Oakbrook Health And Rehabilitation Center

Based on interviews, record review, and facility policy, the facility failed to ensure adequate Registered Nurse (RN) coverage for 4 of 31 days in October 2025; 7 of 30 days in November 2025; and 3 of 31 days in December 2025, totaling 14 days during these 3 months/quarters. This failure has the potential to affect all resident quality of care outcomes that residents experience. Findings include: Record review of facility policy titled Leadership Policies and Procedures, Staffing last revised 11/01/17 revealed The facility's leadership will provide sufficient staff to successfully implement patient/resident focused functions. To provide a sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnosis of the facility's resident population. Procedures include, provides qualified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, observations, and interviews, the facility failed to remove expired medications, and label open medications in 3 of 4 medication carts and 1 of 2 medication rooms. Review of the facility policy, Pharmacy Services Policies and Procedures: Section 8 - Medication Storage with a revision date of 04/17/24, revealed, 7. Once any multi-dose packaged medication or biological is opened, nursing will mark multi-dose products (e.g. inhalers, insulin, ophthalmics, otics, and the like) with the date opened and follow the manufacturer/supplier guidelines with respect to expiration dates, and 12. Outdated, contaminated, or deteriorated medications. are immediately removed from stock, disposed of according to procedures for medication destruction.During an observation on 05/05/26 at approximately 1:50 PM of the Dogwood 1 medication cart, the following was found:1. Buspirone 15mg tablets card - Expired 01/29/26.During an observation on 05/05/26 at 2:02 PM of the [NAME] Front medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure the master menu and the posted daily menu matched the meal served during two lunches for 4 of 4 residents reviewed, (Resident (R)45, 26, 82 and 73).During an observation on 05/03/26 the posted menu for lunch was: Chili with beef, Tossed salad, Cornbread, Chilled fruit cup and a Beverage. During an observation on 05/03/26 at 11:50 AM in the main dining room, R45's lunch ticket read:House Mechanical Soft/ Regular bread, Chopped meats1/2 cup soft seasoned green beans6 oz Chili con carne1 2x3 Cornbread1 ea Margarine1 sl Mech soft pie of choice8 oz Beverage of choiceInner lip plateR45 was served: Bowl of ChiliPlain baked potatoContainer of cheese sauceSlice of cakeR45 did not receive the cornbread, margarine, or pie listed on her lunch ticket. She did not receive the tossed salad or chilled fruit cup listed on the posted menu. Instead, she received a baked potato, cheese sauce, and cake. During an observation on 05/03/26 at approximately 11:55 AM, R26's meal ticket read: Consistent carb/ Large protein portion, No fish1/2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of the facility policy titled Indications for Glove Use, the facility failed to ensure adequate infection control practices were followed related to glove use for one of one observation. Findings included: Findings include: Review of the facility policy titled Indications for Glove Use states under the Key Points, the following: 1A- Gloves are discarded after each use with a patient or resident. 1B-Gloves are changed when contaminated with blood or body fluids, before touching other parts of the same person. 2. Hand hygiene is performed immediately after gloves are removed, before contact with another person or items in the environment. During an observation on 05/05/26 at 1:45 PM, Registered Nurse (RN)2 was observed exiting a resident's room carrying a closed plastic bag with gloved hands. RN2 then entered the code to the soiled utility room while wearing the soiled gloves. During an interview on 05/05/26 at 1:59 PM, RN2 confirmed wearing the gloves in the hallway and entering the soiled utility room. RN2 stated the contents of the bag…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the facility policy, observations, and interviews, the facility failed to ensure foods stored in the main walk in refrigerator and dry storage were labeled, dated and not expired. This failure could potentially affect all 85 residents in this facility, who consumed food from the kitchen. Findings include: Review of the facility policy titled, Food Safety in Receiving and Storage with a complete revision date of 06/20/2023 states, Check expiration dates and use by dates to assure the dates are within acceptable parameters. Store foods at least 6 inches off the floor .Refrigerated, ready to eat Time/Temperature Control for Safety Foods are properly covered, labeled, dated with a use by date . During an observation on 02/09/25 at 10:41 AM, the following food items were observed in the walk in refrigerator and freezer and verified by the Cook; 1 can of beef base open and dated 01/31/2025. 1 plastic bag of chicken nuggets that was open, not sealed or dated. 