Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alta Rehab At Wauconda during CMS and state inspections, most recent first.
A resident admitted with metabolic encephalopathy, UTI, and Type 2 DM was documented as alert and oriented, but the advance directive section of the face sheet was left blank and no admission notes reflected any discussion of code status with the resident or family. The resident arrived from the hospital wearing a DNR wristband, which the admitting RN removed, and the family reported that no staff asked about the resident’s wishes despite the hospital indicating that advance directive forms would be sent. Later, when the resident was found unresponsive, an RN checked the chart, saw a full code order, and initiated CPR until EMS arrived and a pulse was regained. Staff interviews confirmed that facility protocol requires determining and documenting advance directives at admission, yet the admitting RN did not recall doing so, and the facility record contained a hospital discharge summary listing DNR status alongside a physician order for full code.
A resident admitted for short-term rehab with multiple comorbidities and identified fall risk experienced an unwitnessed fall from the bed onto a landing pad while restless and cognitively impaired. Staff CNAs and an RN later confirmed the fall, but the incident report lacked documentation of required notifications, had no completion date, and the record contained no completed post-fall assessment or subsequent assessments. Despite a facility fall prevention policy requiring post-fall assessment, communication, and implementation of safety interventions, these steps were not documented or clearly carried out for this resident.
A resident in a LTC facility reported verbal abuse by a CNA who was involved in a loud argument with an Activity Aide. The CNA used profanity and derogatory language towards the Aide and the resident who intervened. Multiple residents witnessed the incident, which was loud and disrespectful. The facility's Administrator confirmed disciplinary action against the CNA.
A resident reported witnessing a verbal altercation between a CNA and an Activity Aide, during which the CNA used profanity and pointed a finger at the resident. Despite multiple residents corroborating the incident, the facility's investigation was inadequate, as it did not interview all potential witnesses and relied on incomplete information. The facility's policy for investigating abuse allegations was not followed.
A resident at risk of falling was not safely transferred by a CNA who failed to use a gait belt as required by facility policy. The resident's legs became weak during ambulation, and the CNA assisted her to the floor by holding her pants instead of using the gait belt. The facility's policy mandates the use of a transfer belt, but it was not followed, resulting in a deficiency.
A resident experienced an assisted fall in the bathroom, resulting in a wrist fracture that went undiagnosed for several days due to the facility's failure to conduct a proper assessment and notify the physician or family. The nurse on duty did not document the incident as a fall, leading to a lack of follow-up assessments and communication, contrary to the facility's guidelines.
A resident with a history of falls and multiple health conditions fell from the edge of his bed while a CNA was reaching for his shoes, resulting in a subdural hematoma and requiring sutures. Despite being at high risk for falls and having a care plan that required staff to work in pairs, the resident experienced multiple falls, indicating a failure to implement effective fall prevention measures.
A facility failed to notify a physician before and after holding blood pressure medication for a resident. The resident's MAR indicated that Hydrochlorothiazide and Lisinopril were held on multiple occasions, but the physician was not informed. An LPN stated that the protocol is to contact the doctor when a medication is held. The facility's policy requires notifying the physician and family when treatment is significantly altered.
A resident at risk for pressure ulcers was observed with her heels directly on the mattress, despite orders to offload them using pillows or boots. The resident reported inconsistency in applying pressure-relieving boots, and the Wound RN confirmed the need for offloading. The facility's policy on pressure ulcer prevention was not followed.
A resident with hemiplegia and hemiparesis experienced a decline in hand function due to the facility's failure to implement occupational therapy recommendations for a restorative range of motion program. Despite being discharged from therapy with specific instructions, the resident's care plan and medical records showed no evidence of a restorative program, and the restorative aide confirmed the resident was not receiving such care.
Two residents experienced accidents due to inadequate safety measures and care plan updates. One resident hit her head on a mechanical lift during a transfer, while another fell from a wheelchair due to missing footrests. Both incidents highlight failures in following care plans and ensuring resident safety.
A resident did not receive scheduled doses of morphine due to the facility's failure to reorder the medication in time. The resident, with intact cognition, missed two doses on a specific day. The LPN involved could not recall the reason for the missed dose, and progress notes indicated delays in ordering and receiving the medication. The facility's policy to prevent medication interruptions was not followed.
