Oakpark Health and Rehabilitation Center

Inspectors wroteBased on interviews and record reviews, the facility did not ensure one resident (#1) out of three residents reviewed received appropriate treatment and services for mental disorders to attain the highest practicable mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide a sufficient number of certified nurse assistants (CNAs) for four night shifts (4/6, 4/12, 4/26, and 6/21) of the twenty-seven night shifts reviewed.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to ensure skin checks were completed for three Residents (# 6, #14, #35) out of eight residents sampled for skin integrity.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure post fall interventions were implemented to prevent future falls for four residents (#20, #78, #138, #149) out of seven residents sampled for falls.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide sufficient staffing to meet the needs of the residents related to dining and Activities of Daily Living (ADL) assistance with meals for three residents (#134, #50, and #168) observed in the dining room during three days (12/8/2025, 12/9/2025, and 12/10/2025) of three days dining was observed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure proper infection control practices were implemented related to: 1) personal protective equipment (PPE), contact precautions, hand hygiene, soiled linen, and resident bathrooms on two out of three resident units observed; and 2) failed to properly sanitize the heel protector boot for one resident (#2) out of thirty-three sampled residents. Findings Included: An observation was conducted on 12/8/25 at 9:56 a.m. of the 100 unit shower room. The shower room was observed to have dirty linens in a pile on the floor, hanging on the shower chair, and on the rails in the shower. A Certified Nursing Assistant (CNA) was observed wheeling a resident into the shower room to have a shower prior to it being cleaned. An observation was conducted of the 100 hall lunch service on 12/8/25 at 12:18 p.m. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain essential facility equipment in a clean and safe manner within the resident environment related to 1) failing to ensure the Packaged Terminal Air Conditioners (PTAC) system filters were clean and free of debris for four resident room PTAC systems (rooms 364, 266, 272, and 210) out of seven systems observed; 2) failing to ensure the PTAC system was free from leaks in one resident room PTAC system (room [ROOM NUMBER]) out of the seven systems observed; and 3) failing to ensure the ice machines were free of bio growth in one unit ice machine (300 unit) out of four ice machines observed.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to maintain and promote dignity for two of seventy-nine sampled residents (#134 and #13), related to: 1. Staff leaving resident with meal tray in front of her for long periods of time without assistance, and leaving resident and table soiled with liquid and food for long periods of time during four of four meals observed on 12/08/2025, 12/09/2025, 12/10/2025, and 12/11/2025; and 2. Not providing or assisting with provision of clothing leaving resident to wear hospital gowns every day.

Inspectors wroteBased on interviews and record review, facility did not ensure a resident representative was contacted immediately upon a change in condition for one resident (#178) out of three residents reviewed for change of condition.

Inspectors wroteBased on observations, interviews and facility policy, the facility failed to report an allegation of abuse for two (2) residents (# 20, #166) out of five (5) residents sampled.

Inspectors wroteBased on interviews and record review the facility did not ensure preadmission screening for mental disorders was completed accurately for three residents (#3, #149, and #88) out of thirty-three sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide two of seventy-nine sampled residents, (#134 and #153) with Activities of Daily Living tasks to include 1. lack of Eating assistance during three meal observations and 2. lack of assistance with getting out of bed.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to maintain the use of a heart monitor per physician orders for one Resident ( # 138) out of twenty-four residents sampled.2- An observation was conducted on 12/8/25 at 11:57 a.m. of Resident #138's room. On the bedside table there was a round silver metal device with what appeared to be electrodes on a adhesive bandage. The resident was not present in the room at the time. Review of admission Records showed Resident #138 was admitted on [DATE] with diagnoses including essential hypertension, paroxysmal atrial fibrillation and syncope and collapse. Review of Resident #138's orders showed:12/4/25-Do not remove heart monitor. Cardiorenal vision will remove in 14 days. Press button on patient chest if he has a syncopal episode. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide sufficient staffing to adequately meet the residents' needs for nine residents (#131, #117, #26, #147, #144, #80, #72, #537, and #128) out of 63 residents sampled. Findings Included: 1. On 7/30/2023 at 9:10 a.m., an interview was conducted with Resident #131's family member. The family member said the 11:00 p.m.-7:00 a.m. shift was constantly understaffed, which had an impact on Resident #131 because he was always wet when she visited him in the morning. She said that she visited him before the morning shift started their assigned shift, so she knew that it was the night shift who left the resident wet. A review of the staffing assignment sheet, dated 7/30/2023, revealed Staff K, Registered Nurse (RN) worked as a nurse and a Certified Nursing Assistant (CNA) on the 11:00 p.m.-7:00 a.m. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for four residents (#112, #286, #288, #42) of 30 residents sampled for PASARR Level II.

Inspectors wroteBased on observation, resident interview, and record review, the facility failed to 1. provide treatment and services to maintain or improve functional abilities for activities of daily living for one resident (#112) of two residents sampled and 2. failed to assist with meals and offer alternatives for one resident (#74) of seven residents sampled who required assistance with meals.

Inspectors wrote4. A review of Resident #40's admission Record showed diagnoses of ataxic gait, unspecified dementia, anemia, essential hypertension, history of falling, sarcopenia, weakness, atherosclerotic heart disease, and other symptoms and signs of concerning food and fluid intake. Review of the active physician orders as of 8/2/23 showed a physician order, dated 01/31/23, showed, Escitalopram Oxalate Tablet 5 mg- Give 5 mg by mouth one time a day for depression give with 10 mg to equal dose of 15 mg. A second physician order, dated 01/31/23 showed, Escitalopram Oxalate Tablet 10 mg- Give 10 mg by mouth one time a day for depression give with 5 mg to equal dose of 15 mg. A third physician order, dated 11/02/22 showed, Buspirone HCI Oral Tablet 5 mg- Give 5 mg by mouth two times a day for anxiety. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty-five medication administration opportunities were observed and four errors were identified for two residents (#186 and #95) of six residents observed. These errors constituted a 11.43% medication error rate.

Inspectors wroteBased on observation, interview, record review, and Centers for Disease Control and Prevention (CDC) recommended infection control guidelines, the facility failed to ensure infection control practices during an active COVID-19 facility outbreak were followed related to 1) donning of personal protective equipment (PPE) prior to entering designated COVID-19 person under investigation (PUI) rooms (307, 312, and 357); and 2) ensuring all direct care staff wore a well-fitted face mask while inside of the facility on two (300 hall and East Wing) of three hallways observed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure care plan interventions and physician orders were followed related to implementing contact precautions for one (Resident #347) of three residents sampled.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-seven medications were observed, and fifteen late medications were verified for three (3) (Resident #51, # 295 and #347) of eight (8) residents observed. These late medications constituted a medication error rate of 55.56 percent.

Inspectors wroteBased on observation, interviews, and policy review, the facility failed ensure 1) removal of expired medications from one (Med Bridge Hall) of two medication storage rooms observed; and 2) medications were secured in one (Medication Cart A, East Wing) of five medication carts observed.

Inspectors wroteBased observations, interviews, and record review the facility failed to ensure coordination among departments which resulted in the failure of the facility's food and nutrition services system for accommodation of food choices and preferences for two (Residents #141 and #70) out of six sampled residents.