Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Park Oasis during CMS and state inspections, most recent first.
GT Feeding and Flush Orders Not Followed: A resident with severe cognitive impairment, gastrostomy, dehydration, seizure, and anoxic brain damage did not receive ordered GT bolus feeding and free water flushes because the GT port was leaking during observation. An RN was unable to complete the ordered flush, and the DON later confirmed the resident had orders for enteral feeding with 300 ml free water flushes before and after feeds; the resident also had a documented history of hypernatremia.
Surveyors found that nursing staff failed to administer multiple residents’ scheduled medications within the facility’s required one-hour-before/one-hour-after window. An RN was observed beginning a 9:00 a.m. med pass late in the morning and subsequently acknowledged that several other residents’ 9:00 a.m. medications were still outstanding. Medication administration records showed that various drugs, including carvedilol, metformin, gabapentin, laxatives, ophthalmic drops, nasal sprays, inhalation treatments, and diuretics, ordered for specific times were actually given several hours late. Residents involved had conditions such as diabetes, COPD, heart failure, constipation, and hypertension, with some cognitively intact and others cognitively impaired. Review of progress notes revealed no documentation authorizing or explaining the late administration, despite facility policies and DON expectations requiring adherence to the right time of medication administration in accordance with physician orders.
The facility did not ensure timely administration and documentation of medications for several residents, and failed to provide appropriate emergency response for a resident with severe hypoglycemia. Nursing staff delayed calling EMS, did not administer glucagon as required by protocol, and attempted unsafe interventions. The affected resident was hospitalized with critical hypoglycemia, sepsis, and multiple infections, with hospital staff noting poor hygiene and skin breakdown.
Two residents were involved in an incident where one directed a racially derogatory term and spat on another, despite a known history of similar behaviors and cognitive impairment. The aggressor's care plan was not updated with new interventions after repeated incidents, and the facility did not implement timely strategies to prevent further abuse, contrary to its abuse prevention policy.
Multiple residents, including those at risk for falls, were exposed to water hazards on the floor caused by leaking air conditioning vents. Staff and maintenance confirmed recurring leaks and inadequate routine maintenance of condensation pipes, resulting in puddles and slippery conditions in resident rooms. Observations included towels and buckets used to manage leaks, but these measures were insufficient to keep floors dry and safe.
A nurse called off for a day shift on a unit, but the absence was not properly communicated, resulting in no nurse coverage for approximately one to two hours. The off-going nurse left before a relief arrived, and the oncoming LPN was not notified to stay over. This left 36 residents without a licensed nurse, with CNAs unable to administer medications, in violation of facility policy requiring staff not to leave without relief.
A resident was transferred to another skilled facility without receiving discharge instructions or medications, as required by facility policy. The family transported the resident without notifying the nurse, and the nurse only learned of the departure after being contacted by the receiving facility. Documentation confirming that instructions and medications were provided and signed for was not available.
Three residents with indwelling catheters did not receive care in accordance with facility policy. Observed deficiencies included improper positioning of catheter bags, failure to secure catheters, and incomplete hygiene during catheter care, such as not cleaning the labia for a female resident and not retracting the foreskin for an uncircumcised male. Staff interviews confirmed these lapses in required catheter care procedures.
A high fall risk resident with multiple medical and cognitive conditions was not adequately supervised or provided with required fall prevention interventions, resulting in a hip fracture after attempting to clean a spill without assistance. The resident's care plan called for supervision and environmental safety measures, but staff failed to ensure these were in place, and there was a lack of consistent monitoring and follow-up after the incident.
A resident with multiple medical conditions experienced a fall and reported significant pain, but did not receive timely PRN pain medication. Nursing staff failed to document or consistently reassess pain, and there were delays in obtaining diagnostic imaging. The resident's pain remained unaddressed for 44 hours before hospitalization and surgery for a hip fracture.
A dietary aide was found in the kitchen without a required hair restraint, contrary to facility policy. The dietary supervisor acknowledged the lapse, stating the aide had removed the hairnet due to heat and perspiration. The facility's policy mandates hairnets be worn at all times in the kitchen.
A resident with multiple chronic conditions experienced a fall resulting in significant pain and immobility. Nursing staff failed to ensure a timely x-ray was performed and did not promptly report the results indicating a hip fracture. Delays in communication and follow-up led to a delay in the resident being sent to the hospital for further care.
A resident with a known history of substance abuse returned from an outing with a relative, and staff failed to conduct the required contraband search as outlined in facility policy. Shortly after, the resident was found unresponsive with a laceration and a bag of white powdery substance in his pocket, requiring Narcan administration and hospitalization for opioid overdose.
A resident with a legal guardian was administered psychotropic medications without the guardian's informed consent. Facility staff allowed the resident to sign the consent form, unaware of the guardian's status, and the guardian was not notified or consulted as required by facility policy.
A resident did not receive multiple prescribed medications on certain days, and there was no documentation on the MAR to indicate administration or reason for omission. A nurse confirmed that undocumented medications were not given, contrary to facility policy requiring complete documentation.
Two residents were found to have PRN psychotropic medication orders, including Haloperidol and Lorazepam, without required 14-day stop dates as specified by facility policy. The ADON confirmed that such medications should have a 14-day limit, but this was not followed.
The facility failed to maintain a clean and homelike environment, with issues such as missing floor tiles, lack of window curtains, and unclean bathrooms observed in several residents' rooms. Staff interviews revealed a lack of awareness and action, with housekeeping being short-staffed and maintenance acknowledging the need for repairs but lacking resources. The facility's resident rights booklet emphasizes the need for a safe, clean, and homelike environment, which was not met.
A resident with autoimmune conditions missed multiple doses of prescribed medications, including a steroid topical ointment and an immunosuppressive medication, due to the facility's failure to administer them as ordered. The staff, including a nurse and the DON, were unaware of the missed doses and did not notify the physician, contrary to facility policy. The resident reported not receiving the medication as scheduled, which is crucial for managing their condition.