Two residents on a pureed diet received incorrect portion sizes of pureed stuffed shells due to the use of a #8 scoop instead of the required #6 scoop. This discrepancy was observed during meal preparation and serving, and the facility's policy mandates the use of standardized recipes and appropriate scoop sizes to ensure correct nutrient delivery.
A resident received an extra dose of Norco due to a failure in documentation and communication between staff. The LPN documented the administration of Norco only in the narcotic logbook, not in the MAR, leading the RN to administer an additional dose. This resulted in the resident experiencing increased confusion and being sent to the hospital for evaluation.
The facility failed to supervise residents receiving medications and did not administer medications as ordered for seven of ten residents reviewed. One resident's blood pressure medication was held without proper parameters, and incorrect medication was administered. Multiple residents reported that nurses left medications at their bedside without supervision, and no self-administration assessments were conducted.
Failure to Determine and Document Resident Advance Directives on Admission
Penalty
Summary
The deficiency involves the facility’s failure to determine and document a resident’s advance directives upon admission, as required by facility policy. The resident was admitted with diagnoses including metabolic encephalopathy, urinary tract infection, and Type 2 Diabetes Mellitus, and was documented as alert and oriented to person, place, time, and situation, though forgetful. The face sheet section for advance directives was left blank, and admission nursing documentation did not mention any discussion of advance directives with the resident or family. The resident’s son-in-law reported that the resident arrived from the hospital with a DNR wristband in place, which the admitting nurse removed, and that no staff asked him or his wife about the resident’s wishes regarding advance directives, despite the hospital indicating that advance directive forms would be sent with the resident. Subsequently, when the resident was found unresponsive with no respirations or carotid pulse, the RN on duty checked the medical record, saw an order for full code, and initiated CPR while 911 was called. CPR continued until EMS arrived, and a pulse was eventually regained before transfer to the hospital. Staff interviews, including with the RN who performed CPR, another RN present that morning, the DON, the ADON, and the admitting RN, confirmed that facility protocol requires that advance directives be determined and documented at admission, but the admitting RN did not recall whether this was done for this resident. The hospital discharge summary in the facility record listed the resident’s code status as DNR, while the facility’s physician order sheet contained an order for full code, demonstrating that the resident’s actual wishes regarding code status were not properly identified and documented at admission.
Failure to Assess, Document, and Communicate Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to timely communicate and document a fall, complete a post-fall assessment, perform subsequent assessments, and implement fall-prevention interventions for one resident. The resident was admitted for short-term rehabilitation with a medical history including seizures, anemia, hypertension, anxiety, osteoarthritis of the left wrist, and chronic kidney disease. On admission, a fall risk assessment scored the resident as not at risk for falls, but a subsequent assessment two days later identified the resident as at risk, and the care plan was updated to reflect fall risk. An unwitnessed fall incident occurred when the resident rolled or fell from the right side of the bed onto a landing pad while restless and hard to redirect, and the resident was unable to describe the event due to cognitive deficits. Staff, including a CNA and an RN, later confirmed that the resident had fallen from the bed. The unwitnessed fall report documented the incident time and basic description but lacked documentation of notifications to agencies or people, and there was no documented date of when the incident report itself was completed. Although staff reported that the nurse was called and assessed the resident, the record did not contain a completed post-fall assessment or any subsequent assessments following the fall. The facility’s Fall Prevention Program policy required fall risk assessments upon admission, quarterly, with significant changes, and after any fall incident, as well as implementation of safety interventions and communication with direct care staff, physician, and family/legal representative. The survey findings indicate that these required assessments, documentation, and interventions were not carried out or recorded as required for this resident following the fall event.
