Landmark of Oak Lawn Rehabilitation and Nursing Ce

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Guidelines for Incontinence Care by not providing timely incontinence care to dependent residents. This applies to 3 of 3 residents (R3, R6, and R11) reviewed for activities of daily living in a sample of 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order to provide wound treatment and care. This applies to 1 of 3 residents (R3) reviewed for wound treatment and care in a sample of 11.

Inspectors wroteBased on interview and record review, the facility failed to follow their elopement policy by not allowing a resident to leave the facility unauthorized without staff knowledge. This affected one of three residents R1 reviewed for leaving the facility unauthorized. This failure resulted in R1 being found about 450 ft from the facility walking down the street within minutes after leaving. Findings Include: R1's hospital referral package dated 6/16/25 documents: Per emergency department patient (R1) with tendency to roam the street. Psychiatric: Cognition and Memory: Cognition is impaired. Memory is impaired. Comment: Highly impaired insight plus judgement. R1 was admitted on [DATE] with the diagnosis of Dementia with other behavioral disturbance. Minimal data set dated [DATE] documents a score of twelve which indicates moderate cognitive impairment. Nursing note dated 6/20/25 documents: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure activities of daily living (ADL) for dependent resident's, which included showers and grooming of hair and fingernails, was provided for 4 of 4 resident's (R7, R8, R9 and R10) reviewed for activity of daily living.

Inspectors wroteBased on observation, interview and record review the facility failed to allow a resident access to a bedroom shower room for 1 of 1 dependent resident (R10) reviewed for showering assistance.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess resident for safe medication self-administration. This deficiency affects one (R5) of three residents in the sample of three reviewed for Medication safety.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a resident with the proper footwear while up in the dining area and the hallway for 2 of 2 resident's R7, and R8 reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to update care plan of resident with Self-Medication Administration. This deficiency affects one (R5) resident in the sample of three reviewed for Care plan revision.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a dependent resident was not lying flat in bed while an enteral gastrointestinal tract tube feeding was infusing for 1 of 3 residents (R9) reviewed for tube feeding.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen tubing is stored, changed and dated weekly and as needed. This deficiency affects one (R2) of three residents reviewed for Respiratory Care.

Inspectors wroteBased on observation, interview and record review, the facility failed to account for the Shift change accountability record for controlled substances. This deficiency affects one of four medication carts (1st floor medication cart).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medications are stored safely, securely, and properly following manufacturer/supplier recommendations. This deficiency affects one resident (R5) in a sample of three residents reviewed for Self-Administration of Medications by Residents.

Inspectors wroteBased on interview and record review the facility failed to follow their activity calendar and implement and engage the residents in social activities of tabletop games on 2/25/25 for 4 of 6 (R6, R7, R8, R9) residents reviewed for social activities.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate care for residents with incontinence by not ensuring that incontinence care was provided at least every two hours. This affected one of three residents (R10) reviewed for incontinence care. This failure resulted in R10 being left soiled and saturated in urine for over five hours and feeling cold. Finding Include: R10 was diagnosis with hemiplegia and hemiparesis following cerebral infraction affecting left non-dominant side, functional quadriplegia, reduce mobility and need for assistance with personal care. Minimal data set section C (cognitive pattern) dated 11/1/24 documents a score of twelve which indicates moderate cognitive impairment. Section GG (functional abilities) documents: R10 has impairments on one side to the upper and lower extremity. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect a resident with severe cognitive impairment from physical abuse; and failed to follow the facility abuse policy and abuse care planning for one (R1) of five residents reviewed for abuse. This deficiency resulted in R2 hitting R1 in the face. R1 sustained discoloration to left eye, and bleeding to nose and mouth. R1 was sent to the hospital and was diagnosed with facial hematoma as a result of physical trauma.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1.follow their policy on hand washing by not performing hand hygiene when entering the kitchen, 2. failed to follow their policy on use of gloves by not performing hand hygiene prior to putting on gloves and when removed, 3. failed to follow their policy on use of hair restraints by staff entering the kitchen without putting on a hair net, 4. failed to follow their policy on use of wipe cloths by leaving cloths on the food preparation table and not ensuring they are in a sanitation bucket, 5. failed to follow their policy on use of sanitizing buckets by failing to maintain the sanitizing solution at 200 ppm (parts per million) of quaternary solution , 6. failed to follow their policy on use of thermometers by failing to sanitize a thermometer prior to obtaining food temperatures, and 7. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were nine (3) medication errors out of 30 medication opportunities, resulting in a 10% medication error rate. This applies to 2 residents (R20, R42) of 4 residents observed during medication administration.

