Oak Park Place of Nakoma

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 23 residents who reside in the facility. Certified Nursing Assistant entered kitchenette 3 times without wearing a hair restraint during mealtime. Evidenced by:The facility policy, Hair Restraints, dated 7/13/25, states, in part;.Hair must be pulled back and properly restrained when working with exposed food, clean equipment, utensils, linens, and unwrapped single service and single use articles. On 1/20/26 at 12:15 PM, Certified Nursing Assistant D (CNA) entered kitchenette three times to get resident drinks. Surveyor observed hairnets to be available for all staff outside the kitchenette. CNA D indicated she knows she needs to wear a hairnet when going in the kitchen and kitchenette. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure garbage and refuse was disposed of properly. This has the ability to affect all 23 residents who reside at the facility. During the initial walk through of the kitchen Surveyor observed dumpster lids open, bag of garbage outside of dumpsters, food wrappers, gloves, and cardboard on the ground near the dumpsters. Evidenced by:The facility policy, Food-Related Garbage and Refuse Disposal, dated, 2017, states, in part;.Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. On 1/20/26 at 9:30 AM, during the initial walk through of the kitchen, Surveyor observed the facility dumpsters. The dumpster lids were open, a bag of garbage outside of dumpsters, food wrappers, gloves, and cardboard were on the ground near the dumpsters. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly. This practice had the potential to affect the census of 23 residents residing in the facility. The facility did not ensure the required members of the QAPI committee met at least quarterly in 2025. This is evidenced by:The facility's policy Quality Assurance and Performance Improvement (QAPI) Program, dated 2020, includes: This facility shall develop, implement, and maintain an ongoing, facility-wide, data-drive QAPI program that is focused on indicators fo the outcomes of care and quality of life for our residents. Authority 3. The administrator is responsible for assuring that this facility's QAPI program complies with federal, state, and local regulatory agency requirements. Implementation 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 3 of 12 sampled Residents (R2, R19 & R34) and 1 of 1 supplemental residents (R23). R2 was observed with long facial hair. R19 was observed with long facial hair. R23 reported that they were not receiving their showers and had long facial hair. R34 reported that they were not receiving their showers and had long facial hair. Evidenced by:The facility's policy titled Activities of Daily Living (ADL), Supporting dated 3/2018 states in part Policy statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). [...]

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 1 of 1 resident (R3) reviewed for transmission-based precautions. On 1/20/26 Surveyor observed staff entering and exiting R3's bedroom without wearing any PPE and sanitizing hands. R3 has a Contact Precautions sign hanging up outside of R3's bedroom. Evidenced by:CDC's (Centers for Disease Control and Prevention) most recent recommendations state;. Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission. Use personal protective equipment (PPE) appropriately, including gloves and gown. [...]

Inspectors wroteBased on record review and interview the facility did not provide the accurate Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) thus did not provide the accurate potential financial liability to residents whose Medicare coverage was ending for 3 of 3 residents reviewed (R21, R38, and R39). R21, R38 and R39 were not provided SNFABN letters regarding financial liability. Evidenced by:Example 1:R21 was receiving Medicare A benefits. R21's Medicare coverage ended on 1/13/26. R21 was not provided the SNFABN form thus not provided with the accurate financial liability. Example 2:R38 was receiving Medicare A benefits. R38's Medicare coverage ended on 1/8/26. R38 was not provided the SNFABN form thus not provided with the accurate financial liability. Example 3:R39 was receiving Medicare A benefits. R39's Medicare coverage ended on 12/16/25. [...]

Inspectors wroteBased on interview and record review, the facility did not follow their Discharge Planning Process for 3 of 3 residents (R1, R2, R3) reviewed for discharge planning. R1, R2, and R3 did not have a recapitulation of their stay after discharge. R3 did not have a discharge goal in his care plan. Evidenced by: The facility policy entitled Discharge Summary and Plan, dated 10/2022, states, in part: . Policy Statement: When a resident's discharge is anticipated, a discharge summary and post- discharge plan is developed to assist the resident with discharge. Policy Interpretation and Implementation: The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. 3. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure residents were assessed for self-administration of medications for one of four residents (Resident (R) 6) reviewed for self-administration of medications out of 12 sample residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure professional standards were in place for ensuring medication administered was not borrowed from another resident for one of six residents (Resident (R) 9) reviewed for professional standards and medication administration of 12 sample residents. This failure had the potential to affect the potential for negative outcome for 26 residents currently residing in the skilled nursing floor of the facility.

