Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alta Rehab At Oak Brook during CMS and state inspections, most recent first.
A resident with severely impaired cognition had her pubic hair shaved by CNAs after a family member allegedly requested this care, but the designated Healthcare Power of Attorney (HCPOA) was not informed or asked for consent. The resident later indicated she did not want to be shaved, and the HCPOA reported never authorizing this care and stated she would personally trim hair if needed. One family member denied ever requesting shaving, while staff reported that this family member had requested it on multiple occasions. Facility leadership acknowledged that staff were expected to consult the HCPOA for special care requests outside typical services, but this did not occur, resulting in care being provided without appropriate authorization.
A resident with significant mobility impairments and a history of fractures was transported in a wheelchair with only one footrest, leaving one leg unsupported. During transport, the unsupported leg was caught under the wheelchair, causing an acute fracture. Staff proceeded with transport despite being unable to locate the missing footrest, directly leading to the injury.
A resident with severe cognitive impairment and multiple comorbidities was dropped from a mechanical lift during a transfer when only one staff member assisted and the sling was not properly applied, resulting in a fractured ankle and hospitalization.
A resident's representative was not given accurate information about the process for authorizing an electronic monitoring device in the resident's room. Facility staff, including the DON and RN Supervisor, miscommunicated the facility's policy by stating cameras were not allowed, despite the admission contract permitting them if legal steps were followed. This resulted in miscommunication and lack of informed consent regarding the resident's rights.
A resident with multiple medical conditions and significant skin wounds did not have a grievance regarding poor wound care properly identified, documented, or addressed according to facility policy. The resident's spouse reported concerns about wound management to the Social Service Director, but these concerns were not communicated to administration or recorded in the grievance log, resulting in a lack of investigation or resolution.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as identified by surveyors through observation and record review.
Surveyors found that the facility did not maintain an area free from accident hazards and failed to provide adequate supervision to prevent accidents, resulting in a deficiency.
The facility failed to provide adequate ADL care for residents needing assistance with toileting, repositioning, and bathing. Residents with severe cognitive impairments were left in soiled incontinence briefs and not repositioned as required, leading to potential skin breakdown. Staff interviews and grievances highlighted systemic issues with delayed response times and inadequate assistance, contributing to the deficiency.
A resident with multiple diagnoses was not promptly assessed for injury after an incident with a mechanical lift. Despite complaints of severe pain, the facility failed to document vital signs, range of motion, or pain level, and did not notify the physician or family. The resident was later diagnosed with a deep vein thrombosis after being sent to the emergency department.
The facility failed to provide timely care for two residents with indwelling urinary catheters. One resident experienced a leaking catheter that was not changed promptly, resulting in prolonged exposure to wetness and a pressure ulcer. Another resident's catheter was not changed monthly as ordered by the physician, despite a history of UTIs. The facility's policies on catheter care were not followed, leading to inadequate care.
A resident with severe cognitive impairment and multiple diagnoses was transferred using a mechanical lift by a CNA without the required two-person assistance, leading to the resident sliding out of the lift and sustaining a skin tear. The facility's policy mandates two caregivers for such transfers, but the CNA did not follow this protocol, resulting in the incident.
A resident with hypertension and chronic back pain did not receive prescribed antihypertensive and pain medications at an LTC facility. Despite the medications being delivered, they were not administered, leading to elevated blood pressure and the resident leaving against medical advice. The facility's policy requires documentation of medication administration, which was not followed.
The facility failed to provide adequate feeding assistance to a male resident with cervical spine myelopathy, despite a physician's order for one-to-one feeding. The dietary card did not reflect this requirement, leading to the resident eating without assistance. Additionally, a female resident experienced significant delays in receiving incontinent care, resulting in her being left in a urine-soaked brief. Staff acknowledged the oversight and delay in care.
The facility failed to resolve resident grievances and provide adequate care, as evidenced by three residents experiencing inadequate incontinence care, delayed call light responses, and missed showers. Despite grievances being filed and discussed in Resident Council meetings, the facility did not address these issues within the required timeframe, leading to deficiencies in care.
The facility failed to develop and implement resident-centered care plans for three residents, leading to deficiencies in care. A resident was found in a wet incontinence brief that had not been changed for several hours, and her care plan lacked specific interventions for her needs. Another resident was observed with a soaked incontinence brief and stool caked on her skin, and her care plan did not include necessary interventions for feeding assistance or communication strategies. A third resident was left sitting in the dining room for an extended period without being checked for incontinence, resulting in a pressure ulcer. The facility's failure to provide detailed and individualized care plans resulted in inadequate care and unmet needs.
