Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Brook Health Care Center during CMS and state inspections, most recent first.
Resident Mail Not Delivered Timely: A resident reported a package delivered on a Saturday was left by the front door until the next day. Interviews showed the weekend mail process was inconsistent, with the BOM, AD, receptionist, HR, and DON giving conflicting accounts of who was responsible for sorting and delivering resident mail. The facility policy stated resident mail should be delivered unopened and sorted to the resident's room.
Failure to Provide Required Bathing and Grooming Assistance: Two residents who were dependent on staff for ADLs did not receive the bathing and grooming care directed on their assignment sheets and care plans. One resident with cerebral palsy, dementia, and hirsutism was observed with facial hair growth and reported not receiving a shower, while another resident with CVA, hemiparesis, and severe cognitive impairment was observed with facial hair and nasal hair that had not been fully shaved or trimmed. Staff interviews showed missed or incomplete grooming care and a lack of communication about a reported refusal.
Controlled substance count sheets were not completed correctly for 4 of 4 med carts. An MA signed both the oncoming and offgoing count slots at the same time, and an LVN failed to sign when receiving the count at the start of shift. Surveyors also found multiple missing signatures on the narcotic count logs, while the DON stated nurses were required to count and document controlled meds together at shift change.
Menu not followed for two lunch meals when residents on mechanical soft diets were not served the bread items listed on the menu. The DM stated egg rolls and bread were withheld because they were considered bread products, with no substitution provided, and fruit was given instead of a muffin on one meal. Interviews with the RD, DOR, and DON showed conflicting guidance about whether residents on mechanical soft diets could have bread, sandwiches, or other bread products, and the DM acknowledged there was no clear direction on substitutions.
Palatability and Temperature of Noon Meal: A meal tray was observed with beef fried rice, egg rolls, vegetables, and an alternate chicken and dressing tray. The rice was bland and room temperature, the egg rolls were dry and tough, and the vegetables were mushy and barely warm; several residents said the food was cold, bland, or unappetizing and some refused the tray or requested sandwiches. The DON stated the kitchen did not add salt or pepper, and the DM said staff did not always use the spices and flavorings provided.
Failure to Follow EBP and PPE Requirements During Resident Care: An RN provided IV therapy to a resident with a central line without wearing a mask or gown, an LVN provided enteral feeding to a resident with a feeding tube without wearing a mask or gown, and a CNA exited a resident’s room after perineal care before removing and discarding PPE. EBP signage and PPE were present at the room entrances, and the DON/ADON stated staff were trained on the facility’s EBP policy.
Sticky yellowish liquid and brownish-black residue were observed along the seams of vinyl flooring in several resident rooms, with dirt, food particles, and debris adhered to the surface. Residents reported that the substance had been present for weeks to months, that their shoes and belongings stuck to the floor, and that cleaning efforts did not resolve the issue. Staff, including the Housekeeping Supervisor, MS, and DON, described the material as glue coming up through the flooring after the rooms were retiled, and the maintenance log showed only one completed entry despite ongoing observations of the problem.
A resident with dyspnea and multiple chronic conditions had an order for O2 via NC PRN and weekly replacement of oxygen-related equipment. Staff interviews showed charge nurses were responsible for changing the humidifier bottle and NC tubing weekly and documenting it in the TAR, but observation found both items still dated from an earlier week. The ADON confirmed the equipment had not been changed as scheduled, and the facility policy required weekly changes of the humidifier water, cannula, tubing, and humidifier bottle.
Broken Bed Not Maintained in Safe Operating Condition: A resident with hemiplegia, osteoarthritis, and moderate cognitive impairment reported that her bed remote was hard to use and that the foot of the bed creaked and dropped suddenly when lowered. Staff gave inconsistent accounts about the issue, no current maintenance request was found, and the Maintenance Assistant observed the same malfunction during inspection. The DON acknowledged a gap in communication, and the facility policy required equipment to be kept safe and operable at all times.