Inspectors wroteBased on interviews, record review, and review of professional standards of practice, the facility did not ensure that the services provided by nursing personnel met the professional standards of quality for 1 of 5 sampled residents (R1). R1 has diagnoses of CHF (congestive heart failure) and had orders for daily weight for monitoring of CHF. The facility did not monitor daily weights. Evidenced by:The facility policy entitled Weight Assessment and Intervention, dated 3/22, states, in part: . Policy Statement: Resident weights are monitored for undesirable or unintended weight loss or gain. Policy Interpretation and Implementation: Weight Assessment. 2. Weights are recorded in each unit's weight record chart and in the individual's medical record.3. any weight change of 5% or more since last weight assessment is retaken the next day for confirmation. a. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain acceptable parameters of nutritional status and consult with the residents Physician on this for 1 of 3 residents (R1) reviewed for nutrition. R1 had a severe weight loss of 15.3% in 2 months. The facility did not complete daily weights as ordered or notify physician. Evidenced by:The facility policy entitled Weight Assessment and Intervention, dated 3/22, states, in part: . Policy Statement: Resident weights are monitored for undesirable or unintended weight loss or gain. Policy Interpretation and Implementation: Weight Assessment. 2. Weights are recorded in each unit's weight record chart and in the individual's medical record.3. any weight change of 5% or more since last weight assessment is retaken the next day for confirmation. a. [...]

Inspectors wroteBased on interviews and record review, the facility did not ensure that the services provided by nursing personnel met the professional standards of quality for 5 of 6 residents (R5, R8, R9, R10 and R1). R5, R9, R10 and R1's vital signs were not completed as ordered. R8, was admitted to the facility with orders for daily vital signs. The facility did not complete these physician's orders as ordered and assess the Residents' vital signs daily. This is evidenced by: The facility policy entitled, Resident Examination and Assessment, dated 02/2014, states, in part: Purpose: The purpose of this procedure is to examine and assess the resident for any abnormalities in heath status, which provides a basis for the care plan . Physical Exam: 1. Vital Signs: a. blood pressure (standing and sitting); b. pulse (carotid); c. respirations; and d. temperature . Documentation: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that alleged violations are thoroughly investigated for 1 of 10 residents (R3) reviewed for abuse. R3's POA (Power of Attorney) voiced concerns and possible neglect during R3's stay from 11/1/24-11/4/24. NHA A (Nursing Home Administrator) initiated investigation, followed up with R3 and POA, but failed to interview other residents to ensure there were no other allegations or concerns. Evidence by: The facility policy, Abuse Neglect, Exploitation and Misappropriation Prevention Program, dated 2021, states, in part; .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. [...]

Inspectors wroteBased on interview and record review the facility did not ensure residents are free of any significant medication errors for 1 of 3 residents (R1) reviewed for medications. R1 had 8 medications not administered for a duration of time in December and January that could lead to significant negative outcome. This is evidenced by: The facilities Policy and Procedure entitled Administering Medications dated April 2019, documents, in part: .4. Medications are administered in accordance with prescriber orders, including any required time frame . The facilities Policy and Procedure entitled Adverse Consequences and Medication Errors dated February 2023, documents, in part: .Medication Errors 1. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure safe food handling practices were implemented. This had the potential to affect all 14 residents residing in the facility. Cook (CK)-F did not wear an appropriate hair covering. Raw meat was stored in a manner that had the potential to cross-contaminate other food items.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure medications were accurately labeled for 2 residents (R) (R10 and R3) of 2 residents observed during medication administration. In addition, the facility did not ensure medications for 4 (R2, R6, R120, and R1) residents in 1 of 1 medication cart were disposed of when beyond the expiration date. During observations of medication administration, Licensed Practical Nurse (LPN)-G administered open and undated medication to R10 and R3. The facility's medication cart contained open and undated medications for R2, R6, R120, and R1.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R14) of 1 resident reviewed for hospitalization received a transfer notice that included the date of the transfer, the reason for the transfer, the location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. R14 was transferred to the hospital on 8/10/24. Neither R14 or R14's emergency contact were provided with a written transfer notice.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R14) of 1 resident reviewed for hospitalization received the proper bed hold notice when transferred to the hospital. R14 was transferred to the hospital 8/10/24. The facility did not provide R14 or R14's emergency contact with a bed hold notice.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure a continuous positive airway pressure (CPAP) machine was cleaned per the facility's policy for 1 resident (R) (R7) of 1 sampled resident. R7 used a CPAP machine for obstructive sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts). Staff did not clean the CPAP machine per the facility's policy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R2) of 5 sampled residents was monitored for adverse reactions or side effects of a high-risk medication. R2 was prescribed lamotrigine (an anticonvulsant medication), and oxycodone (an opioid medication). R2's plan of care did not contain monitoring for adverse reactions or side effects of lamotrigine and oxycodone.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection. Staff did not sanitize equipment during the provision of care for 1 resident (R) (R2) of 1 resident. In addition, staff did not don appropriate personal protective equipment (PPE) during the provision of care for 1 (R7) of 1 resident. During an observation on 9/17/24, Licensed Practical Nurse (LPN)-G did not sanitize a blood pressure cuff before or after obtaining R2's blood pressure. During an observation on 9/18/24, LPN-J entered R7's room with a vitals machine and obtained R7's vital signs without donning a gown or gloves. R7 was on contact isolation precautions for Clostridium difficile (C. diff).

