Alta Rehab At Oak Brook
ALTA REHAB AT OAK BROOK in OAK BROOK, IL — inspection on August 22, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
establish a grievance policy and make prompt efforts to resolve grievances.
interview and record review, the facility failed to ensure that grievances were identified, documented,
grievances.The Findings Include:
Review of the Electronic Medical Record (EMR) showed that R1, a [AGE] year-old male, was admitted to the facility on [DATE], from a hospital following a fall. R1's documented diagnoses included, but were not limited to: dementia, repeated falls, ataxia, muscle wasting, lack of coordination, type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD), cirrhosis, protein-calorie malnutrition, and depression.
The Minimum Data Set (MDS) dated [DATE], identified R1 as having moderately impaired cognition and requiring substantial to maximum assistance with activities of daily living (ADLs).An admission skin assessment dated [DATE], documented the following impairments: -Left elbow skin tear measuring 0.5 cm x 0.5 cm x 0.1 cm with 100% bright pink tissue and light serous drainage -Deep tissue injury (DTI) to sacrum measuring 3.0 cm x 2.5 cm with 100% dark maroon tissue --Bruise to left hip measuring 2 cm x 2 cm x 0 cmFurther initial assessment observations by the Wound Nurse (V3) included: -multiple bruises to upper arms, lower legs, right chest, right foot, and ankle; edema in the upper arms; scabbing to the right knee and anterior lower leg.
Facility-acquired skin tears were documented as follows: -Left shoulder - Identified August 1,2025 : measured 2 cm x 0.1 cm -Right shoulder - Identified August 1,2025 : measured 1.45 cm x 1.0 cm x 0.1 cm -Right forearm - Identified August 4,2025: measured 15 cm x 13 cm x 0.1 cm with light bloody drainage. -Lesion to top of head - Identified August 1,2025: measured 0.5 cm x 0 cm with scant serosanguinous drainage and 100% slough/necrotic tissue.On August 20, 2025, at 2:30 P.M., the Wound Care Nurse (V4) stated that she performed a dressing change on the right forearm wound on August 6, 2025 at approximately 6:45 A.M.
She observed significant bloody drainage and used four ABD pads and Kerlix wrap for coverage.
However, she did not notify the physician or Nurse Practitioner (V6) despite the change in wound status.On August 20, 2025, at 12:22 P.M., V8 (Social Service Director) stated that V7 (R1's spouse) had voiced concerns regarding poor wound care on August 4, 2025, citing dried blood leaking through R1's shirt. V7 subsequently requested R1's transfer to another facility. V8 acknowledged that she did not report this grievance to either the Administrator (V1) or the Assistant Director of Nursing (V2).During a phone interview on August 20, 2025, at 1:00 P.M., V7 stated: They butchered my husband. 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.
Review of the facility's grievance documentation showed no record that V7's concerns were reported, investigated, or resolved.On August 20, 2025, at 4:40 P.M., both the Administrator (V1) and the Assistant Director of Nursing (V2) confirmed that they had not received any report of a grievance related to R1's wound care from V8 or other facility staff.
Review of the facility's Grievance Policy (dated November 20, 2012) stated: The purpose of this policy is to ensure prompt resolution of all grievances related to care and treatment provided or not provided, staff and resident behavior, and other concerns during the resident's stay.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
145458 08/22/2025
Alta Rehab at Oak Brook 2013 Midwest Road Oak Brook, IL 60521
Executive Director at the receiving facility), R1 arrived on August 6, 2025, around noontime, was
their facility. V11 said that V7 was present during the assessment. V11 described that R1 was a poor
large bandage wrapped around R1's forearm that had extended from the wrist to the elbow. V11 said that the outer bandage was a mixed of saturated dried and fresh red blood drainage. V11 said she used approximately 200 cc of normal saline to ensure that when primary dressing be removed, there would be easy to remove without compromising what was under the dressing. V11 said that she noted multiple ABD pads, and a mesh like dressing that was embedded to the skin tissue to a deep wound on the right forearm. V11 describe the wound an approximated size from wrist to the elbow. V11 added that aside from the multiple dressing to shoulders, R1's extremities were with scattered bruises and note especially the left middle finger that extend to the elbow. V11 said that R1 was retracting his arm when the dressing was removed, whimpering of pain. V11 said she was not able to open other dressing and R1 was send via 911 for further evaluation of the large weeping wounds and pain.The documentation dated August 8,2025 entered by V11 validated V11's statement.
The Hospital ED (Emergency Department) report dated August 6,2025 showed that R1 was noted with diffuse bruising and swelling in upper and lower extremities; multiple skin tears to right forearm and with significant bruising ; upper and lower patchy bruising diffused around trunk. On August 20,2025, V6 (Facility's Nurses Practitioner) stated that she was not notified that it was a large wound and not a skin tear. V6 added that a skin tear was non-significant since it was superficial, but a weeping, draining large wound need further evaluation and treatment. V11 added that should she been notified, R1 would have been sent out for further evaluation and treatment of wounds to prevent complication such as infection.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.