Verbal Abuse Incident Involving CNA and Activity Aide
Penalty
Summary
The facility failed to ensure a resident was free from verbal abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and an Activity Aide. The incident occurred when a resident overheard a CNA and an Activity Aide arguing in the hallway. The resident attempted to intervene, at which point the CNA allegedly pointed her finger at the resident and used profanity. The resident reported feeling verbally abused by the CNA's actions. Multiple residents witnessed the incident, which involved the CNA yelling at the Activity Aide and using derogatory language. The CNA was accused of calling the Activity Aide derogatory names and belittling her job and age. The CNA's behavior escalated to the point where she also directed profanity at the resident who tried to intervene. Witnesses reported that the CNA's actions were loud and disrespectful, causing concern among the residents present. The facility's Administrator confirmed that the CNA received disciplinary action for swearing and leaving her assigned unit. The facility's Abuse Prevention and Reporting Policy defines verbal abuse as the use of oral, written, or gestured communication that is inappropriate, regardless of the resident's ability to comprehend. The incident was documented in the facility's records, and the resident involved was noted to be cognitively intact.
Inadequate Investigation of Staff Altercation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who reported witnessing a verbal altercation between two staff members. The incident occurred when a resident overheard a CNA and an Activity Aide arguing in the hallway. The resident attempted to intervene, and the CNA allegedly used profanity and pointed a finger at the resident. Despite the resident's report, the facility did not substantiate the abuse claim, as the administrator concluded it was a staff altercation not directed at the resident. Interviews with the involved resident and other witnesses revealed that the CNA was yelling at the Activity Aide, using derogatory language, and the altercation was loud enough to be heard by other residents. The resident who reported the incident felt threatened and intervened to stop the CNA, who then directed profanity at the resident. Other residents corroborated the account, noting the CNA's aggressive behavior and the potential for the situation to escalate. The facility's investigation was inadequate, as it relied on incomplete information from the manager on duty, who was unavailable for further interviews. The administrator did not interview all potential witnesses, and the social services designee only spoke with the reporting resident. The facility's policy requires a thorough investigation of abuse allegations, including interviews with all potential witnesses, which was not followed in this case.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as R2, who was at risk of falling. On the specified date, handwritten signs in R2's room indicated that she was a fall risk and required the use of a gait belt. However, during an incident, R2 was assisted by a Certified Nursing Assistant (CNA), identified as V13, without the use of a gait belt. R2 reported that she was walking with a walker when her legs became weak, and V13 assisted her to the floor without the gait belt, holding onto her pants instead. The Assistant Director of Nursing confirmed that R2 experienced a fall when her knees gave out while being assisted by V13. The facility's policy on ambulation assistance, dated January 15, 2018, mandates the use of a transfer belt during such activities. The Interdisciplinary Team (IDT) Fall Committee Meeting Note indicated that R2's fall was due to her knees giving out, likely related to recent illness, and no injuries were observed. Despite the policy, the CNA did not use the gait belt, leading to the deficiency in providing adequate supervision and safety measures for R2.
Failure to Assess and Monitor Resident After Fall
Penalty
Summary
The facility failed to properly assess and monitor a resident after a fall, which was identified during a review of quality of care for one of the three residents sampled. The incident involved a resident who experienced an assisted fall in the bathroom. Despite the resident expressing pain and tingling in her left arm immediately after the fall, the nurse on duty did not perform a comprehensive assessment or notify the physician or family. The nurse did not consider the incident a fall because the resident was lowered to the ground by a CNA, and thus, no documentation or follow-up assessments were conducted. The resident later reported persistent wrist pain, leading to an X-ray that revealed a fracture. The facility's records showed no documentation of the fall in the nursing notes, no initial assessment, and no notification to the physician or family. Additionally, there were no 72-hour post-fall assessments documented. The facility's guidelines require documentation of the incident, assessment, and notification of relevant parties, which were not followed in this case.
Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a resident was positioned safely, resulting in a fall that required medical attention. The resident, who had a history of falls and was at high risk due to multiple conditions including dementia and Parkinson's disease, fell from the edge of his bed while a CNA was attending to him. The CNA was reaching for the resident's shoes when the resident, who was impulsive and had a tendency to attempt movements on his own, fell forward and hit his head, leading to a subdural hematoma and requiring sutures. The resident's care plan noted his resistance to care and combative behavior, necessitating staff to work in pairs for safety. Despite these precautions, the resident experienced multiple falls over several months, indicating a lack of effective interventions to prevent such incidents. The facility's fall prevention policy required individualized assessments and appropriate interventions, which were not adequately implemented in this case, as evidenced by the repeated falls and the serious injury sustained by the resident.
