wheelchair on a flattened pillow. R106 said she has a dressing on the sore on her bottom. R106 said the wound doctor comes, but her wound is not getting better. R106 said the wound doctor did a procedure the last time and her bottom is very inflamed and burns. […]

• Actual harm, isolatedF760Jul 20, 2023

  Based on observation, interview, and record review the facility failed to ensure residents are free from significant medication errors for 1 of 3 residents (R1) reviewed for medications in the sample of 6. This failure resulted in R1 having a hypoglycemic episode with stroke like symptoms, requiring hospitalization for 6 days. The findings include: On 7/19/23 at 10:15 AM, R1 was sitting in his room, talking on his phone. R1 was alert and orient and able to answer questions appropriately. R1 stated I've been back here for a few days now; I was in the hospital a couple times. The last time, they sent me out, I couldn't talk. I was in the hospital a few days because they gave me the wrong medication. The hospital found out I was given diabetes medication, I'm not diabetic. It was very scary. […]

• No harm, potential for more than minimal, widespreadF812Dec 3, 2025

  Based on observation, interview, and record review the facility failed to ensure food service dishes were handled in a way to prevent cross-contamination. This has the potential to affect all residents that receive food from the kitchen. Findings include: Centers for Medicare and Medicaid Services form 671 dated 12/1/25 shows there are 134 residents that reside in the facility. Facility diet report dated 12/1/25 shows two residents have diet orders of nothing by mouth (NPO) and do not receive foods from the kitchen. On 12/1/25 at 9:54 AM. V6 (Dietary Aide) was at the three-compartment sink washing pots, pans, and utensils. V6 went to the dish pit, across the kitchen, and rinsed a large food service pot. […]

• No harm, potential for more than minimal, widespreadF755Nov 21, 2023

  Based on observation, interview and record review the facility failed to have a system in place to reconcile all controlled substances from receipt to disposal; failed to complete documentation for receipt of a controlled substance; and failed to properly store narcotic medications for 3 of 3 residents (R1, R4, and R5) reviewed for pharmacy services in the sample of 7. The findings include: 1. The facility's Incident Report dated 11/10/23 showed, On 11/10/23 at approximately 4:30 AM, a (local police officer) called the facility to confirm that employee [V9 - Registered Nurse (RN)] works at the facility. […]