Health inspection·August 6, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner to 2 of 62 residents (R9, R42) reviewed for safety in the sample of 62. The findings include:1.R9's face sheet printed on 8/4/25 show R9 has diagnoses that include hemiplegia affecting right dominant side, multiple sclerosis, renal failure and bladder mass.R9's facility assessment show R9 has no cognitive impairment.R9's progress notes dated 7/18/2025 timed at 4:20 PM, documents, resident (R9) was transferring from wheelchair to bed with two staff assist using stand lift machine when her legs started to give out, resident said she has right leg pain and cannot stand longer in the machine, so resident was lowered to the floor by staff. Resident eased to lie down on the floor with pillow underneath her head, resident wanted to go back to bed so staff transferred resident to bed using (Mechanical lift machine). NP was notified with orders to administer PRN pain medication and if pain persists order an X-ray follow up assessment, resident said she's fine, no new complaints of pain were reported.On 8/5/2025 at 11 AM, R9 was in bed alert and pleasant. R9 said when she was being transferred from her chair to go to bed, her knees gave out. R9 said she had pain after it happened, then the pain was on and off. On 8/6/25 at 3:30 PM, V22 (R9's daughter) said R9's knees buckled, she was not able to hold unto the lift machine.On 8/4/25 at 12:38 PM, V24 (Certified Nursing Assistant-CNA) said he was R9's CNA. It was around 4PM last 7/18/25, R9 was being transferred from her wheelchair to bed via the mechanical stand lift machine. After the safety straps were applied, it was noted that R9's right side was not working well, her right hand was weak she had a stroke, she was only able to hold unto the handle using her left hand. As R9 was being raised to standing position, she leaned towards her right side, she was not able to stand. V24 said he pulled R9 from the chair to a standing position. R9 made a loud sound like she was in pain while her knees buckled with her legs spread out. V24 said he asked the other CNA to get help. The Nurse was passing meds just outside R9's room, the nurse came and R9 was lowered to the floor.On 8/5/25 at 10:10 AM, V11 (CNA) said it was her second day on the job. This was her first job as a CNA. On 7/18/25, she was working with CNA (V24) who was showing her around and observing how things were being done. R9 was being transferred to bed using the stand lift machine. V11 said she assisted V24 to place R9's foot in the sit to stand. V11 said she then stayed behind the wheelchair to observe how R9 was being transferred in the stand lift machine. V24 transferred R9 by himself As R9 was being lifted with the stand lift, she noticed R9 was no longer in the machine and all of a sudden all of R9's weight came down, R9 was so closed to the ground, V11 said she went to get help, as V24 was holding unto R9. The Nurse (V10) was just outside the room, V10 came in and assisted to lower R9 to the floor. On 8/4/25 at 1PM, V10 (License Practical Nurse-LPN) said she was passing evening meds, she was called to R9's room, R9 was hanging on the sit to stand, her legs buckled. V10 said R9's left hand was able to hold unto the stand lift but R9's right hand was weak, her right arm cannot hold on, that made her buckled. R9 was lowered down to the floor. V10 said she put pillows on the floor to cushion (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145458 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145458 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Alta Rehab at Oak Brook 2013 Midwest Road Oak Brook, IL 60521 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)