Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Oakbrook Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to Report Allegation of Abuse to Law Enforcement: A resident with sepsis, UTI, weakness, and impaired cognition alleged that everyone was hurting them, but the NHA did not report the allegation to local law enforcement within the required 2 hours. Facility staff reported the concern up the chain of command, and the NHA said police were not contacted because the resident did not name a person, despite the facility policy requiring immediate reporting of alleged abuse.
A resident with multiple neurologic, hepatic, and psychiatric diagnoses became verbally and physically aggressive toward staff, then later accused an LPN of threatening them and demanded that police be called. Facility policy required all abuse allegations to be reported immediately, but not later than 2 hours, to the administrator, State Survey Agency, and appropriate authorities. Although the administrator acknowledged this was an abuse allegation, the facility did not notify law enforcement and did not submit the Facility Reported Incident to the State Agency until the following day, after the investigation and staff and resident interviews were completed, contrary to the required reporting timeframe.
Infection prevention and control failures were identified when a resident with open wounds did not have EBP signage or PPE in place, an RN returned to work after a positive COVID test without the required second negative test, and a CNA used contaminated gloves and improper hand hygiene during personal care for a resident on EBP. Surveyors observed the CNA wash the peri area and then continue care to the mouth and face without changing gloves, while the DON confirmed the care was not the expected practice.
A resident’s MDS did not accurately reflect completed PASARR 1 and PASARR 2 assessments. Although both PASARRs were in the record, the annual MDS showed no PASARR 1, and later MDS entries continued to carry the same incorrect information. The SW said PASARRs are completed on admission and the MDS is updated when changes occur, while the CQC noted the system may have been pulling old information.
Antibiotic Stewardship Program Not Followed: A resident with multiple diagnoses had orders for doxycycline and Valtrex without documented end dates or clear rationale for continued use, and neither medication appeared on the facility’s antibiotic stewardship line list. The DON stated that anyone on an antibiotic should be listed, that the Valtrex entry was missed, and that the end date and reasons for both antibiotics should have been verified at admission.
A resident with moderate cognitive impairment and behavioral disturbances repeatedly yelled at their severely cognitively impaired roommate, telling them to "shut up" and making other derogatory remarks, both when the roommate was awake and talking in their sleep. Staff documented multiple incidents of this behavior, and interviews confirmed that such language was considered verbal and mental abuse. Despite staff interventions and reminders, the facility did not prevent the ongoing abuse, resulting in repeated exposure of the affected resident to disruptive and abusive language.
A resident with dementia and anxiety exhibited ongoing verbal outbursts and disruptive behaviors, but the facility did not update the care plan to include interventions or goals addressing these issues. Despite repeated incidents documented in progress notes and staff awareness of the behaviors, the care plan remained unchanged, contrary to facility policy and assessment findings.
A nonverbal, cognitively impaired resident with dementia and aphasia was subjected to verbal abuse by an RN who yelled and swore at the resident while transporting them in a wheelchair. The facility failed to implement or document effective interventions or monitoring to prevent abuse, especially for residents unable to report mistreatment. Staff described the RN as impatient and hurried, and leadership could not provide details on how nonverbal residents are protected from abuse.
A facility did not thoroughly investigate an alleged incident of verbal abuse by an RN toward a resident with dementia and aphasia. Although the RN was suspended and some staff and residents were interviewed, there was no evidence that all potentially affected residents or staff were included in the investigation, despite staff statements indicating the RN was often impatient and in a hurry.
The facility inaccurately coded MDS assessments for two residents. One resident's assessment failed to reflect a completed PASARR level 2 screen, while another resident's assessments did not indicate hospice services despite being enrolled. The errors were attributed to oversight and transition in MDS coordinators.
