Oak Park Oasis

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functioning Gastrostomy Tube (GT) was available for a GT resident to administer bolus feed and free water flush as ordered by the physician. The facility also failed to follow its Gastrostomy or Jejunostomy Feeding policy by not administering the GT free water flush before and after feeding as ordered by the physician. This applies to 1 of 2 residents (R3) reviewed for GT care in a sample of 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications within the expected timeframe. This failure affected five (R3, R5, R6, R8 and R9) residents reviewed for medication administration in the total sample of 9 residents.

Inspectors wroteBased interview and record review facility failed to follow its abuse prevention policy and did not prevent an incident of resident-to-resident abuse. This deficient practice affected two of three residents (R1 and R2) reviewed for abuse. This failure resulted in R2 directing a racially derogatory term at R1 and spitting on R1. R1 was unavailable for interview during the survey; however, based on the Reasonable Person Concept, a reasonable person in R1's situation would likely experience humiliation, emotional distress, fear, and a sense of being unsafe because of the incident. R1 is not available for observation or interview. R1 MDS dated [DATE] denotes BIMS score of 10 (cognitive impairment). [...]

Inspectors wroteBased on interview, observations, and record review the facility failed to ensure that resident floors are free from hazards. Water noted on the floor near door entry ways. Water was observed in a puddle with a white towel over it in R3's room entry way. This failure affected five residents (R3-R7) of 6 residents reviewed for safe environment.

Inspectors wroteBased on interviews and records reviewed the facility failed to ensure staff followed the facility practice of nurses not leaving the unit at the end of a shift without a relief. This failure resulted in the unit not having a nurse on unit for at least 1 hour. This failure has the potential to affect 36 residents residing on the unit.

Inspectors wroteBased on interviews and records reviewed the facility failed to follow their policy to provide Discharge Instructions and Medications to one resident (R1)upon her planned transfer from the facility to another skilled facility. This failure affected 1 of 3 residents reviewed for discharge/transfers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its Urinary Catheter Care policy to provide catheter care to residents. This applies to 3 of 4 residents (R2, R3, and R4) reviewed for indwelling catheter care in a sample of 4.1. R2 is an [AGE] year-old female admitted with moderate cognitive impairment as per the MDS dated [DATE]. On 7/16/25 at 9:00 AM, R2 was observed in her bed with an indwelling catheter bag with one-fourth urine placed flat on the bed. On 7/16/25 at 9:03 AM, V3 (Licensed Practical Nurse/LPN) stated that the indwelling catheter bag shouldn't be on the bed to prevent urine backflow, which could cause infection. A review of the indwelling catheter care plan document interventions including to position catheter bag and tubing below the level of the bladder. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to a high fall risk resident for one (R1) of four residents (R1, R2, R3 and R4) reviewed for falls in the sample of four. This failure resulted in R1's left hip fracture, emergent hospitalization, and subsequent left hip surgery.

Inspectors wroteBased on interview and record review, the facility failed to timely administer a PRN (as needed) pain medications for post fall onset of pain for a one of one (R1) resident reviewed for pain in the sample of four. This failure resulted in R1 having ongoing, unaddressed pain for 44 hours before R1 was hospitalized for left hip fracture, and subsequent surgery of the left hip fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to sanitary requirements by not following its own hair restraints policy when a dietary aide was found not wearing a hair restraint while inside the facility's kitchen. This failure has the potential to affect the quality of food served to all residents at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure diagnostic testing order was carried out and diagnostic testing results were reported in a timely manner for a resident with acute fracture for one of four (R1) residents (R1, R2, R3 and R4) reviewed for diagnostic testing in the sample of four.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to conduct a contraband search on one (R1) of three residents reviewed for contraband possession. This failure resulted in R1 falling and hospitalized with a diagnosis of opioid overdose, and laceration of right eyebrow.

Inspectors wroteBased on interview and record review the facility failed to notify the residents representative psychotropic medications were prescribed. This applies to 1 of 3 residents (R1) reviewed for resident rights in the sample of 4.

Inspectors wroteBased on interview and record review the facility failed to ensure prescribed medications were administered as ordered for 1 of 3 residents (R2) reviewed for medication administration in the sample of 4.

Inspectors wroteBased on interview, and record review the failed to ensure stop dates for residents with prn (as needed) psychotropic medications were in place for 2 of 3 residents (R1, R3) reviewed for psychotropic medications in the sample 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, comfortable, and homelike environment for 9 (R3, R4, R5, R6, R7, R8, R10, R11, and R12) of 12 residents reviewed for environment.