The facility failed to provide timely care and assistance to three residents, including delayed response to call lights, inadequate incontinence care, and lack of feeding assistance. One resident was left in a wet brief for hours, another was found soaked in urine and without feeding help, and a third had a pressure ulcer with no dressing. Documentation showed inconsistencies in providing scheduled showers and hair shampooing.
A resident at high risk for pressure ulcers experienced delayed wound care due to the facility's failure to promptly report and assess a new sacral wound. The wound care nurse discovered the wound had progressed to a stage 4 ulcer with muscle and bone exposure. Despite the CNA reporting the wound in February, the wound care coordinator was only notified on February 27, 2024, with no prior documentation of care initiation. The facility's policy for immediate reporting and assessment was not followed, leading to the wound's deterioration.
The facility failed to maintain food safety and sanitation standards, risking foodborne illnesses. Observations revealed grease-covered vent covers, a dirty meat slicer, and expired food items in refrigerators. The dietary manager admitted to not maintaining sanitizing logs and using the same sanitizer for different purposes without proper documentation. Additionally, the manager did not perform hand hygiene before checking food temperatures, and the facility lacked a policy for kitchen staff hygiene.
The facility failed to ensure call lights were within reach for two residents, one with right-sided hemiplegia and another who was cognitively intact but required assistance. Despite care plans and facility policy, staff left call lights out of reach, confirmed by interviews with staff and the DON.
The facility failed to reassess a resident with a hand wound for an appropriate-fitting device and did not implement skin prevention interventions for a resident with a scratching behavior. Additionally, an LPN did not follow proper procedures for checking blood glucose levels, using the first drop of blood instead of the second. These deficiencies affected two residents with complex medical histories, including dementia and diabetes.
A resident with multiple health conditions experienced a decline in range of motion due to the facility's failure to provide appropriate restorative care. The resident's care plan lacked a hand splint, and assessments were not properly documented or followed. Restorative services were inconsistently provided, contributing to the resident's contracted hand and inability to extend fingers.
The facility failed to act on pharmacy MRRs and provide documentation for two residents, leading to delayed or missing physician responses to medication recommendations. One resident, with multiple diagnoses including dementia and a history of falls, had several pharmacy recommendations for medication adjustments that were not timely addressed. Another resident, with depression and bipolar disorder, also experienced delays in addressing pharmacy recommendations for antipsychotic use. The facility's inability to provide complete MRR documentation indicates a systemic issue in medication management.
A resident with type 2 diabetes was administered 25 units of Humalog insulin by an LPN without priming the insulin pen, contrary to the facility's procedure. The LPN, another LPN, and the DON all acknowledged the requirement to prime the pen with two units of insulin to ensure proper function. The resident had a physician's order for daily insulin administration.
A resident requiring new dentures did not receive necessary dental services due to a lack of follow-up by the facility. Despite requests from the resident's family and notes from a dental hygienist, no dentist evaluated the resident. The facility's dental program, which should have provided free services to Medicaid recipients, was not effectively communicated or utilized, leading to the resident remaining on a mechanical soft diet due to ill-fitting dentures.
A facility failed to obtain an appropriate arbitration agreement from a resident with dementia, who was severely cognitively impaired. Despite the facility's policy requiring agreements to be obtained from a representative in such cases, the resident signed the agreement. Staff interviews confirmed the resident's inability to make decisions, highlighting a lapse in following the facility's policy on resident rights.
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 25 residents who were observed residing on a lower-level floor below ground. The Regional Administrator acknowledged the noncompliance and admitted that the facility had not obtained a building waiver for these rooms.
The facility failed to implement pressure injury prevention strategies for a resident with advanced dementia, who was observed without the prescribed off-loading boots while in bed, despite a physician's order. This contributed to a deficiency in pressure injury prevention and treatment.
Failure to Obtain HCPOA Consent for Atypical Personal Care
Penalty
Summary
The deficiency involves the facility’s failure to inform and obtain consent from a resident’s Healthcare Power of Attorney (HCPOA) before providing atypical personal care. The resident’s MDS documented severely impaired cognition, and the HCPOA (V4) later filed a grievance stating that the resident’s pubic hair had been shaved by a CNA without permission. During an examination with the DON (V2) and restorative staff (V17), the resident’s pubic area appeared recently shaved with approximately 1/4 inch hair regrowth. When asked, the resident indicated awareness that her pubic area had been shaved and indicated she did not want to have been shaved. Staff interviews revealed that a CNA (V5) reported a family member (V7) requested that the resident’s pubic hair be shaved so the resident would be “nice and clean,” and another CNA (V11) confirmed it was clear to them that V7 made this request. V5 stated she obtained razors and shaved the resident’s pubic area while V7 was out of the room. An LPN (V12) also stated that V7 had previously asked her to shave the resident’s pubic hair. V7, however, denied ever asking staff to shave the resident’s pubic hair and stated she knew only the HCPOA (V4) could make such care decisions. V4 stated she had never given permission for staff to shave the resident’s pubic hair and that, if trimming were needed, she would do it herself. Facility leadership (V2 and V14) stated staff were expected to check with the HCPOA before providing any special care requests outside typical services, consistent with the facility’s Resident Rights policy, but this did not occur in this case.