The facility failed to ensure timely delivery of mail to residents on Saturdays, as required by policy. Interviews revealed that mail collected on Saturdays was not distributed until Monday, affecting two residents' access to communication.
Resident Mail Not Delivered Timely
Penalty
Summary
The facility failed to ensure residents had reasonable access to receive their mail in a timely manner. Confidential Resident #1 reported that a package delivered on a Saturday was left by the front door until the resident retrieved it the following day. The report states the facility did not have a consistent system in place to distribute incoming mail daily, and the weekend process for handling resident mail was unclear and inconsistently carried out. During interviews, the BOM stated that during the week she retrieved the mail and gave it to the AD for distribution, while on weekends the weekend receptionist was supposed to obtain and deliver the mail to residents. The AD stated that the weekend receptionist was responsible for distributing mail, but Receptionist L stated she obtained the mail on weekends and did not distribute it to residents, instead placing it in HR's office box because she was new and unfamiliar with the residents. HR stated she did not distribute mail on weekends and had not seen resident mail in her office box, while the DON stated the weekend process was that HR checked the mail, provided it to Receptionist L, and Receptionist L distributed it to residents. The facility policy stated resident mail would be delivered unopened and sorted and delivered to the resident's room.
Failure to Provide Required Bathing and Grooming Assistance
Penalty
Summary
The facility failed to ensure that two residents who were dependent on staff for bathing and grooming received the necessary ADL assistance to maintain good grooming and personal hygiene. Resident #25 was a female with cerebral palsy, speech impediment, muscle wasting, dementia, intellectual disability, and hirsutism. Her MDS indicated moderate cognitive impairment, bowel and bladder incontinence, and dependence on staff for bathing and grooming. Her care plan directed staff to help her with ADLs and facial hair care so she could maintain dignity by being clean, well groomed, and absent of facial hair. Resident #25’s assignment sheet directed that she receive a shower and be shaved on Mondays and Thursdays. During observations, she was seen in bed with 1- to 3-day growth of dark hair on her lower face and neck, and she had not been shaved. She was also observed on Monday afternoon and stated she had not received a shower. On a later observation, she was still not shaved. A CNA said she tried to shave her one morning but Resident #25 refused, and the CNA said she would tell the nurse if a resident refused care. However, the LVN later stated she had not been told that Resident #25 refused to be shaved. Resident #5 was a male with a history of CVA with right-sided hemiparesis and hemiplegia. His MDS showed severe cognitive impairment, bowel and bladder incontinence, and maximum assistance needed for bathing and personal hygiene. His care plan stated he required ADL assistance due to right-sided hemiparesis and had a goal of maintaining dignity by being clean and groomed. His assignment sheet also directed showers and shaving on Mondays and Thursdays. During observations, he was seen with facial hair growth, longer hairs under the lower lip, a mustache, and thick nasal hairs, and he had not been shaved or had nasal hairs trimmed. He stated he had not received a shower on Monday and later said, 'They missed that,' when asked about shaving. A CNA said she shaved him on Sunday but missed the area under the lower lip and could not trim his nasal hairs because she did not have anything to trim them with. The DON stated the aides were supposed to shower and shave residents according to the assignment sheet and turn in a completed shower sheet, and she could not find a shower sheet for Resident #25 for the referenced date.
Controlled Substance Count Sheets Not Signed Correctly
Penalty
Summary
The facility failed to ensure medications were prepared and administered in a manner that prevented medication errors for 4 of 4 licensed nurse medication carts observed for controlled medication storage. During observation and record review, MA B was signing both the coming-on and going-off shift controlled substance count sheets at the same time on Cart #1 and Cart #2, rather than signing at the end of her shift. During the same survey, LVN C had not signed for receiving the controlled drugs on hand at the beginning of her shift on Cart #3 and Cart #4. Surveyors also found missing signatures on the controlled substance count sheets for Hall One and Hall Two on multiple dates, including 06/03/2026, 06/04/2026, 06/05/2026, 06/08/2026, and 06/16/2026. During interview, MA B stated she always signed both the coming and going slots at the same time so she would not forget at the end of her shift, and said she had not considered what would happen if something occurred during her shift. LVN C stated she usually signed when receiving control of the count but had forgotten to do so that day, and acknowledged she knew she should sign because she was responsible for the medication cart and the narcotics it contained. The DON stated nurses were required to sign the Drug Administration Record Controlled Drug Count Record when coming on and going off shift, and that she had in-serviced all nurses on the procedure. The facility policy titled Controlled Substances stated nursing staff must count controlled medication at the end of each shift and that the nurse coming on duty and the nurse going off duty must make the count together and document any discrepancies.