Failure to Notify Physician of Held Blood Pressure Medication
Penalty
Summary
The facility failed to notify a physician before and after holding a blood pressure medication for a resident. This deficiency was identified for one resident who was part of a sample of 27 reviewed for notification of changes. The resident's August 2024 Medication Administration Record (MAR) indicated that Hydrochlorothiazide and Lisinopril, both prescribed for essential hypertension, were held on three separate occasions. However, the resident's electronic medical record showed that the physician was not notified on any of these dates. An LPN confirmed that the protocol is to contact the doctor whenever a medication is held. The facility's policy, dated November 13, 2018, requires informing the resident, consulting with the physician, and notifying the resident's legal representative or family when there is a need to alter treatment significantly.
Failure to Implement Pressure Ulcer Prevention for At-Risk Resident
Penalty
Summary
The facility failed to implement pressure ulcer prevention interventions for a resident at risk for developing pressure ulcers. On multiple occasions, the resident was observed lying in bed with her heels directly on the mattress, contrary to the physician's order and care plan that required her heels to be offloaded using pillows or pressure-relieving boots. The resident expressed uncertainty about the presence of wounds on her heels and noted that the pressure-relieving boots were not consistently applied. The Wound Registered Nurse confirmed that the resident was at risk for pressure ulcers and that her heels should not be directly on the bed. The facility's Pressure Ulcer Prevention Policy also emphasized the use of positioning devices to reduce pressure on vulnerable areas, which was not adhered to in this case.
Failure to Implement Restorative Therapy for Resident with Contracted Hand
Penalty
Summary
The facility failed to follow occupational therapy recommendations for a resident with a contracted hand, leading to a deficiency in maintaining or improving the resident's range of motion. The resident, diagnosed with hemiplegia and hemiparesis following a cerebral infarction, was observed with his right hand in a fist-like shape, indicating a worsening condition since his admission. Despite the resident's efforts to perform hand exercises, he reported that the facility did not assist with any exercises for his hand. The occupational therapy assistant confirmed that the resident had been discharged from therapy with recommendations for a restorative range of motion program, which included using a rolled-up towel in his hand and continuing exercises. However, the facility did not implement these recommendations. The resident's restorative observations and electronic medical records showed no documentation of a restorative therapy program, and the resident was not included in any restorative program at the time of the survey. The restorative aide responsible for the resident's hallway confirmed that the resident was not on any restorative program. Additionally, the resident's care plan lacked any plans for restorative or range of motion care, despite the facility's policy outlining the importance of individualized restorative programs for maintaining or regaining independence.
Deficiencies in Resident Safety and Care Plan Updates
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, identified as R19, resulting in an accident. R19, a female resident with dementia and anxiety, sustained bruising on her forehead after hitting her head on a mechanical lift during a transfer. The incident occurred when R19 became excited and raised her head, causing it to come into contact with the lift. The care plan for R19 indicated a risk for bruising and required extreme care during transfers, but this was not adequately followed, leading to the injury. Another incident involved a resident, identified as R5, who fell from her wheelchair while being transported by a CNA. R5, who requires substantial assistance and uses a wheelchair, fell forward and hit her face on the ground after putting her foot down due to the absence of footrests on her wheelchair. Despite the fall, R5's care plan was not updated with new interventions to prevent future falls. The lack of footrests during transport was identified as a safety hazard, and the staff was not adequately informed about the necessity of using footrests, contributing to the accident.
Failure to Administer Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure that a resident received their routine medication, specifically morphine, as prescribed. The resident, who had intact cognition, was supposed to receive morphine three times a day for pain management. On a specific day, the resident did not receive the 1:00 PM and 9:00 PM doses because the facility ran out of the medication. The resident reported missing these doses due to the facility not reordering the medication in time. The Medication Administration Record confirmed the missed doses, and the Licensed Practical Nurse (LPN) involved could not recall the reason for the missed 1:00 PM dose. Progress notes indicated that a prescription for morphine was sent to the pharmacy after the 1:00 PM dose was due, and the medication was not available for the 9:00 PM dose. The pharmacy confirmed receiving the refill request on the same day, with delivery occurring the following morning. The facility's policy required refilling prescriptions to prevent interruptions, which was not adhered to in this case.