A resident with autoimmune conditions missed multiple doses of a topical steroid ointment and an immunosuppressive medication over two months due to the facility's failure to administer them as ordered. Staff interviews revealed a lack of awareness about the missed doses, and the Medication Administration Record documented several instances of non-administration. The resident was hospitalized with hand ulcerations, and facility policies on medication administration were not followed.
A resident with cognitive impairments was punched by another resident with a history of violent behavior after a bathroom-related altercation. The incident, witnessed by a nurse, resulted in the injured resident being transferred to a hospital for evaluation. The facility's abuse prevention policy was not effectively implemented to prevent this assault.
A facility failed to create a care plan for a resident with violent behavior, leading to multiple altercations with roommates. Despite the resident's history of aggression and hospital admission for choking a roommate, no interventions were documented in the care plan. The DON and Administrator confirmed the absence of a care plan addressing these behaviors, contrary to facility policy.
A resident with dementia and cerebrovascular disease was reported to have a bruise by a family member, which was not documented or investigated by the facility. Despite the facility's policy requiring prompt investigation of injuries of unknown origin, the DON did not notify the administrator or document the incident, resulting in a deficiency.
The facility failed to implement proper infection control protocols, with soiled linens improperly handled and staff neglecting hand hygiene. Soiled linens were found on the floor, and staff did not wear gloves while handling them. Medical equipment was not disinfected properly, and there was a lack of preventive measures for legionella in the water system.
The facility failed to ensure privacy and dignity for residents, as observed in instances where Foley catheter bags were not covered and were placed on the floor. Additionally, an LPN administered intravenous medication without providing privacy, and a resident was found without a privacy curtain. These actions were contrary to the facility's policies on resident rights and dignity.
A resident with a history of falls and an unspecified head injury experienced two unobserved falls, one resulting in a hematoma and hospital transfer, without updates to their care plan. The MDS coordinator responsible for these updates had resigned, and the facility's policy to review and update care plans after changes in condition was not followed.
A resident with multiple health issues, including reduced mobility and severe malnutrition, was found with long and dirty fingernails, indicating a failure in providing adequate nail care. Despite the facility's policy requiring CNAs to check and clean nails during personal hygiene routines, this was not done, as confirmed by an LPN. The resident required substantial assistance with ADLs, and the facility's procedures for nail care were not followed.
A resident with multiple health issues, including reduced mobility, was not provided with a physician-ordered right-hand splint. Observations revealed the resident without the splint, and the therapy department was not informed of the order. The facility's policies on carrying out physician orders and applying restorative devices were not followed.
The facility failed to maintain proper respiratory care protocols for two residents. A resident with a tracheostomy did not have a physician's order for the tube size or oxygen usage, and there was no spare tracheostomy tube at the bedside. Another resident's oxygen nasal cannula tubing was not dated, contrary to facility policy. Staff confirmed these deficiencies, highlighting a lack of adherence to respiratory care protocols.
An LPN administered IV medication to a resident without performing hand hygiene or providing privacy, and was not certified in IV administration. The DON confirmed that LPNs can administer IV medications but emphasized the need for proper hygiene and privacy. The resident had a physician's order for IV medication to treat sepsis.
A facility failed to complete an infection verification tool upon initiating antibiotics for a resident with cellulitis, as required by their Antibiotic Stewardship Program. The resident, who was alert and oriented, was prescribed Cephalexin for cellulitis, but the necessary assessment using McGeer's criteria was not conducted by the responsible nurse.
A resident with dementia and a history of wandering was not adequately monitored, leading to a potential sexual abuse incident with another resident. The incident was reported by a third resident, prompting staff intervention. The involved resident was taken to a hospital for evaluation, and a police report was filed.
A resident with dementia was transferred to a hospital for a psychological evaluation after an incident but was not allowed to return to the facility. The facility failed to document the reasons for the discharge or communicate effectively with the resident's family, leading to a deficiency. Staff interviews indicated no known history of inappropriate behavior by the resident.
A resident with advanced dementia and a history of wandering was inadequately supervised, leading to her entering another resident's room and an inappropriate incident occurring. The facility's staff responded after being alerted by another resident, but the Director of Nursing acknowledged the need for increased supervision due to the resident's condition and behavior.
The facility failed to prevent a verbal argument from escalating into a physical assault between two residents with dementia. Despite known behavioral issues, the facility did not take adequate measures to prevent the altercation, which resulted in one resident pushing the other to the floor. The incident was not classified as abuse due to the residents' cognitive impairments.
GT Feeding and Flush Orders Not Followed
Penalty
Summary
The facility failed to ensure a functioning gastrostomy tube (GT) was available for a resident to receive ordered bolus feeding and free water flushes, and failed to follow its Gastrostomy/Jejunostomy Feeding policy by not administering the ordered free water flush before and after feeding. The deficiency involved one resident in a sample of five who was admitted with gastrostomy, dehydration, seizure, and anoxic brain damage and had severe cognitive impairment. The resident also had a history of hypernatremia, with a hospital admission note documenting a sodium level of 161 and MICU consultation for further management. During observation, an RN attempted to perform a 200 ml free water flush through the resident’s GT, but the GT port was leaking onto the resident’s stomach and the RN was unable to administer the bolus feeding and flush. The RN stated she was supposed to give a free water flush of 200 ml altogether. The resident’s physician orders documented enteral feeding three times daily with 475 ml and a 300 ml free water flush before and after feeding at 0800, 1200, and 1600. Later, the DON attached an extension to the GT port, but it continued to leak and feeding was stopped. The DON stated nurses are supposed to verify physician orders and flush the GT with the ordered amount of water, and noted the resident’s history of hypernatremia and that insufficient feeding and flush can cause dehydration.