Failure to Provide Proper Foot Support During Wheelchair Transport Resulting in Fracture
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including multiple sclerosis, spastic hemiplegia, paraplegia, prior femur fractures, diabetes, and dementia, was transported in a wheelchair without proper foot support. The resident required extensive assistance with activities of daily living and was dependent on staff for lower body mobility and transfers. During transport from the therapy room to the resident's room, only one footrest was attached to the wheelchair, leaving the resident's left leg unsupported. As a result of the missing footrest, the resident's left leg was abruptly placed on the floor and became caught under the wheelchair, leading to an acute nondisplaced fracture of the proximal left tibia. Staff reported that they were unable to locate the second footrest but proceeded with the transport regardless, which directly resulted in the injury. The incident was confirmed through staff interviews, medical record review, and diagnostic imaging.
Resident Injury Due to Improper Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, atrial fibrillation, congestive heart failure, and pain, who was admitted to hospice care, was transferred using a mechanical lift by only one staff member. The resident's care plan required two staff members to assist with mechanical lift transfers, and the facility's policy also mandated two caregivers for such transfers. During the transfer, the staff member did not properly apply the sling, resulting in the resident being dropped from the lift. As a result of this improper transfer, the resident sustained a displaced fracture to the distal tibia and fibula and required hospital evaluation and treatment. Documentation in the electronic medical record, progress notes, and incident report confirmed that the transfer was performed by a single staff member and that the sling was not adequately secured, directly leading to the resident's fall and injury.
Failure to Provide Accurate Information on Electronic Monitoring Rights
Penalty
Summary
The facility failed to provide accurate information to a resident's representative regarding the authorization and process for installing an electronic monitoring device in the resident's room, resulting in miscommunication and lack of informed consent related to resident rights. The resident in question was admitted with multiple diagnoses, including muscle wasting, COPD, acute bronchitis, and COVID-19, and was noted to be alert and oriented to person and place, but with moderate impairment in decision-making and episodes of confusion. The resident's daughter, who held Power of Attorney, requested to install a video surveillance camera in the resident's room and was initially told by the RN Supervisor, based on information from the DON, that cameras were not allowed in resident rooms according to facility policy. The admission contract, however, stated that video cameras are prohibited in resident rooms unless the resident or representative follows steps outlined under Illinois law, which includes notifying the facility and obtaining necessary consents. The admission assistant discussed this policy with the resident and the daughter, and the contract was signed, with the daughter acknowledging that cameras could be allowed if procedures were followed. Despite this, the RN Supervisor continued to inform the family that cameras were not permitted, based on the DON's interpretation of the policy, which overlooked the exception allowing cameras if legal steps were followed. The DON later admitted that she had focused only on the prohibition statement in the contract and did not notice the clause allowing cameras under certain conditions. There was no direct communication between the DON and the resident's representative regarding the request, and the family was not provided with accurate or complete information about the process for authorizing electronic monitoring, leading to confusion and a lack of informed consent regarding the resident's rights.
