Alta Rehab Oak Brook: Wound Care Grievance Failures - IL
The resident, identified in inspection records only by age and gender, was admitted to Alta Rehab at Oak Brook following a fall. He came in already carrying a significant medical burden: dementia, repeated falls, ataxia, muscle wasting, cirrhosis, malnutrition, COPD, and type 2 diabetes. He needed substantial to maximum help with basic daily activities. His cognition was moderately impaired. He could not, in other words, advocate effectively for himself.
His admission skin assessment documented a deep tissue injury to his sacrum, a skin tear on his left elbow, a bruise on his left hip, multiple bruises across his upper arms, lower legs, right chest, right foot, and ankle, edema in both upper arms, and scabbing on his right knee and lower leg. That was the baseline. What happened after he arrived made things worse.
By August 1, skin tears had appeared on his left shoulder, his right shoulder, and the top of his head. The lesion on his head had necrotic tissue. Three days later, on August 4, a new wound appeared on his right forearm, measuring 15 centimeters by 13 centimeters, with light bloody drainage. That wound, running from near his wrist almost to his elbow, was the one his wife would later see soaking through his clothing.
On August 6, the wound care nurse changed the dressing on that forearm wound at 6:45 in the morning. The drainage was significant enough that she used four ABD pads and Kerlix wrap to cover it. She did not call the physician. She did not call the nurse practitioner. She told inspectors on August 20 that she had not notified anyone despite what she herself recognized as a change in the wound's status.
That same day, August 4, the resident's wife went to the Social Service Director with her concerns. She had seen dried blood leaking through her husband's shirt. She asked that he be transferred to another facility.
The Social Service Director confirmed to inspectors that she had received this complaint. She also confirmed that she never reported it to the Administrator or the Assistant Director of Nursing. No grievance was documented. No investigation was opened. No resolution was recorded.
The facility's own grievance policy, in place since 2012, states that the purpose of the policy is to ensure prompt resolution of all grievances related to care and treatment. The Administrator and the Assistant Director of Nursing both told inspectors on August 20 that they had heard nothing about any complaint related to this resident's wound care.
His wife, reached by phone during the inspection, did not speak in the careful language of regulatory findings.
"They butchered my husband," she said. "What they called a 'skin tear' was a huge wound, bleeding, and extending from the wrist almost to the elbow. No one told me how bad it was until I saw it at the other facility. He was immediately sent to the hospital and is now in hospice."
The inspection, completed August 22, 2025, was triggered by a complaint. The deficiency was cited at a level of minimal harm or potential for actual harm, a classification that measures regulatory severity, not the experience of the family waiting to learn the truth about a wound they were never told about.
He is in hospice now.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alta Rehab At Oak Brook from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 8, 2026 · Our methodology
ALTA REHAB AT OAK BROOK in OAK BROOK, IL was cited for violations during a health inspection on August 22, 2025.
The resident, identified in inspection records only by age and gender, was admitted to Alta Rehab at Oak Brook following a fall.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.