Inspectors wroteBased on interview and record review, the facility failed to notify a physician that a resident was not being administered a steroid topical ointment and an immunosupressive medication as ordered and missed 15 doses of the steroid topical ointment and 14 doses of the immunosupressive medication for one out of three residents (R1) reviewed for physician notification in a total sample of three. Findings Include: R1 is a [AGE] year old with the following diagnosis: rheumatoid arthritis, dermatomyositis, herpes vesicular dermatitis, and chronic ulcer of skin. On 2/26/25 at 11:30AM, R1 was only available by phone for interview due to being hospitalized at the time of the investigation. R1 stated R1 does not the get medication for R1's autoimmune disease. R1 was unable to remember the name of the medication but knew it started with an M. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer a topical steroid ointment and an immunosupressive medication as ordered causing the resident to miss 15 doses of the topical steroid ointment and 14 doses of the immunosupressive medication over a two month period for one resident (R1) out of three reviewed for medication administration in a total sample of three. Findings Include: R1 is a [AGE] year old with the following diagnosis: rheumatoid arthritis, dermatomyositis, herpes vesicular dermatitis, and chronic ulcer of skin. On 2/26/25 at 11:30AM, R1 was only available by phone for interview due to being hospitalized at the time of the investigation. R1 stated R1 does not the get medication for R1's autoimmune disease. R1 was unable to remember the name of the medication but knew it started with an M. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by not preventing a resident to resident physical assault. This affected two of three residents (R1, R2) both reviewed for physical abuse. This failure resulted in R1 being punched in the face and being transferred to the local hospital for evaluation

Inspectors wroteBased on interview and record review, the facility failed to develop a plan of care for a resident with a history of violent behavior. This affected one of three residents (R2) reviewed for care plans.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse and injury of unknown origin policy by not initiating and completing a thorough investigation of an injury of unknown origin reported to the facility by a resident's family member. This failure applied to one (R1) of three residents reviewed for injury of unknown origin investigations.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement enhanced barrier precaution protocol. The facility failed to observe appropriate infection control protocol in handling soiled linens. The facility failed to have measures in place to prevent the growth of legionella and other opportunistic waterborne pathogen in building water system. The facility failed to clean, disinfect medical equipment, and perform hand hygiene during Intravenous medication administration. These deficiencies have the possibility to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy and dignity to residents. This deficiency affects three (R65, R112 and R372) of three residents in a sample of 24 reviewed for residents right.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the care plan was updated to reduce the risk of falls for one of three residents (R77) reviewed for falls in a sample of 24.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care to dependent resident. This deficiency affects one (R110) of three residents in the sample of 24 reviewed for ADL (Activity of Daily Living) care.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician order in application for right hand splint to resident. This deficiency affects one (R110) of three residents in the sample of 24 reviewed for Restorative Nursing Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to have an order for tracheotomy tube size and oxygen usage in resident chart. The facility failed to ensure to have an accessible spare tracheostomy tube kit in case of emergency /accidental decannulation. The facility failed to ensure oxygen tubing is changed and dated weekly and as needed. This deficiency affects two (R110 and R372) of three residents in the sample of 24 reviewed for Respiratory Care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs. This deficiency affects one (R112) of one resident reviewed for intravenous medication administration in a sample of 24 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure completion of infection verification tool upon initiation of antibiotic using the McGeer's criteria. This deficiency affects one (R108) of three residents in the sample of 24 reviewed for Antibiotic Stewardship Program.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident from a potential sexual abuse by not monitoring a resident with a history of wandering from going into other resident rooms. This failure affected one (R1) of three residents reviewed for abuse.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedure for Involuntary Discharge by not demonstrating that the safety of individuals in the facility was endangered due to the clinical or behavioral status of a resident who was not permitted to return to the facility after hospital transfer and by not ensuring the required documentation for transfer or discharge was included in the resident's medical record. This failure applies to one (R2) of three residents reviewed for involuntary discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for a resident with dementia and a history of wandering by not ensuring that the resident was not wandering into resident rooms. This failure affected one (R1) of three residents reviewed for supervision.

Inspectors wroteBased on interview and record review, the facility failed to prevent a verbal argument from escalating to a resident to resident physical assault. This affected two of three residents (R1, R2) reviewed for resident to resident abuse in the sample of 8.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a dependent resident has clean and trimmed fingernails. This deficiency affects one (R49) of three residents in the sample of 23 reviewed for Activity of Daily Living (ADL) care.