Failure to Report Allegation of Abuse to Law Enforcement
Penalty
Summary
The facility failed to implement its policies and procedures for reporting an allegation of physical abuse in accordance with section 1150B of the Act when an allegation made by one resident was not reported immediately, and no later than 2 hours, to local law enforcement. The facility policy titled Resident safety Abuse Policy stated that all alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than 2 hours after the allegation is made, if the events involve abuse. On 05/02/26, the facility became aware of the resident’s allegation that "everyone is hurting me," but the Nursing Home Administrator did not report the allegation to local law enforcement within the required timeframe. The resident involved was admitted with diagnoses of sepsis, urinary tract infection, and weakness. The resident’s MDS assessment documented moderately impaired cognitive skills for daily decision making, behaviors of inattention, disorganized thinking, and verbal behaviors directed toward others. The facility’s investigation documented the allegation, and nursing staff reported it to the NHA, who reported it to the State Agency and completed a full investigation. During interview, the NHA stated the allegation was reported to the charge nurse around 9:30 PM and that police were not contacted because the resident did not name a person that could be reported. Staff interviews showed CNA staff understood that allegations of abuse should be reported to the nurse, DON, or NHA, and one CNA stated the resident had sundowning behaviors and bad dementia.
Failure to Timely Report Resident’s Allegation of Physical Abuse to State Agency and Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse reporting policies and federal requirements under section 1150B of the Act when an allegation of physical abuse was made by a resident and not reported to the State Agency or local law enforcement within the required 2-hour timeframe. The facility’s Resident Safety Abuse Policy, reviewed in 03/24, states that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, and misappropriation of resident property must be reported immediately, but not later than 2 hours after the allegation is made, to the administrator, who will ensure reporting to the State Survey Agency and other officials. Despite this policy, the facility did not submit a Facility Reported Incident (FRI) to the State Agency or contact local law enforcement within 2 hours of the allegation. The resident involved had diagnoses including degeneration of the nervous system due to alcohol, convulsions, hepatic failure, altered mental status, major depressive disorder, anxiety disorder, thiamine deficiency, and cerebrovascular disease. On 02/03/26 at 9:38 PM, progress notes documented that the resident was found in a wheelchair with genitals exposed, made sexually suggestive comments to staff, became physically aggressive by pushing and grabbing the nurse’s arm, lunged at a CNA, attempted to block the exit, and shouted threats toward staff. Later, the resident went to the nursing station, accused the nurse of threatening and coming at their throat, and demanded that the police be called. The Nursing Home Administrator was called and arrived, but the facility did not contact local law enforcement and did not submit the FRI to the State Agency until 02/04/26 at 6:47:28 PM. During interview, the administrator acknowledged that the allegation was considered abuse, that the FRI was sent the next day, that law enforcement was not called, and that the facility’s policy for reporting within 2 hours was not followed because the administrator believed the allegation did not occur, even though the full investigation and interviews were not completed until the following day.
Infection Control Failures With EBP, Staff Return-to-Work, and Glove Use
Penalty
Summary
The facility did not provide an infection prevention and control program that maintained a safe, sanitary, and comfortable environment and helped prevent the development and transmission of communicable diseases and infections. Surveyors identified that a resident with open wounds did not have Enhanced Barrier Precautions (EBP) in place. The resident had a history of pressure ulcers and other wounds, and on survey the resident reported an open area to the left lower leg that was draining. Surveyors observed no EBP signage or PPE present for the resident’s room, and the DON acknowledged that EBP would be appropriate for open wounds. The facility also failed to follow CDC guidance for return-to-work after illness for a staff member. The infection line list showed an RN with influenza and a positive COVID test, with symptoms beginning on 01/01/26 and ending on 01/05/26. The record showed one negative COVID test on 01/08/26, and the RN returned to work on 01/09/26 without the second negative test 48 hours after the first. During interview, the DON and CNO described return-to-work expectations, and the CNO stated the facility did not always have staff come in for two tests 48 hours apart. Surveyors also observed inappropriate hand hygiene and glove use during personal care for another resident who was on EBP. A CNA provided care using the same contaminated gloves while washing the resident’s peri area, buttocks, hand, mouth, and face. The CNA used a washcloth placed directly in the sink, did not use a basin, did not rinse the peri area after using soap, did not change gloves between contaminated and clean tasks, and touched a toothette with contaminated gloves before placing it in the resident’s mouth. The resident’s hand brace appeared soiled, and the protective cover of the Hoyer lift cross bar also appeared soiled. The DON stated this was not the expected care and confirmed that a basin should have been used, the area should have been rinsed, gloves should have been changed, and the toothette should not have been touched with contaminated gloves.