1 plastic bag of french fries, open and not dated. During an observation of the dry storage on 02/09/2025 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, observations, record reviews and interviews, the facility failed to ensure that medications were properly stored and labeled in 2 of 2 medication rooms and 2 of 3 medication carts. Findings include: A review of the facility policy entitled Medication Storage revised 4/17/24 states: Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. In accordance with State and Federal laws, the facility will store all drugs and biologicals in locked compartments under proper temperatures and other appropriate environmental controls to preserve their integrity. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates of opened medications. Once any multi-dose packaged medication or biological is opened nursing will mark multi-dose products (e.g. (for example) .insulin ) with the date opened and follow…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, record review, observations, and interviews, the facility failed to ensure that the environment was free from accidents for Resident (R) 231. Findings include: Review of the facility's policy titled, Pharmacy Services Policies and Procedures. Subject: 4.4 Self-Administration of Medications dated 04/17/2024 stated, Procedures: 2. Interdisciplinary Care Team (IDT) assessment will be performed upon admission, readmission and quarterly with the MDS assessment for a resident choosing to self-administer . 3. Residents are not permitted to self-administer or store controlled substances at the bedside. Review of R231's Face Sheet revealed R231 was admitted to the facility on [DATE] with diagnoses including but not limited to: presence of prosthetic heart valve, atherosclerotic heart disease of native coronary artery without angina pectoris, and allergic rhinitis. Review of R231's Physician Orders revealed no order for medication to be kept at the bedside, and no order for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, record review, observations, and interviews, the facility failed to ensure that Resident (R)34 was free of significant medication error for 1 of 1 reviewed for insulin administration. Findings include: Review of the facility policy: Staff education/orientation policies and procedures. Competency: Medication Administration-Insulin Pen dated 01/12/2024 stated, Performance Criteria: Priming the Pen: 1. Removes the outer needle cap and dials 2 units. 2. Points the pen up and presses the plunger button to expel 2 units of insulin. Review of R34's Face Sheet revealed R34 was admitted to the facility on [DATE] with diagnoses of but not limited to: Hypoglycemia and Type 2 diabetes mellitus with diabetic neuropathy. Review of R34's Physician Orders revealed order for Insulin Lispro: Insulin pen give 3 units subcutaneous with meals at 8:00 AM, 11:30 AM, and 5:00 PM. Additionally Physician Orders revealed order for Insulin Lispro Insulin pen per sliding scale before meals and at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, record review, and interviews, the facility failed to complete an annual Minimum Data Set (MDS) for 1 of 3 residents (R)1, reviewed. Findings include: Review of the facility policy titled, MDS Primary Assessment, revised 2023, revealed, Complete at a minimum, three querterly reviews and one comprehensive assessment every 12 months (366 day) period. Review of R1's medical record revealed he was admitted on [DATE] with diagnosis including Parkinsons Disease, Hypertension and a new diagnosis of Fracture Left Femur Neck. His Brief Interview of Mental Status (BIMS) of 2, indicating severe cognitive loss. Review of the last MDS dated [DATE] revealed it was a quarterly assessment. Additional review of the MDS' revealed there were 2 previous MDS quarterly (Q) assessments dated 09/11/23, 06/12/23 and an annual assessment with a date of 03/12/23. On 04/09/2024 at 12:13 PM, an interview with the Director of Nurses (DON) revealed, I believe we complete them quarterly and an annual. We…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the facility policy, record review, and interviews, the facility failed to develop/implement a Comprehensive care plan for 2 of 3 resident (R)2 and R3, reviewed. Findings include: Review of the facility policy revised 2023, and titled Care Plan Process, Person Centered Care revealed, thru on-going assessment, the facility will initiate person centered care plans when the residents clinical status or change of condition indicates the need . Review of R2's medical record revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to; acute respiratory failure with hypoxia, hypertension and left elbow and pelvis fracture. Review of an unspecified Minimum Data Set (MDS) revealed R2 has a Brief Interview of Mental Status (BIMS) score of 12, indicating intact cognition. Review of R2's medical record revealed he had a fall in the hallway on 02/22/24 and the hospital confirmed two new fractures, left elbow and pelvis. Review of R2's care plan revealed there was not a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.