Failure to Identify and Address Grievance Regarding Wound Care
Penalty
Summary
The facility failed to identify, document, and address a grievance in accordance with its policy for a resident who was admitted following a fall and had multiple complex medical conditions, including dementia, repeated falls, ataxia, diabetes, COPD, cirrhosis, malnutrition, and depression. Upon admission, the resident had several skin impairments, including a left elbow skin tear, a deep tissue injury to the sacrum, and a bruise to the left hip, as well as multiple bruises and scabbing on various parts of the body. Facility-acquired skin tears were later documented on the shoulders, right forearm, and head. On one occasion, the Wound Care Nurse observed significant bloody drainage from a right forearm wound but did not notify the physician or Nurse Practitioner despite the change in wound status. The resident's spouse voiced concerns to the Social Service Director about poor wound care, specifically mentioning dried blood leaking through the resident's shirt and subsequently requested a transfer to another facility. The Social Service Director acknowledged not reporting this grievance to the Administrator or Assistant DON. There was no documentation in the facility's grievance records that the spouse's concerns were reported, investigated, or resolved. Both the Administrator and Assistant DON confirmed they had not received any report of a grievance related to the resident's wound care. The facility's grievance policy requires prompt resolution of all grievances related to care and treatment, but this process was not followed in this case.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the actions or omissions that led to this deficiency, as well as information about the resident’s medical history or condition at the time, were not provided in the report.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for residents requiring assistance with toileting, repositioning, and bathing. This deficiency was observed in all 16 residents reviewed for ADL care. Residents with severe cognitive impairments and physical limitations were left without necessary assistance, leading to prolonged periods in soiled incontinence briefs and lack of repositioning, which are critical for preventing skin breakdown and maintaining dignity. One resident, diagnosed with Alzheimer's disease and other cognitive impairments, was observed sitting in a wheelchair for over three hours without having her incontinence brief checked or changed, despite being incontinent of bowel and bladder. Another resident, dependent on staff for transfers and toileting, was left in a wheelchair for over two hours without repositioning or incontinence care. Similar neglect was noted for other residents, including one with a pressure injury related to immobility, who was not toileted or repositioned for extended periods. The facility's incontinence care policy mandates checking and changing incontinence briefs every two hours, yet staff interviews revealed that this protocol was not consistently followed. Multiple grievances from residents and their families highlighted ongoing issues with delayed response times to call lights, inadequate assistance with toileting, and missed showers. These grievances, along with resident council meeting minutes, underscored systemic problems in staffing and resource availability, such as the need for additional mechanical lifts, contributing to the deficiency in care.
Failure to Assess Resident After Mechanical Lift Incident
Penalty
Summary
The facility failed to promptly assess a resident for injury following an incident during a transfer with a mechanical lift. The resident, who had multiple diagnoses including drug-induced polyneuropathy, sepsis, and atrial fibrillation, was cognitively intact and dependent on staff for all activities of daily living, including transfers. During a transfer using a sit-to-stand lift, the resident let go of the machine handles, resulting in an abrasion and redness on the left arm. Despite the resident's complaints of severe pain, the facility did not document a comprehensive assessment, including vital signs, range of motion, or pain level, nor did they notify the resident's physician or family. The incident report and subsequent documentation by facility staff, including a CNA, LPN, and WCN, lacked detailed assessments of the resident's condition following the incident. The LPN and WCN did not assess or document the resident's pain level or range of motion, and the incident report did not include vital signs or a detailed description of the injury. The facility's Director of Nursing acknowledged the lack of documentation and assessment, stating that the resident should have been assessed for pain and other vital signs following the incident. The resident was later seen by a Nurse Practitioner who noted swelling, erythema, and severe pain in the left arm, leading to orders for a Doppler ultrasound and X-ray. The resident's spouse requested a quicker evaluation, resulting in the resident being sent to the emergency department. Hospital records confirmed a diagnosis of left upper extremity deep vein thrombosis. The facility's policy on accidents and incidents requires prompt investigation and documentation, which was not adhered to in this case.
Deficiencies in Catheter Management for Two Residents
Penalty
Summary
The facility failed to ensure timely care for residents with indwelling urinary catheters, leading to deficiencies in catheter management for two residents. One resident, R2, experienced a leaking catheter that was not addressed promptly. Despite reporting the issue to multiple staff members, the catheter was not changed until several days later, resulting in the resident lying in a wet bed with a significant pressure ulcer. The facility documentation shows that the catheter was noted to be leaking on January 31, 2025, but it was not replaced until February 2, 2025. This delay in care was acknowledged by the Director of Nursing, who had instructed staff to change the catheter, but the instructions were not followed in a timely manner. Another resident, R4, had an indwelling urinary catheter that was not changed monthly as per the physician's documented orders. The resident had a history of multiple urinary tract infections (UTIs) and was hospitalized due to a UTI and altered mental status. The physician had repeatedly documented the need for monthly catheter changes, but the facility failed to provide documentation that these changes were carried out as ordered. The physician expressed that it was his expectation for the catheter to be changed monthly, which was communicated to the nursing staff. The facility's policies on equipment replacement and urinary catheter care were not adhered to, contributing to the deficiencies observed. The policies outlined conditions under which catheters should be changed, including physician orders, but these were not followed in the cases of R2 and R4. The lack of timely catheter changes and adherence to physician orders resulted in inadequate care for the residents, as evidenced by the documented events and interviews with staff and family members.