MDS Did Not Reflect Completed PASARR Assessments
Penalty
Summary
Ensure each resident receives an accurate assessment was not met for one resident whose MDS did not accurately reflect PASARR status. The resident was admitted to the facility and had PASARR 1 completed upon admission and PASARR 2 completed shortly thereafter, but the annual MDS dated 03/01/24 indicated the resident did not have a PASARR 1 completed. Although a correction was made to show both PASARR 1 and 2 were completed, subsequent MDS assessments continued to show the earlier incorrect information that neither PASARR had been completed. During interview, the SW stated PASARR 1 is completed upon admission and PASARR 2 is submitted right away when the resident will stay longer than 30 days, and stated the MDS is updated when changes occur. The CQC stated there may be a glitch in the system pulling old information from the MDS and that a nurse may have changed the information back to the original entry.
Antibiotic Stewardship Program Not Followed
Penalty
Summary
The facility did not ensure its antibiotic stewardship program was followed for one resident, including required antibiotic use protocols and a system to monitor antibiotic use. The facility policy titled Infection Prevention and Control Program stated that antibiotic prescribing should include documentation of the dose, route, duration, start date, end date, planned days of therapy, and indication for every course of antibiotics, but the resident’s orders did not include an end date or rationale for continued use for either doxycycline or Valtrex. The resident, admitted with diagnoses including enterocolitis due to Clostridium difficile, pneumonitis due to inhalation of food and vomit, and immune thrombocytopenic purpura, had physician orders for doxycycline hyclate 50 mg daily for bacterial infection and Valtrex 1 gram daily for varicella zoster infection. The resident’s hospital discharge orders documented doxycycline 50 mg daily for meibomian gland dysfunction, also without an end date. Review of the facility’s antibiotic stewardship line lists did not show the resident as receiving doxycycline or Valtrex. During interviews, the DON stated that anyone on an antibiotic should be on the line list, that the resident’s Valtrex use must have been missed, and that the diagnosis listed for Valtrex was incorrect. The DON also stated that the end date and reasons for both antibiotics should have been verified at the time of admission.
Failure to Prevent Repetitive Verbal and Mental Abuse Between Roommates
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal and mental abuse by another resident. Over a period of time, one resident with moderate cognitive impairment and a history of behavioral disturbances repeatedly yelled at their roommate, telling them to "shut up," "shut your mouth," or to stop talking, both when the roommate was awake and when they were talking in their sleep. These incidents were documented in multiple progress notes and 24-hour report sheets, with staff noting that the yelling was disruptive and occurred on several occasions, often during nighttime hours. The roommate who was subjected to this behavior had severe cognitive impairment and a care plan that instructed staff to approach them in a quiet, calm manner. Despite this, the resident was repeatedly exposed to loud and derogatory language from their roommate. Staff interventions included removing the resident from the room or taking the aggressive resident to a different area until the roommate was asleep, but the verbal abuse continued over several days. Staff and leadership interviews confirmed that telling a resident to "shut up" was considered verbal and mental abuse and that such behavior was not appropriate. Facility policy specified that residents have the right to be free from abuse by anyone, including other residents, and defined verbal and mental abuse as including disparaging language, humiliation, and harassment. Despite staff reminders and attempts to educate the aggressive resident, the facility did not prevent the ongoing verbal abuse, and the affected resident continued to be exposed to repeated incidents of yelling and derogatory remarks from their roommate.