Inspectors wroteBased on interview and record review, the facility failed to prevent an accident for a resident assessed to require two staff assistance with incontinence care. This failure affected one (R1) of three residents reviewed for falls and resulted in R1 experiencing a fall while being assisted with incontinence care by only one staff member. R1 required emergent hospital transfer for evaluation and sustained a left forehead hematoma, skin tear to right forearm, and left fifth metacarpal fracture.

Inspectors wroteBased on interviews and records reviewed the facility failed to follow their policy to ensure that medications were stored safely and securely. This affected one of three residents (R4) reviewed for medication storage. This failure resulted in one resident (R4) accessing the medication cart.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe environment and ensure comfortable room temperatures in resident rooms with temperatures above 80 degrees Fahrenheit and humidity above 60%. The facility failed to identify all residents at high-risk for heat stroke/heat exhaustion. The facility failed to follow their extreme weather conditions policy and implement an effective plan to monitor ambient temperatures in resident rooms. The facility failed to develop and implement an effective plan to monitor residents' physical condition and increasing residents' comfort. This failure has the potential to affect all 47 residents (R2-R48) residing in this facility. The Immediate Jeopardy began on 06/18/2024 when the building temperatures were observed to be above 80 degrees Fahrenheit and humidity above 60%. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent or determine an injury of unknown origin for one resident. This affected one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in R1 sustaining bruising to the left hip, left hand, and left shin and superficial scratches to R1's back and treated at the local hospital. Findings Include: R1 is a [AGE] year old, female resident in the facility with diagnoses of but not limited to: Psychosis not due to substance or known physiological condition, anxiety disorder, acute stress reaction, and adult physical abuse. R1 has a BIMS of 15 (Cognition Intact). Facility Reported Incident with date of occurrence of 3/28/24, reads in part: R1 alleged rough treatment/abuse by agency staff nurse. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to honor a residents preference for showering. This affected one of three residents (R4) reviewed for residents rights. Findings Include: Interviewed R4 on 6/29/24 at 10:15AM. R4 stated she's never had a shower and did not know the days of her showers. Surveyor has to give the shower schedule information for R4. R4 shower days are Monday and Thursday Evening shift. R4 stated R4 never knew about the shower chair. R4 requested for shower bed because R4 was using the shower bed at home. The staff never offered the shower chair, so R4 thought there is no shower chair in the facility. R4 stated that staff clean R4 every day, but R4 still wants that water on R4's body. R4 want R4's shower and not just bed bath. R4 stated, (R4)'s been in the facility for 3 weeks now, and has only received bed baths, not shower. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to protect a resident (R1) from physical abuse by staff and failed to follow their abuse protocols by staff not promptly reporting an incident of resident abuse. This failure applied to one (R1) of four residents reviewed for abuse and resulted in R1 being emergently transferred to the local emergency room for evaluation of pain to his head, neck and ribs and subsequently being admitted for assault and a fracture to his right third digit; this failure also led to a delay in the initiation of an abuse investigation as a result of staff not immediately reporting the abuse. The Immediate Jeopardy began on 3/2/24 when R1 was physically abused by V3 (Registered Nurse). V1 (Administrator) was notified of the Immediate Jeopardy on 3/12/24 at 10:12AM. [...]

Inspectors wroteBased on interview and record review, the facility failed to keep one resident (R1) free from restraints, in a sample of 7 residents reviewed for restraints.