Failure to Administer Scheduled Medications Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to administer medications within the expected timeframe of one hour before to one hour after the scheduled time, as required by facility policy and staff expectations. On a specific survey date at 11:30 a.m., an RN (V5) stated she was preparing to pass a resident’s 9:00 a.m. medications. After administering those medications between 11:30 a.m. and 11:43 a.m., V5 reviewed the cloud-based electronic health record and acknowledged that four additional residents still had 9:00 a.m. medications that had not yet been given. The Director of Nursing (V2) confirmed that staff are expected to follow the rights of medication administration, including the right time, defined as within one hour before or after the scheduled time, and explained that medications ordered at specific times should be given within that window so subsequent doses are not too close together and the medications work properly. For one resident (R3) with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, chronic idiopathic constipation, and embolism and thrombosis of deep veins, multiple medications ordered twice daily at 9:00 a.m. were documented as administered between 11:30 a.m. and 11:43 a.m. These medications included bupropion SR, carvedilol, gabapentin, polyethylene glycol, prednisolone ophthalmic drops, and lactulose. R3’s MDS showed a BIMS score of 12, indicating moderately impaired cognition, and progress notes for the relevant dates contained no documentation authorizing or explaining late medication administration. Another resident (R5), cognitively intact with diagnoses including hypertension, skin disorder with pruritus, and type 2 diabetes with polyneuropathy, had metformin, triamcinolone cream, and gabapentin ordered twice daily at 9:00 a.m., but these were documented as administered between 11:55 a.m. and 11:56 a.m., also outside the facility’s defined time window, with no corresponding progress note to indicate permission to give medications late. Additional residents experienced similar delays. A cognitively intact resident (R6) with hypertension, COPD, and type 2 diabetes had carvedilol and fluticasone nasal spray ordered twice daily at 9:00 a.m., but these were administered between 12:03 p.m. and 12:05 p.m. A cognitively intact resident (R8) with constipation, epistaxis, and hypertension had artificial tears, saline nasal spray, and Senna S ordered for multiple daily doses, with one scheduled administration documented at 9:00 a.m. but actually given between 12:19 p.m. and 12:23 p.m. Another resident (R9), with severe cognitive impairment and diagnoses including shortness of breath, COPD, and heart failure, had budesonide inhalation and furosemide ordered twice daily at 9:00 a.m., but these were administered between 12:09 p.m. and 12:13 p.m. For R6, R8, and R9, progress notes for the relevant dates also lacked any documentation permitting or explaining late administration. Facility documents, including the RN/LPN job description, medication administration policy, and physician order guidelines, all required that medications be administered in accordance with physician orders and at the right time, which did not occur in these instances.
Failure to Administer Medications Timely and Inadequate Emergency Response for Hypoglycemia
Penalty
Summary
The facility failed to follow its own policies and procedures regarding medication administration, documentation, and emergency response for multiple residents. Specifically, three residents did not receive their prescribed medications in a timely manner, and medication administration was not properly documented. Observations revealed that medications scheduled for specific times were administered late, and staff did not consistently sign out medications as they were given. The electronic medication administration record (EMAR) showed multiple residents highlighted as overdue for medication, and staff admitted to delays and incomplete documentation due to being busy or unfamiliar with procedures. A critical incident involved a resident with multiple complex medical conditions, including diabetes, chronic respiratory failure, and a history of uncontrolled diabetic status. This resident was found unresponsive with a critically low blood sugar level. Nursing staff attempted to administer oral sugar to the unresponsive resident, which is not a safe or effective intervention, and were unable to obtain intravenous access for dextrose. Glucagon, which was available in the emergency kit per facility policy, was not administered. Emergency medical services were called, but there was a delay in both the response and the appropriate intervention for hypoglycemia. The resident was subsequently hospitalized in the ICU for severe hypoglycemia, sepsis, and multiple infections, with documentation from the hospital noting poor hygiene, extensive skin breakdown, and concerns of neglect. Interviews with staff and review of facility policies confirmed that the required protocols for hypoglycemia and change in condition were not followed. Staff acknowledged that oral administration of sugar to an unresponsive resident was inappropriate and that glucagon should have been administered. There was also a failure to change the resident's Foley catheter as required, contributing to infection risk. The facility's own policies mandate timely medication administration, proper documentation, immediate emergency response, and adherence to hypoglycemia protocols, all of which were not met in these instances.
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and did not prevent an incident of resident-to-resident abuse involving two residents. One resident, who had a history of suspected abuse or neglect and cognitive impairment, was subjected to a racially derogatory term and was spat on by another resident while walking in the hallway. The incident was reported by the affected resident to nursing staff, and a witness confirmed hearing the altercation and intervened by instructing the aggressor to return to his room. The aggressor, who had diagnoses including delusional disorder, schizophrenia, and unspecified psychosis, was known to have a history of spitting on other residents and using offensive language toward both residents and staff. Despite these known behaviors, the care plan for the aggressor did not include updated interventions following the incidents of spitting and verbal abuse. The care plan interventions remained unchanged even after multiple documented behavioral incidents, and there were no new strategies implemented to address the ongoing risk. The facility's policies affirm the right of residents to be free from abuse and to be treated with respect and dignity, but these were not upheld in this case, as evidenced by the lack of timely and appropriate updates to the care plan and interventions for the resident exhibiting abusive behaviors.
Failure to Maintain Safe, Hazard-Free Floors Due to Ongoing Water Leaks
Penalty
Summary
The facility failed to ensure that resident floors were free from hazards, specifically water accumulating on the floor near door entryways and under air conditioning vents. Multiple observations documented water puddles in resident rooms, including one instance where a towel was placed over a puddle without a wet floor sign present. Staff interviews confirmed that leaking from ceiling air conditioning grills had been observed in several rooms over the past weeks, with maintenance staff indicating that the condensation pipes required regular cleaning to prevent clogs and leaks. Maintenance also reported that prior to their recent employment, there was no established routine for cleaning these pipes, and issues were only addressed as they were reported. Residents affected by these leaks included individuals with unsteady gait and those identified as being at risk for falls, as documented in their assessments and care plans. One resident described a situation where a bucket placed to catch leaking water was not emptied, resulting in water spilling onto the floor and creating a slippery surface. Staff acknowledged that water on the floor posed a fall risk, especially for residents who ambulate independently. Review of facility work orders revealed multiple reports of water leaks from air conditioning units in various rooms, with some instances requiring makeshift solutions such as garbage bins to catch the water.
