Oakpark Healthcare Center

Inspectors wroteBased on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 24) was free from unnecessary (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use of psychotherapeutic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures by failing to ensure: 1. Resident 24 had specific target behaviors monitored related to the use of quetiapine (antipsychotic [a psychotherapeutic medication used to treat mental illness]), between 12/11/2025 and 4/8/2026. 2. Resident 24 did not have duplicate (more than one [1]) medication treatment with the use of quetiapine and Nuplazid (an antipsychotic used to treat mental illness,) between 12/11/2025 and 4/8/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document outlining a detailed approach to care customized to an individual resident's need) for 3 out of 5 sampled residents (Residents 3, 15, and 40) when: a. Resident 3's care plan did not indicate the behavioral manifestations of the resident's anxiety. This deficient practice had the potential to result in Resident 3 not receiving the appropriate care and services for his diagnosis of anxiety. b. The injection site during administration of enoxaparin sodium solution (commonly known by the brand name Lovenox, a medication used to prevent and treat harmful blood clots) to Resident 15 was not documented as being rotated. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) one (1) medication emergency kit(s) ([eKIT - kit containing medications needed to be used during emergencies]) containing ([CS - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics or Controlled Medication [CM]) for April 2026, in one (1) of one (1) inspected medication rooms (Medication Room 1.) 2. Reconcile three (3) medication eKITs containing CSs for April 2026, in one (1) of two (2) inspected medication carts (Medication Cart South.) 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label one (1) Rocklatan (a medication used to treat glaucoma [a condition of increased pressure in the eyeball]) eye drop bottle (medication stored in a plastic container) for Resident 9, with an open date in accordance with facility requirements and manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart East.) 2. Label one (1) latanoprost (a medication used to treat glaucoma eye drop bottle for Resident 30, with an open date in accordance with facility requirements and manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart South.) 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. The shelves in a refrigerator in the kitchen storage room were rusted. 2. A cook was wearing a bracelet while handling food. These failures had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 47 of 48 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for one of two residents (Resident 15) reviewed under the hospitalization care area by: 1. Failing to ensure licensed nurses accurately documented the injection site in the MAR during administration of enoxaparin sodium solution (commonly known by the brand name Lovenox, a medication used to prevent and treat harmful blood clot). 2. Failing to ensure licensed nurses accurately documented the injection site and blood sugar value in the MAR during administration of Insulin Glargine Solution (a long acting la-made insulin used to treat diabetes mellitus [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing]). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label one (1) Rocklatan (a medication used to treat glaucoma [a condition of increased pressure in the eyeball]) eye drop bottle (medication stored in a plastic container) for Resident 9, with an open date in accordance with facility requirements and manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart East.) 2. Label one (1) latanoprost eye drop bottle for Resident 30, with an open date in accordance with facility requirements and manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart South.) 3. Store one (1) latanoprost eye drop bottle for Residents 45, in accordance with the manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart South). [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when one of two sampled residents (Resident 15) reviewed under the hospitalization care area, did not receive enoxaparin sodium solution (commonly known by the brand name Lovenox, a medication used to prevent and treat harmful blood clots) as ordered by the physician. This failure in lack of timely notification had the potential to result in delayed care and treatment which had the potential to increase the risk of blood clots, such as deep vein thrombosis (DVT-a serious condition where a blood clot forms in a deep vein, usually in the legs, causing pain, swelling, warmth, and redness) to Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for one out of four residents (Resident 24) investigated under the Environment task when the padding covering the resident's side rail (adjustable rigid plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) was ripped. This deficient practice created the potential for Resident 24 to experience an unsanitary and uncomfortable environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of five (5) sampled residents' (Resident 24) Minimum Data Set (MDS, a standardized assessment and care-screening tool) accurately reflected the resident's behavior indicators for psychosis (a mental health condition where a person loses touch with reality, making it difficult to distinguish what is real from what is not). This deficient practice had the potential to result in incorrect plan of care, services, interventions and psychotherapeutic (any medication capable of affecting the mind, emotions, and behavior) medications for Resident 24.

Inspectors wroteBased on interview and record review, the facility failed to document the presence or absence of seizure (a sudden, uncontrolled burst of electrical activity in the brain that disrupts normal brain function) activity and failed to monitor for complications associated with anti-seizure medications for one of one sampled resident (Resident 40). These deficient practices had the potential to delay the timely identification of changes in Resident 40's condition, which could result in delayed interventions and adverse outcomes.

