Health inspection·December 14, 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 interview and record review, the facility failed to ensure a resident's foot was supported during wheelchair transport which resulted in a fracture of the lower leg. This past noncompliance occurred from October 27, 2025, through October 29, 2025.This applies to 1 of 3 residents (R1) reviewed for accidents in the sample of 6.The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis, spastic hemiplegia affecting the right dominant side. Paraplegia, fracture of both the right and left femurs with surgical repair, diabetes mellitus, dementia, and left tibia fracture added October 27, 2025. R1's MDS (Minimum Data Set) dated November 26, 2025, showed R1 was cognitively intact and required assistance with ADLs including set up assistance with eating, partial assistance with oral hygiene, substantial assistance with upper body dressing and dependent on staff for lower body dressing, toileting, bathing, bed mobility and transfer. The facility sent a report to the department dated October 28, 2025, showed that R1 sustained a fracture to her left lower leg, while a therapy assistant was transporting R1 in a wheelchair from the therapy room to R1's room, and R1's leg was abruptly placed on the floor.On December 12, 2025, at 2:05 PM, V2 (Physical Therapy Assistant), stated on October 27, 2025, V2 was transporting R1 in the wheelchair both to and from therapy using only one footrest on the wheelchair.On December 13, 2025, at 1:35 PM, V5 (NP-Nurse Practitioner) stated on October 27, 2025, V5 was in the facility when R1 was injured, and alerted by staff that R1 was complaining of left leg pain. V5 stated she examined R1 and stated R1 was in pain and had limited ROM (Range of Motion) to the left leg and ordered X-rays of R1's entire left leg due to a history of previous fractures. V5 stated the injury was caused by R1's left leg not being supported by a footrest while being transported in a wheelchair, when R1's leg was caught under the wheelchair. V5 stated staff informed her that the staff was unable to find the second footrest for R1's wheelchair, and proceeded to transport R1 without the footrest, resulting in the fracture.R1's Xray result dated October 27, 2025, showed R1 sustained an acute nondisplaced fracture of the proximal left tibia.Prior to the survey entrance date of December 12, 2025, the facility had taken the following action to address the noncompliance.1. The Facility held an emergency QA (Quality Assurance) meeting, on October 28, 2025, that was attended by the Medical Director and the interdisciplinary team, to develop a plan to address the noncompliance. 2. The Facility found R1's wheelchair footrest and did a 1:1 training regarding supporting feet during wheelchair transport with V2. 3. The Facility in serviced the therapy department staff and nursing staff on October 28, 2025, regarding the use of footrests while transporting residents in their wheelchairs. 4. The facility did a facility wide audit of residents who use wheelchairs for transport to ensure footrests were available and their care plans were updated.5. The Facility developed a QA Audit tool to ensure compliance. The facility had completed the audit tool in accordance with their plan of 5 random residents per week for 2 months. The initial audit was completed (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 12/14/2025 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)