Oak Brook Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided reasonable access to receive their mail in a timely manner for 1 of 8 confidential residents (Confidential Resident #1) reviewed for resident rights. The facility failed to implement a system to distribute incoming mail daily and ensure residents promptly received their mail. This failure could place residents at risk of a delay in residents' personal correspondence, financial information, or other time-sensitive materials.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of five residents (Resident # 5, Resident #25) reviewed for quality of life. The facility failed to ensure Resident #5 and Resident #25 received showers and facial hair care. This failure could place residents at risk for poor hygiene, dignity issues, and a decline in quality of life.

Inspectors wroteBased on observation, interview, and record review, 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 (Cart #1, Cart #2, Cart #3 and Cart #4) observed for controlled medications storage. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for 2 of 2 meals (lunch meals 06/15/2026 and 06/16/2026) reviewed for menus and nutritional adequacy. Dietary staff did not serve bread during the noon meals on 06/15/26 and 06/16/2026 to any residents eating mechanical soft diets. This failure could place residents who eat food from the kitchen at risk of not having their nutritional needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to serve food that was palatable and at an appetizing temperature for 1 of 1 meal (noon meal 06/15/2026) and 9 of 9 residents (Resident #s 2, 23, 30, 37, 56, 59, 67, 81, and 84) reviewed for food palatability. The facility did not provide palatable and appetizing food for the residents for the 06/15/2026 noon meal. Resident #s 2, 23, 30, 37, 56, 59, 67, 81, and 84 complained the food was cool or cold, poorly or not seasoned and was not appealing in appearance. This failure could place residents who received food from the kitchen at risk for diminished meal satisfaction and potential weight loss due to poor meal intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #6, Resident #47, and Resident #30) reviewed for infection control. The facility failed to ensure RN A wore PPE when providing intravenous care to Resident #6. The facility failed to ensure LVN D wore PPE when providing enteral feeding to Resident #47. CNA-M failed to remove PPE and discard prior to leaving resident 's room after providing perineal care, incontinent care for Resident #30. These failures could place residents at risk for cross contamination, spread of infection and sepsis, in violation of infection prevention and control requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for four of five rooms (Rooms 201, 203, 205, and 208) reviewed for environment. The facility failed to maintain clean and sanitary conditions in rooms 201, 203, 205, and 208 which had a yellowish liquid substance and brownish-black sticky residue present throughout the rooms along the seams of the vinyl flooring with dirt, debris and food particles adhering to the substance and residue. This failure could place residents at risk of living in an unsafe, unsanitary and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 2 residents (Residents #59) reviewed for respiratory care. 1. The facility failed to ensure Resident #59's nasal cannula was changed and dated in accordance with facility policy that required weekly replacement. 2. The facility failed to ensure Resident #59's humidifier bottle was changed and dated in accordance with facility policy that required weekly replacement. This deficient practice could place residents at risk for respiratory-related infections

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all mechanical, electrical, and patient care equipment was in safe operating condition for 1 of 6 (Resident #65) reviewed for environment. The facility failed to repair or replace Resident #65's bed after the bed remote jammed and the foot of the bed frame creaked and abruptly dropped during operation. This failure could place residents at risk for impaired positioning, discomfort, and a reduced quality of life due to the use of malfunctioning equipment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 5 of 26 residents (Residents #23, #35, #37, #46 and #52) reviewed for resident rights. The facility failed to maintain resident-use water to be above 100 degrees Fahrenheit. This deficient practice could place residents at risk of discomfort and unsanitary washing conditions .

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that heard grievances without discrimination or reprisal and without fear of discrimination or reprisal, such grievances include those with respect to care and treatment which were furnished as well as that which were not furnished, the behavior or staff and of other residents, and other concerns regarding their LTC facility stay, for 8 of 8 residents reviewed for grievances. The facility failed to ensure residents were informed of their right during their stay in the facility. This failure could place residents at risk of a decreased quality of life, decreased awareness of their right and decreased execution of their rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received mail for 2 of 8 residents reviewed for rights to forms of communication. (Resident #s 38 and 65) The facility did not deliver mail to Resident #s 38 and 65 on Saturdays. This failure could place the residents at risk of not receiving mail in a timely manner and a diminished quality of life.