Inspectors wroteBased on observation, interview and record, the facility failed to provide an environment that is free from accident hazards for one of one sampled resident (Resident 40) by failing to provide a padded side rail to Resident 40, who has a diagnosis of epilepsy (chronic neurological condition characterized by recurrent, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain, causing changes in behavior, consciousness, movements, or feelings])This deficient practice placed the resident at increased risk for injury and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a window screen did not have a gap that may be a potential entry point of insects into a shared resident room affecting two of four residents (Residents 19 and 38) investigated under the Environment task. This deficient practice created an entry point and access for insects to get inside the building which can potentially transmit insect borne illnesses and negatively affect the residents' quality of life.

Inspectors wrotec. During a review of Resident 37's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 6/7/2024 and readmitted on [DATE], with diagnoses including unspecified dementia (a progressive state of decline in mental abilities), difficulty in walking, dysphagia (difficulty swallowing), and epilepsy (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 37's Minimum Data Set (MDS- a resident assessment tool) dated 3/29/2025, the MDS indicated the resident`s cognitive skills (the brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a resident who was at high risk for falls had floor mats (a cushioning pad placed by a resident's bed to absorb the force of a resident falling) as ordered by the physician for one out of four sampled residents (Resident 36) investigated for accidents and hazards. 2. Implement accident risks and hazard intervention by failing to place a personal alarm (a device with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) on a resident`s wheelchair as ordered by the physician for one of four (Resident 21) reviewed under accidents care area. This deficient practice had the potential to place Resident 21 at risk for recurrent falls and injuries. 3. [...]

Inspectors wrote2.c. During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 1/22/2021 and readmitted the resident on 7/17/2023 with diagnoses including compression fracture of second lumbar vertebra (condition when second bone [one of the vertebrae] has collapsed or broken, making it shorter than normal), paroxysmal atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%), due to 10 medication errors observed out of 41 total opportunities (error rate of 24.39 %) affecting two of five randomly selected residents (Resident 151 and Resident 25). The medication errors were as follows: 1. Licensed Vocational 3 (LVN 3) administered Resident 151 carvedilol (a medication used to treat hypertension [HTN-high blood pressure]) and pancrelipase (a medication to improve digestion of foods in adults who cannot digest food normally) at the time specified by the physician's order 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection sites for Resident 4. This deficient practice had the potential for adverse effect (unwanted, unintended results) of same site subcutaneous (SQ- injecting in the fatty layer of the skin) administration of insulin such as bruising, pain, and lipodystrophy (lump or accumulation of fatty tissue under skin). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety by not labeling: a. two boxes (24 count) of ice cream open on 4/17/2025 with use by date and expiration date. b. one gallon of sweet relish with use by date c. one gallon of creamy Italian Dressing with use by date d.one gallon of whole egg mayonnaise with use by date e. 1 pound of unsalted margarine with use by date and expiration date. These deficient practices had the potential for 45 out of 46 residents in the facility to be at risk for food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure Certified Nursing Assistant (CNA 3) was wearing an isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) while dressing a resident in the resident's room for one of five sampled residents (Resident 36) who were on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce exposure to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 1 (LVN 1) knocked on a resident's door before entering the room for one (Resident 25) out of one sampled resident investigated under the care area of dignity. This deficient practice violated the resident's right to be treated with respect and dignity, which had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for one of five sampled residents (Resident 36) addressing Resident 36 being positive for extended spectrum beta-lactamase (ESBL- enzymes [proteins that help speed up metabolism] produced by bacteria that make them resistant to antibiotic) producing Escherichia coli (E. coli- type of bacteria that can cause food-borne illness [food poisoning]). This deficient practice had the potential to result in failure to deliver the necessary care and services.

Inspectors wroteBased on interview, and record review the facility failed to update and revise a resident`s care plan (a document outlining a detailed approach to care customized to an individual resident's need) after a change of condition (COC-an improvement or worsening of a patient`s condition which was not anticipated) on 3/4/2025, for one of three sampled residents (Resident 21) reviewed under the Accidents care area. This deficient practice had the potential to result in Resident 21 receiving inadequate care and supervision at the facility.