Failure to Ensure Nurse Coverage on Unit Due to Call-Off and Lack of Relief
Penalty
Summary
The facility failed to ensure that nursing staff followed the established practice of not leaving a unit at the end of a shift without a relief nurse present. On the day in question, a nurse called off for the day shift on the second floor main unit, but the absence was not communicated in a timely manner to the appropriate supervisory staff. As a result, there was no nurse present on the unit for approximately one to two hours, leaving 36 residents without a licensed nurse available. Interviews confirmed that the off-going nurse left before a replacement arrived, and the oncoming nurse was not notified to stay over. The facility's policy requires staff to call off at least four hours before their shift and not to leave without relief, but this protocol was not followed. Review of time cards and controlled substances check forms corroborated that there was no nurse on duty for the affected shift, as no signatures were present for the day shift on the unit. The Director of Nursing was not aware of the call-off until notified by another staff member after the shift had already started. The facility assessment indicated that four nurses were expected to provide direct care on the day shift, but this standard was not met due to the absence and lack of proper handoff. Certified Nursing Assistants (CNAs) were present but are not permitted to pass medications, further impacting care delivery during the period without a nurse.
Failure to Provide Discharge Instructions and Medications During Resident Transfer
Penalty
Summary
The facility failed to follow its policy regarding the provision of discharge instructions and medications for a resident who was transferred to another skilled facility. The resident had a planned discharge, and the family was responsible for transporting her. According to staff interviews, the family took the resident without speaking to the nurse on duty, and the nurse was unaware of the resident's departure until contacted by the admitting facility. As a result, no medications or discharge instructions were sent with the resident at the time of transfer. Documentation reviewed showed that while a transfer discharge report and discharge planning review were prepared, there was no evidence of a signed discharge instruction form or confirmation that instructions and medications were provided to the resident or her representative on the day of discharge. Progress notes indicated that the resident had requested the transfer and that the family would handle transportation. However, the nurse only became aware of the resident's departure after being notified by the receiving facility, which reported that no medications had accompanied the resident. The facility's policy requires that discharge instructions, medication lists, and any necessary referrals be reviewed and sent with the resident, and that documentation be signed by the resident or their representative. These steps were not completed, and the required documentation was not presented for review.
Failure to Follow Urinary Catheter Care Policy
Penalty
Summary
The facility failed to follow its Urinary Catheter Care policy for three out of four residents reviewed for indwelling catheter care. One female resident with moderate cognitive impairment was observed with her indwelling catheter bag placed flat on the bed, contrary to the care plan intervention requiring the bag and tubing to be positioned below the level of the bladder. During catheter care, a CNA used soap and water to wipe down the catheter but did not clean the labia, stating it was difficult to do so while the resident was in a geriatric chair. Another female resident with mild cognitive impairment was found with an indwelling catheter that was not secured to her thigh, lacking a stat lock or tape as required by policy. A male resident with moderate cognitive impairment was observed with a urine leg bag tied to his thigh, but the catheter itself was not secured. During catheter care for this resident, staff used soap and water to clean the catheter but did not retract the foreskin to clean the catheter-meatal junction, as required for uncircumcised males. Staff interviews confirmed that proper procedures were not followed, including securing catheters to prevent tension, maintaining gravity drainage, and performing appropriate hygiene for both male and female residents. The facility's policy specifies these requirements, but observations and staff statements indicated noncompliance in multiple instances.
Failure to Provide Adequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and accident hazard prevention for a high fall risk resident, resulting in a left hip fracture, hospitalization, and surgery. The resident, an older male with multiple diagnoses including ataxia, epilepsy, gait abnormalities, schizoaffective disorder, diabetes with neuropathy, and heart failure, was assessed as having moderate cognitive impairment and was identified as high risk for falls. His care plan required supervision during transfers and ambulation, prompt response to requests for assistance, and a safe, clutter-free environment with accessible call lights and personal items. On the day of the incident, the resident was found sitting on the hallway floor after attempting to clean up spilled water, without his walker and possibly without shoes. The call light was observed out of his reach, and the room was dark. Staff interviews revealed inconsistent awareness of the resident's fall risk status and required interventions. The assigned CNA was the only one on duty for the unit, despite the usual need for two, and did not recall any special monitoring or interventions for the resident. Nursing staff did not consistently reassess the resident's pain or follow up on the x-ray order after the fall, resulting in a delay in diagnosis and transfer to the hospital. Documentation and interviews indicated that the resident was not adequately supervised, and fall prevention interventions were not reliably implemented. The resident's known behaviors, such as obsessive cleaning and not using the call light, were not sufficiently addressed through increased monitoring or environmental adjustments. The facility's fall prevention policy required individualized interventions and ongoing monitoring, but these measures were not effectively carried out for this high-risk resident, directly contributing to the incident and subsequent injury.
Failure to Timely Administer PRN Pain Medication After Resident Fall
Penalty
Summary
A deficiency occurred when a resident who experienced a fall and reported significant pain did not receive timely administration of PRN pain medication. After the fall, the resident was found unable to move his left leg and expressed considerable pain, especially with movement. Although nursing staff assessed the resident and notified the physician, there was a failure to ensure that pain medication was administered and documented in a timely manner. The resident's pain persisted for 44 hours before he was ultimately hospitalized and diagnosed with a left hip fracture requiring surgery. The resident involved had multiple complex medical conditions, including ataxia, epilepsy, abnormal gait, schizoaffective disorder, hypertension, diabetes with neuropathy, and heart failure. Following the fall, staff interviews and record reviews revealed lapses in pain assessment, documentation, and follow-up. Nursing staff did not consistently reassess the resident's pain or verify the effectiveness of any pain interventions. There was also confusion regarding the x-ray order, with delays in obtaining diagnostic imaging and a lack of follow-up with the diagnostic company. Documentation in the resident's medical record and Medication Administration Record (MAR) did not show evidence of pain medication being administered between the time of the incident and the resident's transfer to the hospital. Despite the facility's pain management policy requiring prompt assessment and intervention for pain, these procedures were not followed, resulting in the resident experiencing unaddressed pain for an extended period prior to hospitalization.
