Health inspection·November 5, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to transfer a resident using a mechanical lift safely. This failure caused R1 to be dropped from mechanical lift resulting in an ankle fracture. This applies to one of three (R1) reviewed for falls in the sample of 7.This past non-compliance occurred from May 16, 2024, to June 2, 2024.Past noncompliance-no plan of correction required.The findings include:On 10/31/2025 at 11:30 AM, V10 (R1's family) said R1 was dropped from the mechanical lift on 05/16/2024 due to only one staff member attempting the transfer and without properly applying the sling. V10 stated the fall broke R1's ankle. V10 said R1 was transferred to the hospital the next day. R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility with diagnoses of dementia, atrial fibrillation, congestive failure, and pain. A physician order dated 05/06/2024 showed R1 was admitted to hospice care. Minimum Data Set, dated [DATE] showed R1 was severely cognitively impaired. The care plan dated 04/18/2024 showed R1 required two assist transfers per mechanical lift. The progress notes dated 05/16/2024 by V13 (Registered Nurse-former employee) stated V14 (Agency Certified Nursing Assistant [CNA]- former employee) reported R1 had fallen from the mechanical lift while being transferred to bed and slings were not appropriately applied. The nursing notes dated 5/17/24 at 12:12 PM stated the hospice nurse visited the facility and arranged for R1 to be transported to the hospital for an evaluation.The hospital physician's progress notes dated 5/17/24 showed R1 was sent to the emergency room after a fall from a mechanical lift, and the x-ray report dated 5/17/24 showed a displaced fracture to the distal tibia and fibula (lower leg bones).The facility's incident report dated 5/16/24 showed R1 required two people's assistance and had a fall while a former Certified Nursing Assistant transferred R1 via mechanical lift, and that staff were in-serviced on mechanical lift transfers.The facility policy for manual gait belt and mechanical lifts with a revision date of 1/19/18 in part showed to protect the safety and wellbeing of the staff and residents, and to promote quality care. This facility will use mechanical lifting devices. The transferring needs of residents will be assessed on an ongoing basis and designated into one of the mechanical lift with two caregivers.On 10/31/2025 at 3:00 PM, V1 (Administrator) and V2 (Director of Nursing) stated the facility had an ownership change survey with an exit date of 05/23/2024, and the facility was cited for R1's fall and a plan of correction was submitted and accepted. V2 Director of Nursing said two staff should be present during mechanical lift transfers, and the staff should ensure the sling is attached adequately prior to lifting the resident. V2 said all staff were provided with in-services and training has been ongoing.The facility's accepted Plan of Correction (POC) showed their date of completion as June 2, 2024.-A whole-house transfer audit was conducted. -The training binder showed the facility provided in-services beginning on 5/17/24, indicating the appropriate number of staff assistants for mechanical lift transfers is two and sling pads must be securely placed before transfers.-Signs were in place as reminders to have two assists for mechanical lift transfers.-The (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 11/05/2025 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)