Failure to Follow Transfer Protocols with Mechanical Lift
Penalty
Summary
The facility failed to ensure that a resident was transferred with the assistance of two people while using a mechanical lift, as required by the facility's policy. This deficiency was observed during the transfer of a resident who has severe cognitive impairment and multiple diagnoses, including dementia and agitation. The resident requires substantial assistance for various activities, including transfers, and is dependent on staff for these tasks. The care plan for the resident clearly states that transfers should be conducted with a total body mechanical lift and two-person assistance. On a specific occasion, a CNA attempted to transfer the resident alone, resulting in the resident sliding out of the mechanical lift and sustaining a skin tear on the left lower extremity. The incident occurred because the CNA did not request assistance from another staff member, contrary to the facility's guidelines. The Director of Nursing confirmed that the CNA was aware of the protocol but failed to adhere to it, leading to the resident's fall and injury.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to administer prescribed antihypertensive and pain medications to a resident with multiple diagnoses, including hypertension and chronic back pain, following a recent back surgery. The resident was admitted to the facility and had physician orders for Gabapentin and Losartan Potassium-HCTZ, which were not administered as scheduled. The medications were delivered to the facility, but the nursing staff did not administer them, leading to the resident's elevated blood pressure and subsequent distress. On the morning of the resident's discharge, the resident expressed frustration over not receiving her medications, which was documented by an LPN. The resident's blood pressure was recorded as high, and the attending physician was notified. The physician ordered alternate medications to be administered immediately, but there is no documentation in the EMAR that these alternate medications were given. The resident eventually left the facility against medical advice. The Director of Nursing confirmed that the medications were delivered but not administered, and the facility's policy requires that the MAR be used during medication administration. The attending physician emphasized the significance of the medications, noting that their omission could lead to significant results. The failure to administer the medications as prescribed and document their administration constitutes a significant medication error.
Failure to Provide Adequate ADL Assistance and Timely Incontinent Care
Penalty
Summary
The facility failed to provide adequate feeding assistance to a male resident with cervical spine myelopathy, who was admitted with a physician's order for one-to-one feeding due to his arm weakness. Despite the order being in place since mid-October, the dietary card did not reflect this requirement, leading to the resident having to eat without assistance, which he described as akin to eating like a dog. The oversight was confirmed by multiple staff members, including CNAs and the Dietary Manager, who acknowledged the absence of the one-to-one feeding instruction on the dietary card. The Director of Nursing also confirmed that the staff should have adhered to the physician's order for feeding assistance. Additionally, the facility failed to provide timely incontinent care to a female resident who was dependent on assistance for toileting hygiene and repositioning in bed. The resident reported significant delays in receiving care, including a delay from 3:00 AM to 4:45 AM for a brief change. Observations confirmed that the resident was left in a urine-soaked brief with stained linens. The staff, including the Wound Care Nurse and the assigned CNA, acknowledged the delay in providing care. The Director of Nursing stated that incontinent care should have been offered without delay when requested by the resident.
Failure to Resolve Resident Grievances and Provide Adequate Care
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal and did not establish a grievance policy to resolve grievances promptly. This deficiency was observed in the care of three residents who required assistance with Activities of Daily Living (ADLs). The facility did not provide adequate incontinence care, timely response to call lights, or scheduled showers as per their policy. For instance, one resident was found in a wet incontinence brief and bed sheets, with no record of receiving scheduled showers or hair washing. Another resident, who was dependent on staff for all ADLs, was found with a soaked incontinence brief and stool caked on her skin, despite a grievance being filed by her family weeks earlier. The facility lacked documentation of providing the resident with scheduled showers. Additionally, a third resident was left in a wheelchair without incontinence checks, resulting in a pressure ulcer on her sacrum. A grievance had been filed by the resident's family regarding similar issues, but no resolution was documented. The Resident Council meeting minutes revealed ongoing concerns about call light response times, incontinence care, and the behavior of Certified Nursing Assistants (CNAs), particularly agency CNAs. Despite these grievances being discussed in meetings, the facility did not resolve the issues within the timeframe outlined in their grievance policy. The facility's failure to address these grievances in a timely manner contributed to the deficiency in care provided to the residents.
Deficiencies in Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement resident-centered care plans for three residents, leading to deficiencies in care. Resident 1 (R1) was found in a wet incontinence brief that had not been changed since 2:00 AM, despite being dependent on staff for toilet hygiene and other activities of daily living (ADLs). The care plan for R1 lacked specific interventions for her needs, such as the requirement for bed baths due to the absence of a suitable shower chair. Additionally, the care plan did not specify the amount of assistance needed for ADLs, and the green care card in R1's room did not detail her specific care needs. Resident 2 (R2) was observed with a soaked incontinence brief and stool caked on her skin, indicating a lack of timely incontinence care. R2's care plan did not include necessary interventions for her one-to-one feeding assistance, specific transfer methods, or communication strategies for her unclear speech. The care plan also failed to address R2's dietary needs and the assistance required for eating, despite her dependence on staff for all ADLs and her moderate cognitive impairment. Resident 3 (R3) was left sitting in the dining room for an extended period without being checked for incontinence, resulting in a pressure ulcer. R3's care plan did not specify the type of assistive mobility device needed, nor did it address her incontinence issues or communication needs due to her lack of speech. The facility's failure to provide detailed and individualized care plans for these residents resulted in inadequate care and unmet needs, as confirmed by staff interviews and record reviews.