Failure to Enforce Hair Restraint Policy in Kitchen
Penalty
Summary
A deficiency occurred when a dietary aide was observed inside the facility's kitchen without wearing a hair restraint, in violation of the facility's own policy requiring hairnets to be worn at all times in the kitchen. The surveyor, upon entering the kitchen with the dietary supervisor, immediately noticed the aide sitting by the wall without a hair restraint. The supervisor then instructed the aide to put on a hair restraint, after which the aide briefly left the kitchen and returned wearing one. During an interview, the dietary supervisor acknowledged that the aide was not supposed to be in the kitchen without a hairnet, but allowed it because the aide reported being hot and having just wiped sweat from his brow, causing the hairnet to slip off. The facility's policy, dated 2021, clearly states that food and nutrition services employees must wear hair restraints at all times in the kitchen. No residents or their medical conditions were directly involved or mentioned in this deficiency.
Failure to Timely Obtain and Report Diagnostic X-ray Results After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a diagnostic x-ray order was carried out and the results were reported in a timely manner for a resident who had sustained an acute fracture. The resident, an older male with multiple complex medical conditions including ataxia, epilepsy, schizoaffective disorder, diabetes with neuropathy, and heart failure, experienced a fall and was found unable to move his left leg, in significant pain, and unable to recall the incident. The nurse on duty assessed the resident, notified the physician, and received an order for an x-ray, which was communicated to the external diagnostic company. However, there was no confirmation of when the x-ray would be performed, and the nurse did not follow up with the company or reassess the resident's pain before the end of the shift. The following day, another nurse discovered that the x-ray had not been completed and, upon contacting the diagnostic company, learned that no order had been received. A STAT x-ray was then ordered, and the resident was found to be immobile and in pain, with a visible bruise on the left hip. The x-ray was performed later that day, and the results, indicating an impacted transcervical fracture of the left femoral neck, were posted in the electronic medical record in the evening. However, the results were not promptly identified or reported by the nursing staff, and the Director of Nursing was not made aware of the findings until the next morning. During this period, the resident remained in bed, continued to experience pain, and was not returned to his baseline level of mobility. The delay in both obtaining the diagnostic test and reporting the results led to a delay in the resident being sent to the hospital for further evaluation and treatment. The deficiency was identified through interviews and record reviews, which confirmed lapses in communication, follow-up, and timely reporting of critical diagnostic information.
Failure to Conduct Contraband Search Results in Resident Overdose and Injury
Penalty
Summary
The facility failed to follow its policy regarding contraband searches for a resident with a known history of substance abuse. The resident had previously been found unresponsive with a rolled-up dollar bill containing a white powdery substance, and after this incident, restrictions were put in place requiring that the resident only go out with a responsible party and that his belongings be searched upon return from outings. Despite these measures, on a subsequent occasion, the resident was allowed to leave the facility with a relative and upon return, there is no evidence that the required contraband search was conducted by social services as per facility policy. Shortly after returning from the outing, the resident was found unresponsive on the floor of another resident's room, with a laceration to the right eyebrow. Staff assessed the resident, administered Narcan, and called 911 for transport to the emergency room. During this time, a bag containing a white powdery substance was found in the resident's pocket. The resident was hospitalized with a diagnosis of opioid overdose and a laceration. Interviews with staff revealed that there was confusion and lack of communication regarding who was responsible for searching the resident upon return from outings. The social services director was not present when the resident returned and was not informed of the resident's return, and it was unclear if any staff conducted the required search. The facility's policy allows for searches when there is reasonable suspicion of contraband, and in this case, the policy was not followed, resulting in the resident's overdose and injury.
Failure to Obtain Guardian Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain proper informed consent from the resident's legal guardian prior to administering psychotropic medications. The resident in question had a documented guardian, as indicated on the face sheet, but the facility allowed the resident to sign their own consent for Haloperidol and Lorazepam. The Assistant Director of Nursing, who oversees psychotropic medications, was unaware that the resident had a guardian and permitted the resident to sign the consent form. The guardian was not informed or asked for consent regarding the administration of these medications. The guardian later reported that the facility had started the resident on psychotropic medications without her knowledge or consent. When questioned, facility staff stated that the medications were necessary to manage the resident's behaviors. The facility's own policy requires that informed consent for psychotropic medications be obtained from the resident's guardian or authorized representative, not solely from the resident when a guardian is in place.
Failure to Administer and Document Prescribed Medications as Ordered
Penalty
Summary
The facility failed to ensure that prescribed medications were administered as ordered for one resident. Review of the resident's Medication Administration Record (MAR) for April 2025 showed that several medications, including Benztropine Mesylate, Divalproex Sodium ER, Olanzapine, and Trazodone, were not administered on specific dates as prescribed. The MAR indicated missed doses on 4/10/25 and 4/13/25 for these medications, with no documentation to explain the omissions. A registered nurse confirmed that if there is no entry on the MAR, the medication was not given. The facility's policy requires that all medication administration be documented on the MAR with the date, time, and nurse's initials.
Lack of Stop Dates for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that stop dates were in place for as-needed (PRN) psychotropic medications for two of three residents reviewed for such medications. Specifically, one resident had physician orders for Haloperidol 5 mg every 6 hours as needed for behavioral disturbances and Lorazepam 1 mg every 6 hours as needed for behaviors, both lacking a documented stop date. Another resident had an order for Lorazepam Injection 0.5 ml every 8 hours as needed for agitation, also without a stop date. According to the facility's undated policy, PRN psychotropic medications should be ordered with a 14-day time limit, after which a physician must re-evaluate and reorder if necessary. The Assistant Director of Nursing confirmed that PRN psychotropic medications should have a 14-day stop date, but this was not implemented for the residents in question.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for several residents, as observed during a survey. Multiple deficiencies were noted, including missing floor tiles in residents' rooms, a lack of window curtains, and a bathroom with a toilet seat smeared with a brown substance. Residents reported issues such as non-functional window curtains, insufficient hot water, and unclean rooms. These issues were observed in the rooms of nine residents, indicating a widespread problem with maintaining the facility's environment. Interviews with staff revealed a lack of awareness and action regarding these deficiencies. The Assistant Administrator acknowledged the issues but did not provide a plan for addressing them. Housekeeping staff mentioned being short-staffed and not having cleaned certain areas, while the Maintenance Director admitted to being aware of the need for tile replacements but stated that no tiles were available. The facility's resident rights booklet emphasizes the need for a safe, clean, and homelike environment, which was not met according to the observations and interviews conducted.
