Alta Rehab at Fairmont: Discharge Paperwork Failures - IL
The patient, identified in inspection records only as Resident 5, had been admitted to the facility with hemiplegia, a condition that causes paralysis on one side of the body, along with sequelae of cerebral infarction. He had told staff he wanted to go home to his family. His care plan said he would receive written instructions to make sure his care continued after he left.
He didn't.
Federal inspectors who visited the facility on September 4, 2025, found that the discharge instruction form completed before his departure had five of its seven sections left entirely empty. The medications section was blank. The diet and nutrition section was blank. The section covering activities of daily living and bowel and bladder care was blank. The section for education and follow-up appointments was blank. The section documenting his skin condition and treatments was blank. The spaces where a nurse was supposed to sign, and where Resident 5 or a family member was supposed to acknowledge receiving the instructions, had no entries at all.
Only the two sections completed by the Social Services Director had been filled in.
The facility's own electronic health records system was designed to signal when something was missing. Each section of the discharge assessment turns green once a staff member completes it. Inspectors found sections that had never turned green.
A registered nurse who served as the night shift supervisor explained to inspectors how the process was supposed to work. The nurse assigned to discharge a resident is expected to complete the assessment in the EHR system before the resident leaves. The night shift nurse is specifically responsible for the medications section. Once the assessment is finished, the discharging nurse is supposed to print it, because the resident or their legal representative has to sign it in person. That signature is the acknowledgment that they received the medication list and the discharge instructions.
Without it, the supervisor said, a resident may miss follow-up appointments or may not take their medications correctly.
The facility's medical records and transportation coordinator, identified as V15, told inspectors on September 3 that she checks a physical scan box every other day for documents that need to be uploaded to the system. Resident 5 had been discharged nearly three weeks earlier. There was nothing in the box for him.
"It means the nurse did not print the discharge instruction for him to sign," she said.
Nobody could produce the paperwork. Nobody could explain who had been responsible for completing it. The nurse assigned to discharge Resident 5 had left the medications section untouched, and no one had caught it before he walked out.
A regional nurse consultant, reached by email on the day of the inspection, confirmed in writing what the expectation had always been: staff are supposed to complete the discharge assessment before the resident leaves and give them a copy when they go.
The facility's own written discharge procedure, though undated, spelled out the same requirement in plain terms. Staff are instructed to explain the discharge procedure to the resident and family, provide medication instructions in plain language, complete the transfer form accurately and completely, and document specific instructions given about medications to the resident and their representative.
None of that happened for Resident 5.
Inspectors cited the deficiency under federal tag F0628, which covers discharge planning and the requirement that residents receive complete information before leaving a facility. The level of harm was cited as minimal harm or potential for actual harm, and the violation was found to affect a small number of residents.
The citation reflects the lowest tier of harm in the federal inspection system. But the gap between what the paperwork required and what Resident 5 actually received when he left is not a minor clerical error. A man who had suffered a stroke, who had spent time in a rehabilitation facility learning to manage the aftermath, left without a written list of his medications, without instructions on how to take them, without documentation of his skin condition or ongoing treatments, and without a confirmed appointment for follow-up care.
His care plan had promised him written instructions. The system had been built to catch exactly this kind of failure. The sections that were supposed to turn green never did.
Nobody noticed until a federal inspector asked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Alta Rehab At Fairmont from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 30, 2026 · Our methodology
ALTA REHAB AT FAIRMONT in CHICAGO, IL was cited for violations during a health inspection on September 4, 2025.
He had told staff he wanted to go home to his family.
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.