Deficiencies in Resident Care and Assistance
Penalty
Summary
The facility failed to promptly respond to call lights and provide timely incontinence care, feeding assistance, and showers/bed baths as per their policy for three residents. Resident 1, who was admitted with multiple diagnoses including lymphedema, hypertension, and morbid obesity, was found in a wet incontinence brief that had not been changed since 2:00 AM. The resident's call light was illuminated for over 26 minutes before staff responded. The facility lacked appropriate equipment to provide showers for Resident 1 due to her obesity, and documentation showed inconsistencies in providing scheduled showers and hair shampooing. Resident 2, with diagnoses including metabolic encephalopathy and hemiplegia, was found in a wheelchair with soaked pants and a strong urine odor. The CNA assigned to her care admitted to not checking her incontinence brief since 9:30 AM. Additionally, Resident 2 was observed attempting to feed herself without assistance, despite having an active order for 1:1 feeding assistance. Documentation also showed a lack of hair shampooing during the 30-day review period. Resident 3, who has multiple diagnoses including metabolic encephalopathy and UTI, was observed sitting in the dining room for over two hours without being checked for incontinence. When finally attended to, stool was found in her incontinence brief, and a pressure ulcer was visible on her sacrum without a dressing. The facility's policies on call light response, bathing, and incontinence care were not adhered to, as evidenced by the ongoing issues discussed in Resident Council meetings and concern forms submitted by family members.
Delayed Reporting and Treatment of Pressure Ulcer
Penalty
Summary
The facility failed to report, assess, and obtain treatment orders for a resident identified with a new wound before it became unstageable. This resulted in delayed wound care and deterioration of the wound for the resident, who was at high risk for pressure ulcers due to multiple health conditions including encephalopathy, malnutrition, and dementia. The resident required substantial to maximal staff assistance with personal hygiene and bed mobility, and had a history of skin alterations. The wound care nurse discovered the resident's sacral wound had muscle and bone exposed, with significant slough tissue, indicating a stage 4 pressure ulcer. The certified nurse assistant reported noticing a small open area on the resident's sacrum in February, which was reported to the nurse on duty. However, the wound care coordinator was only notified of the wound on February 27, 2024, and found no documentation of the wound's identification or initiation of care prior to this date. The wound physician managing the resident's care noted the resident was at risk for pressure ulcers due to immobility, incontinence, poor nutrition, and dependency on staff for repositioning. The facility's policy required immediate reporting and assessment of new skin alterations, but this was not followed, leading to the wound's deterioration. The resident's care plan included interventions for skin integrity, but the lack of prompt reporting and treatment initiation contributed to the wound becoming unstageable.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards, which could lead to foodborne illnesses. During a kitchen tour, it was observed that the vent covers over the stove were covered with grease and lint/dust, and the meat slicer had smears of grease and crust on its base. The dietary manager admitted that testing logs for sanitizing buckets were not maintained, and the same sanitizer used for the three-compartment sink was also used for disinfecting buckets without proper documentation of its concentration or contact time. The facility's policy did not specify the frequency of testing or documentation for the dishwasher, three-compartment sink, or sanitization buckets, nor did it document the disinfecting product used. Additionally, expired food items were found in various refrigerators, including expired orange juice concentrate, milk, applesauce, and sour cream. Some items were not labeled or dated, contrary to the facility's signage that stated items should be discarded after three days or if they lacked information. The dietary manager acknowledged that expired food might be overlooked and served to residents. Furthermore, the dietary manager was observed not performing hand hygiene before conducting food holding temperatures, and the facility did not provide a policy for kitchen staff hand hygiene and head coverings.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that residents' call lights were placed within reach, affecting two residents assessed for accommodation of needs. One resident, who had right-sided hemiplegia and other medical conditions, was found with her call light out of reach on multiple occasions. Despite having a care plan that specified the call light should be accessible on her left side, staff repeatedly left the call light behind her bed or chair, making it inaccessible. Interviews with staff confirmed that the call light should be placed within reach of the resident's functional side, yet this was not consistently done. Another resident, who was cognitively intact but required assistance for various activities, also had her call light placed out of reach. The call light was left behind her on the bed while she was in a wheelchair, preventing her from reaching it. The facility's policy stated that call lights should be accessible to residents at all times, but this was not adhered to, as confirmed by the Director of Nursing and other staff members.
