Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0574
The resident has the right to receive notices in a format and a language he or she understands.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to follow their policy to update family on their
grievance regarding insulin ordering issues for 1 (R4) out of three residents reviewed for grievance.
Residents Affected - Few
Findings include:
On 09/24/2024 at 12:00 PM, R4 was seen sitting in his room. R4 state he was not sure about his insulin
being monitored.
On 09/24/2024 at 11:32 AM, V2 (Director of Nursing) stated, the doctor will order the insulin then it will be
confirmed by the nurse. After the nurse confirms the order, it goes to the pharmacy. The pharmacy will
dispense on their next delivery. We request from the pharmacy exactly what the doctors' order. Pharmacy
said that when it is ready to refill, they will dispense a new order.V2 was informed that R4 has a lot of
insulin being billed to him. Lyumjev was the name of the insulin. Even though R4 doesn't take it, we have to
discard it after 28 days. R4 is private pay. The pharmacy is charging the family extra. V2 stated we are
talking to pharmacy but we are not sure if R4's insulin issue has been taken care of. V2 stated that this
issue was not addressed in the care plan meeting on 09/23/2024.
On 09/24/2024 at 11:47 AM, V8 (Minimum Data Set Care Plan Coordinator) states that she is familiar with
R4. V8 stated that R4's son emailed her regarding the insulin that has been charged to them. Once the
doctor changes the dose of the insulin, the nurse's order another set of insulin. The nurses should not be
doing that. V8 stated that they should be changing the dose from what was previously dispensed insulin
from pharmacy. Pharmacy will send the insulin when the nurse's click 'send'. This has been addressed to
the nurses and I have no idea why they still keep doing it. V8 stated that they had a quarterly meeting
yesterday. Care plan consisted of more insulin. We did not give them an update about this issue.
On 09/24/2024 at 12:31 PM, V7 (R4's Financial Power of Attorney) stated that he wasn't aware of the
meeting that took place yesterday 09/23/2024. V7 stated he notified V2 and V8 back in July about his
grievance with this insulin issue for R4 and still has not received any update.
On 09/24/2024 at 1:42 PM, V1 (Administrator) stated that they had a care plan meeting yesterday with the
whole family where they addressed R4's full plan of care. After yesterday's meeting, the family had no
concerns about that meeting. V1 stated that he was not aware of the situation with insulin. V1 stated that V2
did not mention to him about that issue. If he knew he would have addressed it immediately. V1 stated that
they had a care plan meeting on 09/23/2024, but this issue was not brought up because the family did not
bring it up. V1 spoke to the son and we are trying to find who
(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 4
Event ID:
145867
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
145867
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alta Rehab at Fairmont
5061 North Pulaski Road
Chicago, IL 60630
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)
F 0574
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
ordered the extra pens. V1 and V2 are also trying to find out if the pharmacy credited some amount back to
the patient. We try to get them an update on any grievances as soon as possible. As soon as I hear about
it, I go with our business office manager and that's where I follow up. I try to follow up as soon as possible;
at least within 24 hours.
Facility's Grievance Policy (09/25/2017) documents in part: Every effort shall be made to resolve grievances
in a timely manner, usually within 5 business days. Under certain circumstances, additional time may be
needed to complete an investigation and implement measures to resolve the grievance. In such cases
resident or complainant should be notified of the extension.
Event ID:
Facility ID:
145867
If continuation sheet
Page 2 of 4
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
145867
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alta Rehab at Fairmont
5061 North Pulaski Road
Chicago, IL 60630
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)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to implement interventions to prevent
development of deep tissue injuries (DTIs) for one of three residents (R6) reviewed for pressure ulcers.
Residents Affected - Few
Findings include:
R6's Face Sheet documents resident was admitted to the facility on 7.10.2023 with diagnoses including but
not limited to: Displaced fracture of greater trochanter of right femur (hip fracture), Chronic obstructive
pulmonary disease, Hypertension, and Hypothyroidism.
R6's MDS (Minimum Data Set, dated 7.10.2024) documents the following - BIMS: 14 (cognitively intact).