Menu Not Followed for Mechanical Soft Diet Meals
Penalty
Summary
The facility failed to follow the planned menu for 2 of 2 lunch meals reviewed for nutritional adequacy and menu compliance. On 06/15/2026, the planned noon meal was beef fried rice, egg rolls, Oriental vegetable blend, and a fudge cookie. During observation and interview in the kitchen, the DM stated residents receiving mechanical soft diets were not being served the egg rolls because they were considered the bread item, and nothing was substituted for that bread item. She said she would instead give an extra vegetable and heat carrots, and acknowledged that no substitutions were made for the bread items. On 06/16/2026, the planned noon meal was Dorito Casserole, mixed vegetables, Mexican rice, a slice of bread, and a chocolate chip muffin. Residents ordered a mechanical soft diet received fruit for dessert instead of the muffin and no bread, with nothing extra given in place of the bread. During interviews, the DM stated she had not received guidance from the RD about what to substitute for the missed bread items and acknowledged residents could be losing calories when bread items were not served. She also stated she did not know whether residents allowed soft sandwiches could also have other bread products. Interviews with the DOR and DON showed conflicting understanding of the mechanical soft diet. The DOR stated mechanical soft diets could not have bread or bread products, but also said some residents could tolerate bread or sandwiches if a bedside evaluation by speech therapy showed they could safely do so. The DON stated residents on mechanical soft diets could have bread or sandwiches if speech therapy had done a bedside evaluation and a communication form had been sent to dietary. A review of the Mechanical Soft Diet eating plan dated 06/12/2025 stated that bread is a primary obstacle for a typical sandwich on a mechanical soft diet and that fillings and condiments must also be selected carefully.
Palatability and Temperature of Noon Meal
Penalty
Summary
The facility failed to serve food that was palatable and at an appetizing temperature during the noon meal. During observation, the test trays left the kitchen on the last hall cart, and when tasted after the last resident had been served, the regular tray of beef fried rice, egg rolls, oriental mixed vegetables, and a fudge cookie was described as very dark in appearance, bland, room temperature, and lacking soy sauce or oriental flavor. The egg roll was tough, slightly doughy, dry, and difficult to chew and swallow, and the vegetables were mushy, unseasoned, and lukewarm. The fudge cookie was commercially prepared and tasted good. The alternate tray of chicken and dressing with green beans and carrots was warm and flavorful for the chicken and dressing, but the green beans and carrots were bland and barely warm. Multiple residents stated the meal was not appealing or did not taste good. One resident said the lunch did not look good and requested a peanut butter and jelly sandwich. Another said the vegetables were too soft, the egg rolls were tough, and she planned to eat snacks instead. Other residents reported the vegetables were mushy, the meal was barely warm or cold, the stir-fried rice and meat did not look good, and the vegetables tasted like they came straight from the can with no seasoning. One resident refused the tray and requested a sandwich, another ate only part of the meal, and another ate only the cookie and drank tea before asking for a sandwich. The dietary manager stated the department did not put salt or pepper in the foods prepared. She said she added soy sauce to the beef fried rice because it looked pale, and she did not taste it. She explained the beef mixture was made with frozen vegetable rice, hamburger meat, chicken broth, low-sodium soy sauce, onion powder, garlic powder, chicken bouillon base, and sugar, but said the cook may not have added spices. She also stated she bought spices and flavorings for the cooks, but staff did not always use them, and she agreed the food was bland. Review of the recipe for beef fried rice showed ingredients including hamburger meat, pre-cooked rice and vegetable medley, chicken broth, low-sodium soy sauce, onion powder, garlic powder, chicken bouillon base, and sugar.