Deficiencies in Wound Care and Blood Glucose Monitoring
Penalty
Summary
The facility failed to reassess a resident, R61, for an appropriate-fitting device despite having a hand wound. R61, who had multiple diagnoses including encephalopathy, dementia, and anxiety, was dependent on staff for activities of daily living. Observations revealed that R61 had a contracted left hand with a wound between the first and second fingers, and was using a palm protector device with a finger separator strap, which was not reassessed despite the presence of the wound. The wound care nurse and restorative nurse were unaware of the wound and the inappropriate use of the device, indicating a lack of communication and reassessment. Additionally, R61's care plan included interventions for skin impairment and behaviors such as scratching, but these were not effectively implemented, as evidenced by untrimmed fingernails and the absence of protective gloves. The facility also failed to ensure proper skin prevention interventions for R61, who had a known behavior of scratching. The wound care coordinator noted that R61's plan of care included keeping nails trimmed, applying gloves, and monitoring for scratching, but these measures were not consistently followed. R61 was observed with untrimmed nails and without gloves, contributing to self-inflicted injuries. The facility's policies on pressure injury and skin condition assessment, as well as restorative services, were not adequately followed, leading to the oversight in reassessing the appropriateness of the contracture device and implementing preventive measures. Additionally, the facility failed to adhere to proper procedures for checking blood glucose levels for another resident, R58. An LPN was observed testing R58's blood glucose using the first drop of blood, contrary to the procedure of wiping the first drop and testing the second to avoid alcohol contamination. This was confirmed by the LPN and the Director of Nursing, who stated the expectation to follow the correct procedure. R58 had a history of type 2 diabetes mellitus and was on a physician-ordered regimen for blood glucose monitoring and insulin administration, highlighting the importance of accurate testing procedures.
Failure to Prevent Decrease in Range of Motion for Resident
Penalty
Summary
The facility failed to prevent a decrease in range of motion for a resident, identified as R36, who was admitted with multiple diagnoses including acute kidney failure, dementia, and poly-osteoarthritis. Upon observation, R36 was found with a contracted left hand and was unable to extend her fingers. The resident reported not having a splint for her hand, and the Certified Nursing Assistant confirmed that a hand splint was not included in her care plan. The Restorative Nurse acknowledged that R36 should have undergone an Occupational Therapy (OT) and Physical Therapy (PT) assessment upon admission to guide her care, but there was no documentation of contractures at that time. The Restorative Aide, responsible for documenting changes, stated that R36 was supposed to receive restorative services three times a week, but these sessions were sometimes missed due to staffing issues. The Director of Rehab Services was unable to access R36's OT and PT assessments, and the Occupational Therapist evaluated R36 during the survey, noting tightness and decreased ability to extend her fingers. The resident's care plan indicated a need for restorative nursing and active range of motion exercises, but there was no completed and signed restorative nurse assessment since February. The facility's policies required services to be provided according to assessment results and care plans, but these were not adequately followed, leading to the resident's decline in range of motion.
Failure to Act on Pharmacy Medication Regimen Reviews
Penalty
Summary
The facility failed to act on the pharmacy Medication Regimen Review (MRR) and provide documentation of monthly MRRs for two residents, R44 and R52, out of a sample of 23. For R44, the pharmacist made several recommendations regarding the resident's medication regimen, including requests for gradual dose reductions (GDR) and stop dates for certain medications. However, these recommendations were not consistently addressed by the physician or prescriber, with some responses delayed by months or not provided at all. Additionally, the facility was unable to provide documentation of MRRs for several months, indicating a lack of consistent review and action on pharmacy recommendations. R44, who has multiple diagnoses including dementia, psychosis, and a history of falls, was on psychotropic therapy with medications such as Mirtazapine, Quetiapine, and Lorazepam. The pharmacist highlighted potential risks associated with these medications, such as increased fall risk, and recommended reevaluation and dose adjustments. Despite these recommendations, there was a lack of timely physician response, and the facility did not document MRRs for several months, failing to ensure appropriate medication management for R44. Similarly, for R52, the facility did not provide complete documentation of MRRs, and there were delays in addressing pharmacy recommendations. R52, with diagnoses including depression, bipolar disorder, and a history of falls, was prescribed multiple antipsychotics. The pharmacist recommended reviewing the use of these medications due to potential side effects, but the physician's response was delayed. The facility's failure to provide complete MRR documentation and timely responses to pharmacy recommendations indicates a systemic issue in managing medication regimens for residents.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the improper administration of insulin to a resident. On July 17, 2024, an LPN was observed administering 25 units of Humalog insulin to a resident without priming the insulin pen, which is a necessary step to remove air bubbles and ensure the needle is functioning properly. The LPN acknowledged the need to prime the pen before administration, as did another LPN and the Director of Nursing, who confirmed that the procedure requires priming with two units of insulin. The resident involved had a medical history including type 2 diabetes mellitus, generalized osteoarthritis, hypertension, asthma, pain, low back pain, tremors, and repeated falls, and had a physician's order for Humulin KwikPen to be administered daily. The facility's insulin pen procedure, reviewed in August 2020, clearly stated the requirement to prime the pen before each injection.
