Alton Memorial Rehab & Therapy

In the surveyor’s words

From the most serious findings on record at Alton Memorial Rehab & Therapy, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 16, 2026

  Based 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. Findings include:R3's Face Sheet, not dated, documents R3 was admitted on [DATE] with the following diagnosis: Other pulmonary embolism without acute cor pulmonale (Primary, Admission), Paroxysmal atrial fibrillation, Heart failure, unspecified, Peripheral vascular disease, unspecified Irritable bowel syndrome, unspecified, Pain, unspecified, Weakness, Presence of automatic (implantable) cardiac defibrillator, Depression, unspecified, Type 2 diabetes… […]

• Actual harm, isolatedF689Jan 6, 2026

  Based 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. […]

• Actual harm, isolatedF677Oct 10, 2024

  Based 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. Findings include: 1. 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 dated ,d+[DATE], documents R23 is alert and oriented x4, occasionally incontinent of urine, and requires assistance from staff for toileting. […]

• Actual harm, isolatedF690Oct 10, 2024

  3. R24's face sheet, print date of 10/9/24, documented R24 has diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia and aphasia following cerebral infarction, depression, multiple sclerosis, epilepsy, and hypertension. R24's MDS dated [DATE] documented R24 is cognitively intact. R24's MDS dated [DATE] documented R24 depends on a wheelchair for mobility and requires partial to moderate assistance to ambulate 10 feet. On 10/8/24, during the Resident Council meeting R24 agreed that she helps her roommate (R23) get on the bed pan at night and cleans her up due to staff not answering the call light. 4. […]

• Actual harm, isolatedF760Oct 10, 2024

  Based 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. Findings include: R195's face sheet, print date of 10/8/24, documented R195 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, Sjogren syndrome with peripheral nervous system involvement, Parkinson's disease, anemia, obstructive sleep apnea, and… […]