Failure to Administer Medications and Notify Physician
Penalty
Summary
The facility failed to notify a physician about a resident not receiving prescribed medications, specifically a steroid topical ointment and an immunosuppressive medication, as ordered. This resulted in the resident missing 15 doses of the steroid topical ointment and 14 doses of the immunosuppressive medication. The resident, who has rheumatoid arthritis, dermatomyositis, herpes vesicular dermatitis, and chronic skin ulcers, reported not receiving the medication for their autoimmune disease as scheduled, which is supposed to be administered twice daily. Interviews with facility staff, including a nurse and the Director of Nursing (DON), revealed a lack of awareness regarding the missed doses. The nurse confirmed that medications should be administered as ordered and documented in the Medication Administration Record (MAR). However, the nurse and DON were not aware of the multiple missed doses and had not been notified of the issue. The facility's policy requires physician notification when a resident misses a dose of medication, but this protocol was not followed in this case. The MAR for January and February documented several instances where the medications were not administered as ordered. Hospital records indicated that the resident presented with bilateral hand ulcerations, pain, and swelling, and the plan was to continue the prescribed medications. Despite this, the facility did not ensure the medications were administered as ordered, nor did they notify the physician of the missed doses, which is a requirement according to their policies.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer a topical steroid ointment and an immunosuppressive medication as ordered, resulting in a resident missing 15 doses of the topical steroid ointment and 14 doses of the immunosuppressive medication over a two-month period. The resident, who has rheumatoid arthritis, dermatomyositis, herpes vesicular dermatitis, and chronic skin ulcers, reported not receiving the medication for their autoimmune disease as prescribed. The resident was supposed to receive the medication twice daily, but it was often given only once a day or not at all. Interviews with facility staff revealed a lack of awareness regarding the missed doses. A nurse stated that if a medication is not signed out on the Medication Administration Record (MAR), it is considered not given. The Director of Nursing (DON) and other staff members were unable to recall the specific medications the resident was taking and denied any reports of missed doses. The MAR documented multiple instances where the medications were not administered as ordered, with specific dates and times noted for both January and February. The resident was hospitalized with bilateral hand ulcerations, pain, and swelling, and the hospital records indicated the continuation of the immunosuppressive medication. The facility's policies on medication administration and physician orders emphasize the importance of administering medications as ordered and documenting them accurately. However, the facility failed to adhere to these policies, resulting in significant medication errors for the resident.
Failure to Prevent Resident-to-Resident Physical Assault
Penalty
Summary
The facility failed to prevent a resident-to-resident physical assault, which affected two residents. Resident 1, who has a history of heart failure, dementia, schizophrenia, depression, and auditory hallucinations, was punched in the face by Resident 2. This incident occurred after Resident 1 repeatedly opened the bathroom door while Resident 2 was using it, leading to Resident 2 exiting the bathroom and hitting Resident 1 in the face. Resident 1 was subsequently transferred to a local hospital for evaluation due to eye pain and injury. Resident 2, who has a diagnosis of Huntington's disease and violent behavior, was described as very aggressive and angry during the incident. A nurse witnessed the assault and intervened to separate the residents. The facility's abuse prevention policy, which aims to protect residents from abuse and establish a secure environment, was not effectively implemented in this case, as the incident was not prevented. The facility's final abuse report documented the incident and the injuries sustained by Resident 1, including swelling and redness below the right eye.
Failure to Develop Care Plan for Resident with Violent Behavior
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of violent behavior, which resulted in multiple incidents of aggression. The resident, who was admitted with diagnoses including Huntington's disease, violent behavior, brief psychotic disorder, and schizoaffective disorder, was involved in several altercations with roommates. On one occasion, the resident was involved in a physical altercation with a roommate, which escalated to the point where staff intervened and were inadvertently struck. The resident was subsequently sent to the hospital due to aggressive behavior, including choking a roommate. Despite these incidents, the facility did not document any interventions or updates to the resident's care plan to address the aggressive behaviors and altercations. The Director of Nursing confirmed the absence of documented interventions following these events, and the Administrator was unable to locate any care plan addressing the resident's behaviors. The facility's policy requires a comprehensive assessment and individualized care plan for all residents, but this was not adhered to in the case of this resident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to follow its abuse and injury of unknown origin policy by not initiating and completing a thorough investigation of an injury of unknown origin reported by a resident's family member. This deficiency involved a resident who was admitted for respite care and had a history of cerebrovascular disease and dementia with behavioral disturbance. The resident was described as moderately impaired in cognitive status, requiring cues and supervision for decision-making. During the resident's short stay, a family member reported a bruise on the resident's arm, which was not documented upon admission or during routine care. Interviews with various staff members, including LPNs and CNAs, revealed that none had observed the bruise prior to the family's report. The Director of Nursing (DON) assessed the bruise but did not document the incident or notify the administrator, as required by the facility's policy. The family took the resident home without further communication about the bruise. The facility's policies require prompt investigation of injuries of unknown origin, including documentation, notification of the administrator, and potential initiation of an abuse investigation. However, these procedures were not followed in this case. The DON did not document the bruise in the resident's medical record, complete an incident report, or conduct a thorough investigation to determine the cause of the injury, leading to a deficiency in the facility's compliance with its own policies.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control protocols, as evidenced by multiple observations of improper handling of soiled linens. Soiled linens were found in green plastic bags on the floor in various locations, including hallways and near the therapy room. Staff members, including CNAs and housekeeping aides, were observed handling these soiled linens without wearing gloves, and using inappropriate methods such as a recliner chair to transport them. The laundry chute was found overflowing with soiled linens, and the facility's policy on linen handling was not adhered to, as soiled linens were placed on the floor and not immediately transported to the appropriate area. Additionally, the facility failed to maintain proper hand hygiene and equipment disinfection protocols. Staff members, including LPNs and CNAs, were observed not performing hand hygiene after glove removal and before exiting resident rooms, even when dealing with residents on enhanced barrier precautions. Medical equipment, such as blood pressure machines, was not properly disinfected between uses, with staff failing to adhere to the required contact time for disinfection as per the product label. The facility also lacked measures to prevent the growth of legionella and other waterborne pathogens in the building's water system. Despite having a negative legionella test result from July, the facility was unable to provide documentation of ongoing monitoring or preventive measures. This lack of documentation and preventive action poses a risk to all residents, as the facility does not have a maintenance team to address these issues.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to provide privacy and dignity to residents, affecting three residents in a sample of 24 reviewed for residents' rights. On multiple occasions, residents were observed with Foley catheter bags that were not covered with privacy bags, and in some cases, the bags were placed on the floor. Specifically, one resident was seen with a Foley catheter bag hanging visibly without a privacy cover, and another resident had their catheter bag sitting on the floor without a cover. These observations were confirmed by a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), who acknowledged that the catheter bags should have been covered and not placed on the floor. Additionally, the facility failed to ensure privacy during medical procedures. An LPN administered intravenous medication to a resident without closing the room door or pulling the privacy curtain. Another resident was observed without a privacy curtain available in their room, a situation confirmed by both the LPN and the Housekeeping Supervisor. The facility's policies on resident rights and dignity, which emphasize the importance of privacy and respect, were not adhered to in these instances, leading to the identified deficiencies.
