Oak Forest Health and Rehabilitation

Inspectors wroteBased on observations, record review, resident, staff and family interviews, the facility failed to maintain a bathroom sink in good repair in 1 of 12 resident rooms and a clean environment in 8 of 12 resident rooms on 1 of 2 halls which affected sixteen (16) residents reviewed for environmental concerns (Resident #71, Resident #65, Resident #56, Resident #61, Resident #108, Resident #115, Resident #119, Resident #86, Resident #42, Resident #25, Resident #30, Resident #68, Resident #112, Resident #100, Resident #67, and Resident #137).

Inspectors wroteBased on observations and staff interviews, the facility failed to secure two full oxygen cylinders stored in a resident's room for 1 of 1 resident reviewed for being free of accident hazards (Resident #65). Resident #65 did not have a current order for oxygen use.

Inspectors wroteBased on observation, record review, Resident and staff interviews, the facility failed to follow a physician order for supplemental oxygen for 1 of 1 resident reviewed for respiratory care (Resident #38).

Inspectors wroteBased on record review, resident, staff, Registered Dietitian, and dialysis center Administrator interviews, the facility failed to serve breakfast or provide snacks before dialysis treatment for 2 of 3 resident reviewed for dialysis (Resident #140 and Resident #6).

Inspectors wroteBased on observations, record review and resident, staff and Medical Director interviews, the facility failed to secure medications stored at the bedside for 1 of 1 resident reviewed for medication storage (Resident #31).

Inspectors wroteBased on observation, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to provide care in a safe manner when Resident #71 was rolled out of her bed during incontinent care hitting the floor. Resident #71 was sent to the Emergency Department (ED) and diagnosed with a fracture of her left distal (away from the center) clavicle, a closed fracture of the second rib on the left side, and a large left-sided scalp hematoma. The facility also failed to conduct smoking assessments when Resident #117 was not assessed for smoking. The deficient practice occurred for 2 of 4 sampled residents reviewed for supervision to prevent accidents (Resident #71 and Resident #117).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to allow residents who had been assessed as a safe independent smoker the choice to smoke unsupervised for 2 of 3 residents reviewed for choices (Resident #114 and Resident #117).

Inspectors wroteBased on record reviews, and staff, Pharmacy Consultant and Medical Director interviews, the facility failed to protect the resident's right to be free from misappropriation of narcotic medications (Oxycodone) for 2 of 3 residents reviewed for misappropriation of property (Resident #2 and Resident #3).

Inspectors wroteBased on record review, observation and staff interviews, the facility failed to develop and implement care plan interventions for 2 of 5 residents reviewed for smoking (Resident #30 and Resident #159).

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to shave facial hair for 1 of 3 dependent residents reviewed for assistance with activities of daily living (ADL) (Resident #56).

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to arrange or coordinate podiatry care for 1 of 3 dependent residents reviewed for assistance with activities of daily living (ADL) (Resident #134).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 1 of 5 residents reviewed with urinary catheters (Resident #14).

Inspectors wroteBased on record review and staff and Pharmacist interviews, the facility failed to have an effective system and safeguards in place to prevent drug diversion when they did not ensure narcotic medications for discharged residents were secured for 2 of 3 residents (Resident #1 and Resident #271) reviewed for medication management. As a result, a total of 75 doses of Oxycodone (a narcotic medication) 5 milligrams (mg) were unaccounted for.

Inspectors wroteBased on record review, observations, and interviews with staff and the Pharmacist, the facility failed to store unused narcotics prescribed to Resident #122 and #271 in a separately locked, permanently affixed compartment. The narcotics for Resident #122 were stored in a pharmacy tote with a numbered zip lock tag and the doses for Rsdt #271 were placed in an unlocked desk drawer in the Unit managers office by the Nurse #2, the night shift supervisor. The Unit Manager's office was not always locked and several staff had keys to the office. On 5/1/2025, the Pharmacy identified that 45 doses of oxycodone, 5 milligrams, were missing for Resident #122 when they received the narcotic count sheet without the narcotic medication in the medication tote that was delivered to the pharmacy. [...]

Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of the use of continuous positive airway pressure (CPAP) machine for 2 of 3 residents whose MDS assessments were reviewed (Residents #1 and #2).

Inspectors wroteBased on record reviews, interviews with resident, staff, Nurse Practitioner (NP), and Medical Director, the facility failed to protect a resident from a significant medication error when on 10/18/24, Nurse #1, an agency nurse, administered the wrong medications to Resident #1. On 10/18/24, Nurse #1 administered Resident #1's prescribed medications during the morning medication pass and then later in the morning administered medications prescribed for Resident #2 to Resident #1. The wrongly administered medications included olanzapine (antipsychotic medication), lamotrigine (anticonvulsant medication), gabapentin (anticonvulsant medication), paroxetine (antidepressant medication), haloperidol (antipsychotic medication), and clonazepam (antianxiety medication). [...]

Inspectors wroteBased on record reviews, and interviews with staff, Nurse Practitioner (NP) and the Medical Director, the facility failed to protect a resident from non-significant medication errors for 1 of 3 residents reviewed for medication administration (Resident #1).

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the area surrounding 1 of 1 trash compactor remained free from garbage, refuse, and standing water.

Inspectors wroteBased on observations, record review, and staff interview the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey completed on 6/14/21. This was for 2 deficiencies that were cited in the area of Food Procurement, Store/Prepare/Serve-Sanitary (F812) and Infection Prevention & Control (F880) that were cited on the recertification survey on 6/14/21 and then recited on the current recertification and complaint survey of 2/15/24. The continued failure of the facility during two federal surveys showed a pattern of the facility's inability to sustain an effective Quality Assessment and Assurance Program.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure meal trays used to serve residents' meals were in good condition for 1 of 1 tray line observation. This practice had the potential for cross contamination of food from chipped and cracked meal trays.

Inspectors wroteBased on record review, staff interviews and resident interview the facility failed to provide the resident the opportunity to participate in the care planning process for 2 of 2 residents (Resident #31 and #8).

Inspectors wroteBased on record review, observation, staff, and resident interviews the facility failed shave facial hair for a female resident that was dependent on staff for activity of daily living (ADL) care needs in 1 of 5 residents (Resident #70) reviewed for ADL care.

Inspectors wroteBased on record review, observations, and staff interviews the facility failed to follow their policy regarding transmission-based precautions for 1 of 2 residents (Resident #93) reviewed for contact precautions. A nursing staff member, Nurse #2, entered Resident #93's room, who was on contact precautions, without the required Personal Protective Equipment (PPE) including gloves and a gown, she was observed to check the resident's blood pressure, touch the resident's clothing, touch the resident's bed linens, repositioned the resident's ventilator tubing, touched the side rails, and then proceeded to provide care to Resident #93's roommate (Resident # 58) without washing her hands or using hand sanitizer. Upon completion of providing care to Resident #93's roommate (Resident #58), Nurse #2 then exited the residents' room without washing her hands or using hand sanitizer.

Inspectors wroteBased on observation and staff interviews the facility failed to post accurate daily nurse staffing information for 3 of 7 days reviewed.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to provide care in a safe manner and failed to ensure fall mat was in place for 1 of 3 residents reviewed for accidents (Resident #1). Resident #1 sustained a fall from his bed after the Nurse Aide walked away after raising the height of the bed and failed to ensure the fall mat was placed next to his bed when she left to retrieve items from his closet. The fall resulted in a 6.5 centimeter laceration to the forehead, 2 centimeter laceration to the nose, 1.5 centimeter laceration to the upper lip, 1 centimeter laceration inside of the mouth, and an 8 millimeter parenchymal hematoma corresponding in location to a previous hematoma (Resident #1). The resident was sent to the Emergency Department and discharged the following day where he required sutures for his lacerations.

Inspectors wroteBased on record review and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions that the committee put into place following a complaint survey completed on 01/20/22 and a recertification and complaint investigation survey completed on 11/15/22. This was for one deficiency in the area of the supervision to prevent accidents and subsequently recited during the complaint survey dated 12/18/23. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance program.