Inspectors wroteBased on staff interview and record review, the facility did not ensure pneumococcal vaccinations were reviewed, offered, or administered for 2 residents (R) (R12 and R10) of 5 sampled residents. The facility did not review R12's vaccination history or offer R12 the PCV20 (Prevnar 20) vaccine. The facility did not review R10's vaccination history or offer R10 the PCV20 vaccine.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a COVID-19 immunization was offered, declined, or administered for 2 residents (R) (R12 and R10) of 5 sampled residents. R12 and R10's medical records did not indicate the facility offered or administered COVID-19 immunizations.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the food was stored, distributed, and served in accordance with professional standards for food service safety. This has the potential to affect all 12 residents residing at the facility. -Surveyor observed four examples of improper hand washing/hand hygiene -Surveyor observed three examples of wet stacking (staking dishes while wet) during dishwashing process. -Surveyor observed three examples of food stored outside of professional standards for food safety. -Surveyor observed one example of kitchen equipment used to cook food to be dirty. -Surveyor observed the garbage and refuse containers to be improperly storing garbage and refuse, and garbage and refuse to be scattered on the ground of the garbage and refuse disposal area. This is evidenced by: [...]

Inspectors wroteBased on interview and record review, the facility did not maintain a Quality Assessment and Assurance Committee consisting of at a minimum, the Director of Nursing Services, the Medical Director or his/her designee, at least three other members of the facility's staff at least one of whom must be the administrator, owner, a board member or other individual in a leadership role, and the Infection Preventionist, which met at least quarterly. This has the potential to affect all 12 Residents residing within the facility. QAPI meetings did not consist of the required attendees/members for the month of October 2022, January 2023, March 2023, and April 2023. This is evidenced by: The facility policy entitled, Quality Assurance and Performance Improvement (QAPI) Program, dated February 2020, states, in part: . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that they have 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. This has the potential to affect the census of 12 residents. The facilities Legionella Water Management Program is incomplete. The facility was unable to show that they have been completing their reporting in National Healthcare Safety Network (NHSN). This is evidenced by: The facility's Policy and Procedure entitled Legionella Water Management Program dated 7/17, documents in part: .2. The water management team will consist of at least the following personnel: a. The infection preventionist; b. The administrator; c. The medical director (designee); d. The director of maintenance; and e. [...]

Inspectors wroteBased on interview and record review, the facility did not make prompt efforts to resolve resident grievances for 1 resident (R16) out of 8 residents reviewed for grievances, out of a total sample of 10 Residents. The facility did not investigate FM I's grievance regarding R16 receiving fish nor did the facility provide resolution for R16's Activated Power of Attorney for Healthcare (APOAHC). FM I also requested an updated copy of R1's care plan following a care conference meeting. The facility failed to provide the requested care plan to FM I. FM I stated the facility's lack of follow up lead to her decision to have R16 transferred to inpatient hospice. This is evidenced by: The facility Policy and Procedure, Grievance and Grievance Program, with a date of 2/17/23, includes, in part: [...]

Inspectors wroteBased on interview and record review the facility did not ensure that they had a system in place to maintain records showing that staff are qualified to perform cardiopulmonary resuscitation (CPR). This had the potential to affect 3 of 3 supplemental full code (means they would expect CPR to be started if they were pulseless and non-breathing) residents (R6, R115, and R65) of a total census of 12 residents. R6, R115, and R65 all opted to be a full code. This is evidenced by: The Facility's Policy and Procedure entitled Emergency Procedure- Cardiopulmonary Resuscitation dated 2/18, documents, in part: .6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Basic Life Support) shall initiate CPR .8. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 2 errors in 25 opportunities that affected 1 out of 4 residents (R11) out of a sample of 10 residents included in the medication pass task, which resulted in an error rate of 8%. R11 was administered an incorrect eye drop and an incorrect lidocaine patch. Evidenced by: The facility policy, entitled Administering Medications, dated April 2019, states, in part: . Policy Statement- Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders, including any required time frame . 10. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that the mandatory staffing data that had been submitted from 1/1/22-3/31/23 was complete, accurate, and auditable. This has the ability to affect the census of 12. The submitted data from 1/1/22-3/31/23 was not complete, accurate, or auditable. This is evidenced by: The Payroll Based Journal (PBJ) Staffing Data Reports that were generated quarterly document that the facility triggered for Failed to have Licensed Nursing Coverage 24 Hours/Day from 1/1/22-3/31/23 for specified dates. The specified dates are as follows: FY (Fiscal Year) Q2 (Quarter 2) 2022 ([DATE]-[DATE]): 1/2, 1/9, 1/14, 1/18, 1/22, 1/23, 1/27, 1/29, 2/4, 2/5, 2/6, 2/12, 2/19, 2/20, 2/21, 2/22, 3/1, 3/2, 3/3, 3/4, 3/9, 3/12, 3/15, 3/23, 3/27, 3/29 FY Q3 (Quarter 3) 2022 (April 1-June 30): [...]