Incorrect Portion Size for Pureed Diets
Penalty
Summary
The facility failed to ensure that residents receiving a pureed diet were provided with the correct portion size of pureed stuffed shells. Specifically, two residents, identified as R390 and R81, were affected by this deficiency. The facility's diet type report confirmed that both residents were on a pureed diet. During the lunch service, a dietary aide, V12, used a #8 scoop instead of the required #6 scoop to serve the pureed stuffed shells, resulting in a portion size of 4 ounces instead of the required 5.33 ounces. This discrepancy was observed during the preparation and serving of meals on the 500, 600, and 700 units. The Food Service Director, V9, acknowledged that staff could use the diet spreadsheet in the kitchen to verify the correct scoop sizes for meal service. However, the dietary aide, V12, admitted to using the incorrect scoop size while pre-plating the pureed meals. The facility's Pureed Food Preparation policy, dated 2020, mandates the use of standardized recipes and appropriate scoop sizes to ensure the correct nutrient density is delivered to each resident. The failure to adhere to these guidelines could potentially lead to residents not receiving the necessary nutrients, as noted by V9.
Medication Administration Error Due to Documentation Oversight
Penalty
Summary
The facility failed to ensure a resident's opioid pain medication was administered as prescribed, resulting in a significant medication error. A resident was given Norco 10/325 mg, an opioid pain medication, three hours after the previous dose, despite the prescription indicating it should be administered every six hours as needed for pain. This error occurred because the RN administering the medication did not check both the electronic Medication Administration Record (MAR) and the narcotic logbook, leading to the resident receiving an extra dose. The resident subsequently exhibited increased confusion and was administered Narcan, a medication to reverse the effects of opioids, but showed no significant improvement and was sent to the hospital for further evaluation. The incident was compounded by documentation errors. The LPN who administered the initial dose of Norco at 6:45 AM documented it only in the narcotic logbook and failed to record it in the MAR. This oversight led the RN to believe no dose had been given recently, prompting the administration of an additional dose at 9:27 AM. The Assistant Director of Nursing confirmed that staff are required to document opioid administration in both the MAR and the narcotic logbook, which was not done in this case. The facility lacked a specific medication administration policy related to the documentation of opioid pain medications, contributing to the oversight.
Failure to Supervise and Administer Medications as Ordered
Penalty
Summary
The facility failed to supervise residents receiving medications and did not administer medications as ordered for seven of ten residents reviewed. Specifically, one resident's blood pressure was recorded as 120/54, and the LPN held both metoprolol and losartan despite only losartan having parameters to be held if blood pressure was less than 110/60. Additionally, the LPN administered sennosides instead of the ordered senna with docusate sodium. The RN confirmed that metoprolol should not have been held without parameters and that losartan should have been administered given the recorded blood pressure. The RN also noted the difference in medication composition between sennosides and senna with docusate sodium, which includes a stool softener. This indicates a failure to follow physician orders accurately and administer the correct medications as prescribed. Multiple residents reported that nurses often left medications at their bedside without supervising their intake. One resident's daughter confirmed that the nurse left medications at the bedside, and the resident had a tendency to hide or discard them. The LPN admitted to leaving medications at the bedside on at least one occasion and was not counseled against this practice. The DON acknowledged that nurses should follow up with residents to ensure they take their medications but admitted that the facility was relying on residents to self-administer without proper supervision. The facility's Pharmaceutical Services policy requires assistance with medication administration and an evaluation for residents to self-administer medications safely. However, the report indicates that no self-administration assessments were conducted for the residents involved. This lack of supervision and failure to follow established protocols led to the deficiency in medication administration and resident safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wauconda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avantara Lake Zurich | 6.1 mi | — | 0 | 0 |
| Prairieview At The Garlands | 6.8 mi | — | 0 | 0 |
| Pearl Of Crystal Lake, The | 7 mi | — | 0 | 0 |
| Thrive Of Lake County | 8 mi | — | 2 | 0 |
| Ignite Medical Mchenry | 8.4 mi | — | 3 | 0 |
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