Failure to Update Care Plan for High Fall Risk Resident
Penalty
Summary
The facility failed to update the care plan to reduce the risk of falls for a resident identified as a high fall risk. The resident, who has a history of falls and an unspecified head injury, experienced two unobserved falls on 5/25/2024 and 9/10/2024. The first fall resulted in a hematoma and required hospital transfer, while the second fall resulted in no injury. Despite these incidents, the care plan was not updated. The Director of Nursing noted that the MDS coordinator, responsible for updating the care plan after falls, had resigned the previous week. The facility's policy requires that the care plan be reviewed and updated when a change occurs in a resident's condition, but this procedure was not followed.
Failure to Provide Adequate Nail Care to Dependent Resident
Penalty
Summary
The facility failed to provide adequate nail care to a resident, identified as R110, who was dependent on staff for assistance with activities of daily living (ADLs). On two consecutive days, observations revealed that R110 had long and dirty fingernails with black matter inside them. Despite the facility's policy requiring CNAs to check and provide nail care during personal hygiene routines, this was not done for R110. The LPN acknowledged that the CNA should have cleaned and trimmed the resident's fingernails during bathing or showering and checked them weekly. R110 was admitted with multiple diagnoses, including acute respiratory failure with hypoxia, tracheostomy status, reduced mobility, and severe protein-calorie malnutrition. The comprehensive care plan indicated that R110 required substantial to total assistance with ADLs due to self-care performance deficits. The facility's policy on nail care emphasized cleanliness, infection prevention, and safety, outlining specific procedures for nail care during bathing. However, these procedures were not followed, leading to the deficiency observed by the surveyors.
Failure to Apply Physician-Ordered Splint for Resident
Penalty
Summary
The facility failed to follow a physician's order for the application of a right-hand splint for a resident, identified as R110, who was part of a sample reviewed for the Restorative Nursing Program. The resident, who was admitted with conditions including acute respiratory failure with hypoxia, tracheostomy status, reduced mobility, and severe protein-calorie malnutrition, was observed on two consecutive days without the prescribed right-hand splint. The resident's care plan indicated a need for substantial to total assistance with activities of daily living (ADLs) due to various health issues, and the restorative nursing assessment noted a moderate loss of range of motion in the right wrist and fingers. Despite the physician's order dated 7/30/24 for the right-hand splint, the resident was not wearing it during observations, and the therapy department had not been notified to evaluate the resident for the splint. The Restorative Nurse mentioned that the splint was ordered and awaiting arrival, while the Therapy Director was unaware of the order. The facility's policies require that physician orders be carried out and that a physician's order is necessary for applying splints or restorative devices, which was not adhered to in this case.
Deficiencies in Respiratory Care Protocols
Penalty
Summary
The facility failed to maintain proper respiratory care protocols for two residents, R110 and R372, as observed during a survey. For R110, the facility did not have a physician's order for the size of the tracheostomy tube or the oxygen usage, and there was no accessible spare tracheostomy tube kit at the bedside in case of emergency or accidental decannulation. The oxygen tubing connected to R110's tracheostomy was not dated, which is against the facility's policy that requires oxygen tubing to be changed and dated weekly. R110 was admitted with acute respiratory failure with hypoxia, tracheostomy status, and other conditions, yet the facility lacked a respiratory therapist and a comprehensive policy on respiratory services. For R372, the facility also failed to date the oxygen nasal cannula tubing, as confirmed by staff members. R372 was receiving oxygen via nasal cannula without a date on the tubing, which contradicts the facility's policy. R372 was admitted with conditions including cellulitis, type 2 diabetes mellitus, and heart failure, and had a physician order for oxygen as needed for shortness of breath. The facility's failure to adhere to its own policies on respiratory care and equipment maintenance was evident in these observations.
LPN Administers IV Medication Without Proper Training and Hygiene
Penalty
Summary
The facility failed to ensure that licensed nurses possessed the necessary competencies and skills to administer intravenous medications safely. During an observation, a Licensed Practical Nurse (LPN), identified as V14, administered intravenous medication to a resident, R112, without performing hand hygiene between glove changes and without providing privacy by closing the room door or pulling the privacy curtain. V14 acknowledged the oversight in hand hygiene and privacy provision during an interview. The Director of Nursing (V3) confirmed that LPNs are permitted to administer intravenous medications but emphasized the importance of hand hygiene and privacy during the process. Further investigation revealed that V14 was not certified in intravenous administration and could not recall receiving any training related to intravenous medication administration. The Director of Nursing stated that V14 should not have administered intravenous medication without the supervision of a Registered Nurse. The resident, R112, had been admitted with diagnoses including sepsis and acute cystitis with hematuria and had a physician's order for intravenous medication to treat sepsis. The facility's policy on intravenous therapy, revised in 2014, mandates that only trained personnel with demonstrated competency should administer intravenous medications, and thorough hand washing is required before and after the procedure.