On 9.24.2024 at 12:45 PM, R6 was observed awake and alert. R6 was sitting up in bed with head of bed
elevated. R6 had pillows under her legs, with her legs externally rotated. R6 said she developed pressure
ulcers to her ankles after staff crossed her legs (at the ankles) during care. Staff did not reposition ankles
when they were through providing care. R6 said my legs stayed like that for maybe eight hours. I told the
nurse. They uncrossed my legs and some skin came off. Resident not observed moving legs during
interview/observation.
On 9.24.2024 at 11:59 AM, V5 (Wound Nurse/LPN-Licensed Practical Nurse) said R6 has two facility
acquired DTIs (Deep Tissue Injuries) to left lateral ankle and anterior right ankle. V5 said per R6, she
developed DTIs after staff left R6's legs crossed at the ankles. That's the only way that I think it could have
happened. V5 said R6 is unable to cross/uncross legs by herself.
On 9.25.2024 at 10:44 AM V23 (RN-Registered Nurse/Wound Nurse) reviewed progress note of 8.29.204
at 1:39 PM, acknowledged she is the author of the note. V23 said, I was notified by the CNA (Certified
Nursing Assistant) who was responsible for R6's care that day. R6 was up in the chair that day; she wanted
me to look at R6's ankles. I noticed R6 had discoloration (maroon in color) to the right medial ankle and the
left lateral ankle. The skin was intact at that time. I notified V31 (Wound Coordinator) and V30 (In-house
Nurse Practitioner). Initially we (V23 and V30) thought they might be venous or arterial ulcers, but then we
heard R6 say that her legs were crossed, we (V23 and V30) determined that pressure was the cause of the
DTIs (Deep Tissue Injuries).
Nurses Note dated 8.29.2024 at 1:39 PM documents in part: Wound Care the resident was seen by the
wound care team per the CNA request. There are skin alterations noted to the right medial and left lateral
ankles. Skin is intact. No erythema or s/s (signs/symptoms) indicative of infection.
8.29.2024 at 4:01 PM Nurses Note documents in part: Wound care staff was informed by CNA that there
was skin changes noted to the right and left ankle. Resident stated that she has a habit of crossing her
legs, while ankles typically rest on top of each other. Resident stated that there is increased pain during
digital palpitation.
Wound Assessment Details Report documents:
-Wound: Right ankle inner
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145867
If continuation sheet
Page 3 of 4
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
145867
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Alta Rehab at Fairmont
5061 North Pulaski Road
Chicago, IL 60630
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)
F 0686
-Assessment Date: 8.29.2024 at 1:06 PM
Level of Harm - Minimal harm
or potential for actual harm
-Type: Pressure
-Classification: Ulceration
Residents Affected - Few
-Source: Facility-acquired
-Clinical Stage: Deep Tissue Pressure Injury
-Deep Maroon=100%
-Size: 1.50 x 1.20 x Unknown (L x W x D)
Wound Assessment Details Report documents:
-Wound: Left ankle outer
-Assessment Date: 8.29.2024 at 1:07 PM
-Type: Pressure
-Classification: Ulceration
-Source: Facility-acquired
-Clinical Stage: Deep Tissue Pressure Injury
-Deep Maroon=100%
-Size: 1.00 x 0.80 x Unknown (L x W x D)
R6's care plan documents I have pressure ulcer right medial and left lateral ankles related to history of
ulcers and immobility (revised 8.29.2024). R1's care plan documents the following intervention: Follow
facility's policies/protocols for the prevention/treatment of skin breakdown.
Pressure Ulcer Prevention Policy (Revisions 1.15.2018) documents: 11. Use positioning devices or pillows,
rolled blankets, etc. to reduce pressure and friction/shear from heels, toes, and malleoli as indicated.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145867
If continuation sheet
Page 4 of 4
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F574 - The resident has the right to receive notices orally (meaning spoken) and in
The resident has the right to receive notices in a format and a language he or she understands.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
FAQ · About this visit
Common questions about this visit
What happened during the September 27, 2024 survey of ALTA REHAB AT FAIRMONT?
This was a inspection survey of ALTA REHAB AT FAIRMONT on September 27, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALTA REHAB AT FAIRMONT on September 27, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "The resident has the right to receive notices in a format and a language he or she understands."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.