Failure to Follow EBP and PPE Requirements During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 3 residents reviewed for infection control. During an observation, RN A was providing IV therapy to Resident #6 without wearing a mask or gown, even though Enhanced Barrier Precautions (EBP) signage was posted at the room entrance and PPE was available there. During an interview later that day, RN A stated he did not notice that he had not put on a gown for Resident #6, but said he was aware of the EBP and what he should have done when caring for a resident with an IV. During another observation, LVN D was observed providing enteral feeding to Resident #47 without wearing a mask or gown, despite EBP signage and PPE being present at the room entrance. During an interview, LVN D stated she did not realize she did not have a gown and mask on, but knew she had gloves on. Record review showed Resident #47 was a [AGE]-year-old female admitted on 4/11/2013 with diagnoses including severe dementia, major depression, anxiety, dysphagia, and gastrostomy, and she was unable to voice any concerns. During a separate observation, CNA-M provided perineal care and changed Resident #30's brief while wearing appropriate PPE, but exited the room before removing and discarding the gown and gloves, then discarded them in the hallway trash can. CNA-M returned to the room and stated she forgot to remove the gown and gloves before leaving the room and said they should have been discarded in the blue-lined trash receptacle in the resident's bathroom. The DON and ADON/IP Nurse stated staff were trained on the facility's EBP policy and that staff were required to wear appropriate PPE during resident care and remove and discard PPE before exiting the resident's room.
Sticky Flooring and Residue in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in Rooms 201, 203, 205, and 208. Surveyors observed yellowish liquid and brownish-black sticky residue along the seams of the vinyl flooring, with dirt, debris, food particles, and other material adhering to the substance. In one room, pieces of plastic bags, food particles, and dirt were stuck to the floor, and a 3-foot by 5-foot rug was adhered to the floor and could not be moved. Another room had pea-sized areas of yellowish glue-like substance around the flooring seams, along with brownish-black residue containing dirt and food particles. Residents and staff stated the condition had been present for an extended period and recurred after cleaning attempts. One resident reported that maintenance had tried to clean the sticky substance, but it returned, and that her feet adhered to the floor and the substance transferred to her shoes and belongings. Another resident stated the sticky substance had been present since moving into the room and that dirt adhered to it. A CNA-E stated the yellowish glue-like substance and brownish-black sticky residue had been present in Hall 2 rooms since she began working in October 2025, and she reported nearly falling when her shoes stuck to the floor. Other residents stated the floor remained sticky despite housekeeping efforts and that glue was coming up through the flooring seams. Staff interviews confirmed awareness of the issue across multiple rooms. The Housekeeping Supervisor stated the flooring had been installed about one year earlier and that maintenance had been notified, but the substance repeatedly returned. The Housekeeping Supervisor, HSK-F, the MS, and the DON all described the material as glue coming up through the flooring seams, and staff stated the condition had existed since the rooms were retiled more than one year earlier. Record review showed only one maintenance entry for sticky flooring in one room, dated 05/10/2026, and marked completed, while observations later showed the yellowish liquid and brownish-black residue still present. The facility policy stated maintenance service shall be provided to all areas of the building, grounds, and equipment in a safe and operable manner at all times.