Failure to Update Care Plan for Ongoing Behavioral Symptoms
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan to address ongoing verbal behavioral symptoms for a resident with a history of dementia and generalized anxiety disorder. Despite multiple documented incidents of the resident yelling, being disruptive, and directing verbal outbursts toward others, there was no evidence that the care plan included goals or interventions to manage these behaviors. The facility's own policy required that care plans be developed and revised as needed to reflect the resident's current needs, but this was not done in this case. Progress notes over a two-month period detailed repeated episodes where the resident yelled for staff to call their spouse, was disruptive to other residents, and had conflicts with a roommate. Staff interventions included calling family members, attempting redirection, and moving the resident to different locations, but these actions were not formalized in the resident's care plan. The Minimum Data Set (MDS) assessment triggered the need for care planning related to behavioral symptoms, yet the care plan remained unchanged and did not address the ongoing issues. Interviews with facility staff, including an LPN, the MDS Coordinator, the Medical Director, the DON, and the Social Services Director, confirmed that the care plan should have been updated to include interventions for the resident's behaviors. The lack of care plan updates persisted despite clear evidence of recurring behavioral symptoms and staff awareness of the problem. The deficiency was identified through interviews, record reviews, and policy review, all of which indicated a failure to follow established procedures for care planning.
Failure to Protect Nonverbal Resident from Verbal Abuse by RN
Penalty
Summary
A deficiency occurred when a registered nurse (RN) verbally abused a nonverbal, cognitively impaired resident by yelling and swearing at the resident while transporting them in a wheelchair. The resident had diagnoses including dementia and aphasia, with both short and long-term memory problems and severe cognitive impairment, making them particularly vulnerable and unable to report abuse. The facility's own incident report confirmed that the RN used inappropriate language and admitted to being impatient and tired, but there was no evidence that interventions were in place to prevent such abuse, especially for nonverbal residents. Further review revealed that the facility failed to provide adequate supervision or monitoring of the RN's interactions with residents after the incident. Audit notes lacked details about which residents were interviewed, what questions were asked, or what was specifically observed regarding the RN's behavior. Staff interviews indicated that the RN was often impatient and in a hurry, but not necessarily mean. The Director of Nursing was unable to provide information on how the facility monitors for abuse among nonverbal residents or what measures are in place to protect them, highlighting a lack of effective oversight and preventive strategies.
Failure to Thoroughly Investigate Alleged Verbal Abuse by RN
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged incident of staff-to-resident verbal abuse involving a registered nurse and a resident with dementia and aphasia, who was severely cognitively impaired and non-interviewable. The incident was reported after staff observed the nurse yelling at the resident and noted that the nurse had been impatient, anxious, and in a hurry. The nurse admitted to not being as nice as she should have been and cited fatigue as a contributing factor. The facility's policy requires all alleged violations to be thoroughly investigated, with evidence of such investigations. Although the facility immediately suspended the nurse and interviewed the staff witness and three additional staff members, as well as three residents, there was no evidence that other residents or staff who may have had contact with the nurse were interviewed to determine if further abuse had occurred. Statements from interviewed staff described the nurse as impatient and not always nice, suggesting a need for broader investigation. The Nursing Home Administrator confirmed that only the documented interviews were conducted, and the Director of Nursing acknowledged that the nurse could have contact with all residents during a shift.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in their records. Resident 1 was admitted with diagnoses including schizophrenia and anxiety. Despite having a PASARR level 2 screen completed on March 1, 2024, the admission MDS assessment dated March 7, 2024, incorrectly indicated that no PASARR level 2 had been completed. This error was identified during an interview with the MDS coordinator, who had not been in the position at the time of the assessment and was still in training. Resident 27, who was receiving hospice services since December 29, 2023, had MDS quarterly assessments dated July 8, 2024, and October 8, 2024, that were not coded to reflect the hospice services. The MDS coordinator admitted to possibly copying from a previous MDS, leading to the oversight. The executive assistant confirmed that the previous MDS coordinator was responsible for the earlier assessment, and a correction was planned.
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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 Thorp
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clark County Rehabilitation & Living Center | 12.7 mi | ★★★★★ | 18 | 0 |
| Cornell Health Services | 22.2 mi | ★★★★★ | 0 | 0 |
| Colonial Health Services | 23.4 mi | ★★★★★ | 2 | 2 |
| Abbotsford Health Care Center | 23.8 mi | ★★★★★ | 7 | 0 |
| Augusta Health And Rehabilitation | 24.7 mi | ★★★★★ | 0 | 0 |
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