Inspectors wroteBased on interview and record review, the facility failed to schedule sufficient staff to meet resident care needs in a timely manner for seven shifts of ninety shifts reviewed. This failure has the potential to affect all 56 residents listed on the facility census.

Inspectors wroteBased on interview and record review, the facility failed to have RN (Registered Nurse) coverage for 8 hours/day 7 days/week for one day, 11/24/23 of thirty days reviewed for nursing coverage. This failure has the potential to affect all 56 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who are dependent on staff for toileting received incontinence care. This applies to 4 of 9 residents (R4, R5, R6 and R9) reviewed for activities of daily living in the sample of 9.

Inspectors wroteBased on interviews and records reviewed the facility failed to follow their policy to prevent or determine an injury of unknown origin. This affects one of three residents (R1) reviewed for injury of unknown origin. This failure resulted in (R1) being found with a change in skin pigmentation and sent to the hospital for an evaluation and admitted with a hip wound consistent with a second degree burn.

Inspectors wroteBased on interviews and records reviewed the facility failed to follow their policy to report an injury of unknown origin for one (R1) of three residents reviewed for abuse reporting.

Inspectors wroteBased on interviews and record review the facility failed to follow their policy to investigate the cause an injury of unknown injury for one resident (R1) of three residents reviewed for investigation of injury of unknown origin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident privacy by not knocking on the door and introducing themselves before entering the resident rooms. This failure affected 9 residents (R21, R41, R27, R39, R19, R9, R32, R56, and R13) of 9 residents reviewed for privacy in a total sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control practices for the medication refrigerator for one of one medication rooms observed for medication storage. The facility failed to date and discard inhalers per manufacturer's recommendation for one of two medication carts affecting three residents (R24, R32, R57) in a sample of 22. The facility also failed to have a system to account for the receipt of all controlled medications for two of two medication carts (First floor Team 1 and Team 2 medication carts) observed for medication storage affecting all 11 residents receiving controlled medications on both carts.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain infection control practices for the medication refrigerator for one of one medication rooms observed for medication storage. The facility failed to date and discard inhalers per manufacturer's recommendation for one of two medication carts affecting three residents (R24, R32, R57) in a sample of 22. The facility also failed to have a system to account for the receipt of all controlled medications for two of two medication carts (First floor Team 1 and Team 2 medication carts) observed for medication storage affecting all 11 residents receiving controlled medications on both carts.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the recipe for pureed bread for five residents (R4, R37, R40, R57, and R58) of five residents reviewed for pureed diets in the sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement appropriate transmission-based precautions and ensure nebulizer and C-pap mask were properly stored in plastic bag and left open to air. This failure affects six of six residents (R10, R16, R29, R37, R47, R48) observed for infection control in a sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services to maintain range of motion for three of three residents (R37, R39, R47) reviewed for range of motion in a sample of 22.

Inspectors wroteBased on observation, interviews and record review, the facility failed to follow their oxygen administration policy and failed to follow the orders for oxygen administration. This deficient practice affects one resident (R43) of three residents reviewed for oxygen administration in a total sample of 22 residents. Findings Include: On 9/19/23 at 10:45 AM, observed R43 in bed and using CPAP (Continuous Positive Airway Pressure) machine connected to an oxygen concentrator. Oxygen concentrator observed to be at 7L (Liters) per minute. On 9/19/23 at 11:00 AM, confirmed with V5 (LPN) that the oxygen concentrator is set at 7L. V5 stated that R43 is supposed to be on 2-4L of oxygen. On 9/20/23 at 8:55AM, observed R43 sitting in bed, CPAP not in use. R43 awake and oxygen concentrator is set to 3L with bottle humidifier. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents are free from significant medication error for one of four residents (R9) observed for medication administration in a sample of 22.

Inspectors wroteBased on interview and record review, the facility failed to prevent R212 from falling on 4/17/23 resulting in R212 sustaining a laceration to the back of the head requiring 3 staples on the right side. The facility also failed to prevent R212 from falling again on 4/26/23 resulting in R212 sustaining a laceration to the left side of his forehead and receiving steri-strips and surgical glue to the forehead. This failure affected one resident (R212) of four residents reviewed for falls in a total sample of 22.

