Oakbrook Health and Rehabilitation

Inspectors wroteBased on interview and record review the facility did not implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the local law enforcement in accordance with state law through established procedures for 1 of 3 residents (R) reviewed (R1). On 05/02/26, the facility was made aware of R1's allegation of abuse. The facility did not report this allegation to local law enforcement within 2 hours. This is evidenced by:Facility policy titled, Resident safety Abuse Policy, with reviewed date of 03/24, states in part: 8. Reporting Suspected Violations: .e. [...]

Inspectors wroteBased on record review and interview, the facility did not implement policies and procedures for ensuring the reporting of physical abuse in accordance with section 1150B of the Act when an allegation of physical abuse was not reported immediately, but no later than 2 hours to the State Agency and local law enforcement in accordance with state law through established procedures for 1 of 3 residents (R) reviewed (R1). On 02/03/26, the facility was made aware of R1's allegation of abuse. The facility did not report this allegation to State Agency (SA) or to local law enforcement within 2 hours. This is evidenced by:Facility policy titled, Resident safety Abuse Policy, with reviewed date of 03/24, states in part: 8. Reporting Suspected Violations: .e. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections which has the potential to affect all 39 residents.-R44 has open wounds with no Enhanced Barrier Precautions (EBP) in place.-RN I returned to work too soon after illness.-Inappropriate hand washing/gloving during cares (R2). Example 1 The facility protocol titled, Infection Prevention and Control Program, last revised 01/26, reads in part: During an infectious disease outbreak, facility staff along the with medical director will follow prevailing infectious disease protocol at the time-as directed by local or state health agencies or the Centers for Disease Control and Prevention (CDC). [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the accuracy of assessment related to Minimum Data Set (MDS) for 1 of 1 resident reviewed (R1). R1 had a Preadmission Screening and Resident Review (PASARR) 1 and 2 completed, which the MDS assessment did not reflect. R1 was admitted to the facility on [DATE]. Surveyor reviewed R1's health record. PASARR 1 was completed upon admission dated 03/01/24. PASARR 2 was completed on 03/13/24. Surveyor reviewed R1's MDS assessments. The annual MDS on 03/01/24 indicated R1 did not have a PASARR 1 completed. A correction was made to reflect that R1 did in fact have both PASARR 1 and 2 completed. Upon further review, the MDS assessments completed after the correction had the previous information stating R1 did not have either PASARR completed. On 01/28/26 at 2:46 PM, Surveyor interviewed Social Worker (SW) D. [...]

Inspectors wroteBased on record review and interview, the facility did not ensure to follow their antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 resident (R36) reviewed. This is evidenced by:Facility's policy titled Infection Prevention and Control Program revised date of 08/25 documented in part. 9. Antibiotic Stewardship. A. The facility follows the current CDC guidelines for Preventing Antimicrobial Resistance among Long-Term Care Facility Residents and has adopted facility-specific protocols (i.e. see Urinary Tract Infection Protocol) for certain high antibiotic-use infections. B. Additional antibiotic use protocols and systems to monitor antibiotic use: i. Antibiotic prescribing will include documentation of the dose (including route), duration (i.e. [...]

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to protect Resident #3's right to be free from repetitive verbal and mental abuse perpetrated by another resident (Resident #1). Specifically, Resident #1 yelled at their roommate, Resident #3, to shut up, shut their mouth, or stop talking on multiple occasions. This deficient practice affected 1 of 13 sampled residents.

Inspectors wroteBased on interview, record review, and facility document and policy review, the facility failed to ensure a care plan was developed to address ongoing verbal behavioral symptoms directed toward others for 1 (Resident #1) of 13 sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for 1 of 32 residents (R) reviewed for abuse (R2). Registered Nurse (RN) C verbally abused R2 by yelling and swearing at R2 while wheeling R2 down the hallway in the wheelchair. Facility did not ensure interventions were in place to ensure verbal abuse did not occur to nonverbal, vulnerable residents. This is evidenced by: Facility's policy titled Facility policy titled: Resident Safety Abuse policy, dated 2/22, states in part, under Section titled Protocol: states in part, 2. Application (a) the policy is regarding resident safety has application in the manner in which: .v. The staff members are supervised. R2 was admitted to the facility on [DATE] with diagnoses that include dementia and aphasia. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure a thorough investigation was conducted of a staff to resident verbal abuse. The facility did not conduct a thorough investigation to ensure other residents have not been affected by abuse or have knowledge to prevent further potential abuse by Registered Nurse (RN) C for 1 of 32 residents (R2).

Inspectors wroteBased on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) assessments for 2 of 13 residents (R) reviewed. (R1 and R27) R1's MDS assessment is coded in error stating that a PASARR level 2 screen had not been completed when it was completed at the time of assessment. R27 receives hospice services; the MDS assessments were not coded for hospice service. This is evidenced by: Example 1 R1 was admitted to the facility on [DATE] with diagnoses including schizophrenia effective disorder, and anxiety. Review of R1's medical record found a PASARR level 2 screen was completed, dated 03/01/24. R1's admission MDS assessment, dated 03/07/24, indicated for question A1500 that no PASARR level 2 had been completed. [...]