Failure to Provide Necessary Dental Services
Penalty
Summary
The facility failed to provide necessary dental services to a resident who required new dentures. The resident, who had a history of hemiplegia, dysphagia, and dementia, was on a mechanical soft diet due to ill-fitting dentures. Despite the resident's family requesting a dental evaluation and the dental hygienist noting the need for better-fitting dentures, no dentist visited the resident. The dental hygienist's notes indicated that the family requested a dentist to evaluate and possibly make new dentures, but the facility did not follow up on this request. The facility's dental program, which was supposed to provide free dental services to eligible Medicaid recipients, was not effectively communicated or utilized. The Director of Nursing and other staff members were unclear about the enrollment process and responsibilities for scheduling dental appointments. The Medical Records Director confirmed that the dentist had not visited the resident, and the Social Services Director was unaware of the resident's denture needs. The lack of coordination and communication among facility staff led to the resident not receiving the necessary dental care.
Failure to Obtain Proper Arbitration Agreement for Cognitively Impaired Resident
Penalty
Summary
The facility failed to properly explain and obtain an appropriate arbitration agreement from a resident with impaired decision-making abilities. The resident, identified as R67, was admitted with multiple diagnoses, including dementia, and was documented as severely cognitively impaired. During an interview, R67 was found to be confused and unable to engage, with a registered nurse confirming the resident's inability to make decisions. Despite this, the facility had R67 sign an arbitration agreement, which was not in compliance with their policy requiring the agreement to be obtained from the resident's representative in cases of cognitive impairment. The admissions assistant, responsible for obtaining arbitration agreements, stated that she contacts the next of kin or the resident's decisional maker if a resident has a cognitive deficit. However, in this case, the arbitration agreement was signed by R67, who was not capable of making such decisions. The admissions director confirmed that the facility's policy mandates obtaining the agreement from a representative when a resident is cognitively impaired. The facility's policy on resident rights emphasizes promoting the exercise of rights for residents facing barriers such as cognitive limitations, which was not adhered to in this instance.
Residents Housed Below Ground Level Without Waiver
Penalty
Summary
The facility failed to ensure that residents' rooms were located at or above ground level, affecting 25 residents. During an initial tour, it was observed that these residents were residing on a lower-level floor in rooms below ground level. The facility's Resident Roster confirmed that these residents were indeed housed in rooms on the lower floor. The Regional Administrator acknowledged the noncompliance and admitted that the facility had not obtained a building waiver for these rooms located below ground level.
Failure to Implement Pressure Injury Prevention Strategies
Penalty
Summary
The facility failed to implement strategies and equipment to prevent pressure injuries for a resident (R2) with advanced dementia who requires moderate assistance with bed mobility and substantial assistance with all transfers. R2 was admitted to the facility on January 9, 2024, and had a pressure injury to the left heel, diagnosed as unstageable. Despite a physician's order dated February 12, 2024, to apply off-loading boots while in bed every shift, R2 was observed without heel floating boots during an intermittent observation period on April 17, 2024, from 1:00 pm to 3:05 pm. During this time, no staff entered R2's room with the boots, and the boots could not be located when checked by the RN at 3:00 pm. The wound assessment performed by the Wound Doctor on April 10, 2024, showed the wound as worsening, but an assessment on April 17, 2024, indicated improvement. However, the lack of adherence to the physician's order for off-loading boots was confirmed by both the RN and the Wound Care Nurse, who stated that the boots should be on the resident while in bed to prevent the wound from worsening. This failure to follow the prescribed care plan contributed to the deficiency in pressure injury prevention and treatment for R2.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,894 citations issued within 25 miles in the last 12 months — including the 33 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oak Brook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bella Terra Elmhurst | 1.4 mi | ★★★★★ | 1 | 0 |
| Park Place Christian Community | 2.2 mi | ★★★★★ | 0 | 0 |
| Oakwood Rehab And Nursing Center | 2.7 mi | ★★★★★ | 14 | 0 |
| The Pearl Of Downers Grove | 2.8 mi | ★★★★★ | 3 | 0 |
| Bella Terra Lombard | 2.8 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.