Inspectors wroteBased on interview and record review the facility failed to complete an investigation for an allegation of resident-to-resident abuse for two residents (R9, R51) of four residents reviewed for abuse in the sample of 22.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policies and procedures for fall prevention by not developing a comprehensive and individualized plan of care for a resident admitted at risk for falls and failed to evaluate and modify interventions following an unwitnessed fall. This failure applied to one (R19) of one resident reviewed for fall interventions and resulted in R19 requiring emergent transfer to hospital as a result of a head injury.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedures for preventing and minimizing pain by not ensuring that pain was adequately controlled by not ensuring that pain medication was available to be administered as ordered. This failure applied to two (R33 and R49) of two residents reviewed for pain management and resulted in R33 and R49 experiencing pain greater than a level ten for multiple days.

Inspectors wroteBased on observations and interviews, the facility failed to follow their policy and procedures for ensuring menus are followed and failed to identify the residents meal preferences resulting in meals being served that were insuffient for meeting the resident's needs. This failure applied to four (R17, R48, R73, and R126) of four residents reviewed for nutrition and has the potential to affect all 75 residents currently in the facility.

Inspectors wroteBased on observations and interviews, the facility failed to follow their policy and procedures for preparing food under sanitary conditions by not using PPE (Personal Protective Equipment properly, not wearing required hair covering while working in the kitchen, not performing hand hygiene when necessary, not ensuring sanitizer solution was prepared properly, not ensuring the kitchen area is in good repair and free from contamination, not ensuring food equipment was cleaned and stored properly, and not ensuring the ice machine was thoroughly clean when in use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly prevent the spread of infections by staff not wearing proper personal protective equipment (PPE's), failing to ensure that staff were properly notified of residents on isolation precautions, failing to ensure that blood pressure equipment was properly sanitized in between residents, and they failed to ensure that urine collection containers were properly cleaned. This failure has the potential to affect all 75 residents currently residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean, and homelike environment by failing to keep furniture, equipment, and room condition functional and in good repair, by failing to keep rooms in a clean, sanitary condition, and by failing to store resident's belongings in a dresser/closet. The failures applied to three of three (R35, R42, and R73) residents reviewed for environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their medication storage policy for eye drops and expired or discontinued medications. This failure applies to four (R34, R52, R60, R77) of four resident's medications reviewed in one medication storage room, and in two of four medication carts during the medication storage and labeling facility task.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide notices of resident transfer to the resident's representative and to the Office of the State Long-Term Care Ombudsman after a resident was emergently transferred to the hospital. This failure applied to one (R7) of one resident reviewed for discharge and transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident's representative with a notice of bed-hold policy after a resident was emergently transferred to the hospital. This failure applied to one (R7) of one resident reviewed for discharge and transfer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a resident centered baseline care plan for a newly admitted resident within 48 hours of admission in order to meet the resident's individualized needs and to determine specified care to be provided. This failure applied to one (R78) of one resident reviewed for baseline care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare a discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of all pre- and post-discharge medications; the facility also failed to convey the discharge summary to the receiving facility at the time of discharge. This failure affected one (R76) of one resident reviewed for transfer and discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician medication orders by not administering medication by the correct route and by failing to ensure that pain medication was available and in stock for resident to receive according to physician orders. This failure applied to two (R33 and R64) of two residents reviewed during medication administration.

Inspectors wroteBased on observations and interviews the facility failed to follow their protocol for ensuring timely incontinence care for a resident who had been sitting with a loose stool for an extended period of time resulting in the resident experiencing discomfort. This failure applied to one (R49) of one resident reviewed for incontinence care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications as ordered to maintain a medication error rate of less than 5% (percent). There were 25 medication opportunities with four errors resulting in a 16% (percent) medication error rate. This failure applied to three (R3, R33, R64) of six residents observed during the medication administration task.