Failure to Complete Infection Verification Tool for Antibiotic Use
Penalty
Summary
The facility failed to ensure the completion of an infection verification tool upon the initiation of antibiotics for a resident, as required by their Antibiotic Stewardship Program. This deficiency was identified during a survey when it was observed that the infection verification assessment was not completed using McGeer's criteria for a resident who was prescribed Cephalexin for cellulitis. The Director of Nursing and the Infection Preventionist confirmed that the assessment was not done, and it was noted that the floor nurse is responsible for completing the McGeer's criteria/Antibiotic assessment when an antibiotic order is received from the physician. The resident involved was admitted with diagnoses including cellulitis, lymphedema, and morbid obesity. At the time of the survey, the resident was alert, oriented, and able to communicate needs to the staff. The active physician order sheet indicated that the resident was prescribed Cephalexin 500mg, two tablets orally twice a day for cellulitis, starting on a specified date. The facility's policy mandates that the infection verification tool be completed by the nurse upon initiation of antibiotics using McGeer's Criteria, which was not adhered to in this case.
Failure to Monitor Resident with Wandering Behavior Leads to Potential Abuse
Penalty
Summary
The facility failed to protect a resident from potential sexual abuse by not adequately monitoring a resident with a history of wandering. The incident involved a female resident with dementia and behavioral disturbances, who wandered into another resident's room. This resident, identified as R1, was found in a compromising situation with a male resident, R2, who has a history of dementia and other medical conditions. R1's wandering behavior and lack of supervision led to an inappropriate encounter with R2, who was found with his pants off, while R1 had her dress up to her waist without her brief. The incident was reported by another resident, R3, who witnessed the event and informed the nursing staff. The staff, including a Licensed Practical Nurse (V5) and a Certified Nursing Assistant (V6), responded to the situation by separating the residents and reporting the incident. R1 was subsequently taken to a hospital for a Sexual Assault Exam, and a police report was filed. The facility's administrator and Director of Nursing acknowledged the need for increased supervision for R1 due to her dementia and wandering behavior, which was not adequately provided at the time of the incident.
Failure to Document and Communicate Involuntary Discharge
Penalty
Summary
The facility failed to adhere to its policy and procedure for involuntary discharge by not adequately documenting the reasons for a resident's transfer and discharge. The resident in question, a male with a history of vascular dementia, depression, and other medical conditions, was transferred to a hospital for a psychological evaluation following an incident involving inappropriate behavior with another resident. Despite the incident, there was no documentation in the resident's care plan or medical records indicating a history of sexually inappropriate behavior or any other behaviors that would endanger other residents. The facility did not provide the necessary documentation to justify the resident's discharge, as required by their policy and federal regulations. The Director of Nursing and the Administrator acknowledged that the resident was their responsibility, yet they did not ensure that the proper procedures were followed. The resident's family was not given the option for the resident to return to the facility, and the decision to transfer the resident to another facility was made without their input or the resident's consent. Interviews with staff members revealed that the resident was not known to engage in inappropriate behaviors, and there was no evidence of previous incidents. The facility's failure to document the reasons for the discharge and to communicate effectively with the resident's family led to the deficiency. The lack of documentation and communication highlights a significant oversight in the facility's handling of the resident's transfer and discharge process.
Inadequate Supervision of Wandering Resident Leads to Incident
Penalty
Summary
The facility failed to provide adequate supervision for a resident with dementia and a history of wandering, which resulted in the resident entering another resident's room. The resident, a female with advanced dementia and a history of behavioral disturbances, wandered into a male resident's room. This male resident, who also has dementia, was involved in an inappropriate incident with the female resident. The incident was witnessed by another resident who reported it to the nursing staff. The staff, including a Licensed Practical Nurse and a Certified Nursing Assistant, responded to the situation after being informed by the witness. The facility's Director of Nursing acknowledged that the female resident's wandering behavior and inability to consent due to her advanced dementia required increased supervision, which was not adequately provided. The facility's policy on wanderers, which includes making visual rounds on residents every two hours or more frequently as needed, was not effectively implemented in this case.
Failure to Prevent Resident-to-Resident Physical Assault
Penalty
Summary
The facility failed to prevent a verbal argument from escalating into a physical assault between two residents, R1 and R2. Both residents have moderate cognitive impairments and a history of behavioral issues related to dementia. On the day of the incident, R1 attempted to enter R2's room, leading to a verbal altercation. R2 then pushed R1, causing her to fall. A Certified Nursing Assistant (CNA) witnessed the incident but did not intervene in time to prevent the physical assault. Both residents were subsequently sent to the local hospital for evaluation and did not return to the facility immediately after the incident. R1's medical history includes dementia without behaviors, a history of transient ischemic attack, depression, and heart disease. R1's care plan noted a risk for increasing confusion and aggressive behaviors. In the days leading up to the incident, R1 exhibited multiple episodes of verbal outbursts, threats, and delusions, which disturbed other residents. R2 also has moderate cognitive impairment and a history of pacing and roaming behaviors. The facility's investigation concluded that the physical altercation was not willful or intentional due to both residents' cognitive impairments. The Director of Nursing and the Administrator both acknowledged the incident but did not classify it as abuse, citing the residents' dementia as a mitigating factor. The facility's policy on abuse prevention emphasizes the right of residents to be free from abuse and the importance of creating a secure environment. However, the facility's response to the incident suggests a lack of adequate measures to prevent such altercations, despite the known behavioral issues of both residents involved.
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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 Oak Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Berkeley Nursing & Rehab Center | 1.2 mi | ★★★★★ | 1 | 0 |
| West Suburban Medical Ctr | 1.5 mi | ★★★★★ | 2 | 0 |
| Complete Care At The Boulevard | 1.8 mi | ★★★★★ | 7 | 0 |
| Aperion Care Forest Park | 2.1 mi | ★★★★★ | 12 | 0 |
| Austin Oasis, The | 2.2 mi | ★★★★★ | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.