Inspectors wroteBased on observation, interview and record review the facility failed to identify, assess/monitor, and report the presence of a stage 2 pressure ulcer, and failed to notify the physician for appropriate treatment. The facility also failed to implement pressure ulcer prevention interventions. This failure affects two (R49 and R80) of three residents in the sample of 23 reviewed for Pressure ulcer Prevention Management.

Inspectors wroteBased on observation, interview, and record review the facility failed to apply a resident's splint/brace as ordered by the physician and as indicated in the resident's restorative assessment and care plan to prevent further contractures. This deficiency affects two (R49 and R80) of three residents in the sample of 23 reviewed Limited Range of Motion.

Inspectors wroteBased on observation, interview and record review the facility failed to obtain physician order for indwelling catheter, the medical indication for usage and the care of the catheter. This deficiency affects one (R80) of three residents in the sample of 23 reviewed for Indwelling catheter management.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the Registered Dietician's recommendations and failed to notify the Physician for approval of the recommendations for 1 of 4 residents (R53) reviewed for nutrition in a sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their facility menu for 1 of 4 residents (R75) reviewed for menus in a sample of 23.

Inspectors wroteBased on interview and record review the facility failed to ensure coordination of care and communication between the facility and the hospice provider for 1 of 3 residents (R97) reviewed for hospice care in a sample of 23.

Inspectors wroteBased on observation, interview and record review the facility failed to wear appropriate Personal Protective Equipment (N95 mask, face shield, gown, and gloves) when entering a COVID isolation room, failed to change gloves and perform hand hygiene after providing incontinence care for a resident on COVID isolation precautions. This deficiency affects 3 residents (R49, R16 and R95) in the sample of 23 reviewed for Infection Control Management.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident identified to be at risk for abuse from a resident-to-resident sexual abuse. This affected one of three residents (R1) reviewed for resident-to-resident sexual abuse. This failure resulted in resulted in R1 feeling sad, scared, and powerless.

Inspectors wroteOn 1/10/2023 at 04:15 PM, surveyor observed R45 with V7 (Certified Nursing Assistant/CNA) sitting in his wheelchair in his room. R45 was observed with long dirty nails. R45 said that he wants his nails trimmed. On 1/10/2023 at 04:18 PM, V7 (CNA) said that R45's nails should be trimmed. On 1/12/2023 at 10:35 AM, surveyor observed R45 with V12 (Minimum Data Set/Restorative Registered Nurse/RN) in his room. R45 still had long dirty nails, and R45 said that he wants his nails to be trimmed. On 1/12/2023 at 10:37 AM, V12 said that the restorative CNA is supposed to trim the resident's nails. On 1/12/2023 at 10:39 AM, V10 (Restorative CNA) said that R45 should have his nails trimmed. On 1/12/2023 at 02:50 PM, V2 (Director of Nursing) said that the CNA should trim the residents' nails and if the residents' refuse, CNA should notify the nurse or DON. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to apply splint to residents with limited range of motion for five (R28, R45, R49, R60, R75) of five residents reviewed for range of motion in a sample of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the urinary catheter bag was covered for 1 of 7 resident (R38) reviewed for dignity in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide privacy during an injection administration for one (R57) of one resident observed for privacy in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide recommended communication board to one (R36) of one resident reviewed for communication in a sample of 26.

Inspectors wroteBased on observation interview and record reviewed, the facility failed to obtain wound care orders and develop and implement a wound care plan for 1 resident (R256) of 2 residents reviewed for wound care in a sample of 26. This failure resulted in R256 missing wound care treatments. Facility also failed to assess and treat 1 resident's (R39) foot wounds based on physician's orders.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that fall prevention interventions were in place for 1 of 7 residents (R18) reviewed for falls in a sample of 26.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate pain management for one (R100) out of six residents reviewed for pain management in a sample of 26.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the refrigerator temperature is monitored and maintained for one (R76) of one resident observed for food storage in a sample of 26.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing that includes facility name, date, census, and the total number and actual hours worked per shift for licensed and unlicensed staff responsible for resident care in an accessible area for visitors and residents to review. This failure effects all residents in the facility. Findings Include: On 1/10/2023 at 09:30 am, surveyor observed that the nurse staffing was not posted and easily accessible to the residents. On 1/10/2023 at 1:11 PM, V2 (Director of Nursing) said that nurse staffing is only in the binder by the front nurses station and not posted anywhere else. On/13/2023 at 03:30 PM, V1 (Administrator) said, So we are required to post it now. Facility was unable to provide a policy on posting nurse staffing in an accessible area for both visitors and residents.