Failure to Replace Oxygen Equipment Weekly
Penalty
Summary
Resident #59, a cognitively intact female with diagnoses including dyspnea, congestive heart failure, chronic kidney disease, dementia, anxiety disorder, hypertension, and type 2 diabetes mellitus, had an active order for oxygen at 2 liters per minute by nasal cannula as needed for shortness of breath. The physician orders also directed that the nebulizer tubing be changed every week on Wednesday and that the tubing, applicator, and related equipment be dated and initialed. During observation, the resident’s oxygen concentrator humidifier bottle and nasal cannula tubing were both labeled and dated 6/2/2026. Facility staff interviews identified that nursing staff, including charge nurses, were responsible for changing the oxygen concentrator humidifier bottles and nasal cannula tubing weekly, typically on Wednesdays, and documenting the changes in the TAR. However, during later observation the same humidifier bottle and nasal cannula tubing were still labeled and dated 6/2/2026, and the ADON stated the equipment had not been changed as scheduled and could not explain why. The facility policy titled Administration of Oxygen required distilled water in the humidifier to be changed weekly and oxygen cannula, tubing, and humidifier bottles to be changed weekly and as needed.
Broken Bed Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to ensure Resident #65’s bed was maintained in safe operating condition. Resident #65 was a female with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, unspecified lack of coordination, torticollis, primary generalized osteoarthritis, cognitive communication deficit, and restless leg syndrome. Her most recent Quarterly MDS indicated a BIMS of 10, showing moderate cognitive impairment, and she required substantial to maximum assistance for bed mobility and was dependent for bed-to-chair transfers. She was also always incontinent of bowel and bladder. During observation and interview, Resident #65 was lying in bed and stated her bed was broken. She reported that when she pressed the remote button to lower the foot of the bed, it would creak and then drop all at once, and that this had startled her when she lowered it during the night. She stated she had told LVN H about the problem weeks earlier and said the Maintenance Assistant had told her the Maintenance Supervisor was ordering a new bed. The Maintenance Supervisor later stated he was unaware of any problem with the bed and found no current maintenance request for it in the work orders or maintenance request log. When the Maintenance Assistant inspected the bed, he initially said he did not know it was broken and was able to operate the remote only by pushing the buttons with force. When he lowered the foot of the bed, a loud creaking sound was heard and the foot dropped suddenly. Resident #65 later stated she had multiple problems with the remote, including times when she could not push the button and needed CNA assistance, and times when pressing the button caused the opposite movement. Staff interviews showed inconsistent communication: CNA G said she told the Maintenance Assistant about the bed issues, LVN H said she was unaware of any problems, and the Maintenance Assistant said he did not complete a maintenance request. The DON stated staff should have completed a maintenance request and acknowledged there was a gap in communication regarding the bed concerns. The facility policy stated maintenance service shall be provided to all equipment and that the Maintenance Department is responsible for maintaining equipment in a safe and operable manner at all times.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail in a timely manner, specifically on Saturdays. During a group interview, two residents reported that although mail was delivered to the facility on Saturdays, it was not distributed to them until Monday. The HRD confirmed that she collected the mail on Saturdays and placed it on the BOM's desk, which was locked over the weekend. The BOM stated that she sorted the mail on Monday and placed the residents' mail in the Activity Director's mail slot for distribution. The Administrator mentioned that the Activity Director worked on Saturdays and was responsible for delivering the mail to the residents. However, the Activity Director stated that she separated the business office mail from the residents' mail and slid the business office mail under the office door, including any cards or items for the residents. The facility's policy, revised in May 2017, required that mail and packages be delivered to residents within 24 hours of delivery to the premises, including Saturdays. The failure to deliver mail on Saturdays as per the policy was confirmed through interviews with the HRD, BOM, Administrator, and Activity Director. This deficiency was identified for two residents who did not receive their mail on Saturdays, potentially impacting their quality of life and timely access to communication.
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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 Whitehouse
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Center At Grande | 4.8 mi | ★★★★★ | 3 | 0 |
| The Waterton Healthcare & Rehabilitation | 6 mi | ★★★★★ | 5 | 0 |
| Meadow Lake Health Center | 6.5 mi | ★★★★★ | 0 | 0 |
| Providence Park Rehabilitation And Skilled Nursing | 6.5 mi | ★★★★★ | 2 | 1 |
| Reunion Plaza Healthcare & Rehabilitation | 7.8 mi | ★★★★★ | 0 | 0 |
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