Inspectors wrote2. During a review of Resident 16's admission Record, the admission Record indicated the facility admitted the resident on 1/22/2021 and readmitted the resident on 7/17/2023, with diagnoses including compression fracture of second lumbar vertebra (condition when second bone [one of the vertebrae] has collapsed or broken, making it shorter than normal), paroxysmal atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of three sampled residents (Resident 2). This deficient practice had the potential to delay the provision of services and resident's needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity and respect in full recognition of their individuality by staff members by failing to knock prior to entering a resident's room for three of three sampled residents (Resident 29, 30, and 33). This deficient practice had the potential to affect Resident 29, Resident 30, and Resident 33's self-esteem and self-worth. a. [...]

Inspectors wroteBased on interview and record review, the facility to implement their policy and procedure for resident council (a group of nursing home residents who meet regularly to discuss their rights, quality of care, and quality of life) by failing to ensure residents had a private space to conduct resident council meetings for five of five sampled residents (Resident 11, 12, 39, 38, and 4). This deficient practice had the potential of violating residents' rights of holding a resident council meeting privately.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) opioid pain medication (a class of drugs that are used to treat moderate to severe pain) for one of 14 sampled residents (Resident 43). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure licensed nurses administered blood pressure (the force of blood pushing against the walls of the arteries) medications within prescribed parameters (a set of defined limits) for one of 14 sampled residents (Resident 16). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from the medication. 2. Ensure the Medication Count Sheet (MCS- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR, a report detailing the drugs administered to a patient by the licensed nurses) for one of 14 sampled residents (Resident 5). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for one of 14 sampled residents (Resident 16). This deficient practice had the potential to cause a delay in resident care and for the resident's needs to remain unmet.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy on changes of condition (COC- a sudden clinically important deviation from a resident's baseline in physical, cognitive [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses], behavioral, or functional domains) by failing to notify a resident's responsible party (RP) and the resident's physician after a fall incident for one of three sampled residents (Resident 30). This deficient practice had the potential outcome to have had a negative effect on Resident 30's treatment if any decisions were needed at the time of the change of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the window screen was affixed to the frame and did not have any gaps or openings from top to bottom for one of 18 resident rooms (Room A). This deficient practice had the potential to result in insect infestation (a large number of animals or insects that carry disease) that could pose harm to the residents.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a written document that summarizes a resident's needs, goals, and care/treatment) for antibiotic (medicines that fight infections caused by bacteria) use for one of two sampled residents (Resident 6). This deficient practice had the potential to result in failure to deliver the necessary care and services.

Inspectors wroteb. A review of Resident 33's admission Record indicated the facility admitted the resident on 6/23/2020 and readmitted the resident on 6/12/2024 with diagnoses that included heart failure (a condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), difficulty in walking, and history of falling. A review of Resident 33's MDS dated [DATE], indicated that Resident 33's cognitive skills for daily decision making were moderately impaired. The MDS indicated that Resident 33 required partial/moderate assistance with oral hygiene, upper body dressing, and personal hygiene. The MDS also indicated Resident 33 required substantial/maximal assistance with toileting hygiene and shower. [...]

Inspectors wroteDuring an interview and record review, the facility failed to implement the facility's fall policy, by failing to ensure a post-fall evaluation was conducted for two of two sampled residents (Resident 29 and Resident 30). This deficient practice placed the residents at risk of not receiving appropriate care and services after a fall incident.

Inspectors wroteBased on interview and record review, the facility failed to complete a post-dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of two sampled residents (Resident 5). This deficient practice placed Resident 5 at risk for complications of dialysis such as redness at the dialysis access site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions).

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control practices by failing to: 1. Ensure Certified Nursing Assistant 4 (CNA 4) donned (put on) gloves, gown, and goggles prior to entering a droplet isolation room (used to prevent the spread of pathogens that are passed through respiratory secretions) for one of three sampled residents (Resident 33). This deficient practice had the potential for the spread of infection and cross contamination among residents. 2. Ensure a resident's nasal cannula (a medical device that provides supplemental oxygen or increased airflow to people who need respiratory help) was not touching the floor for one of 14 sampled residents (Resident 25). This deficient practice had the potential to place the resident at increased risk of contracting an infection.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure by failing to monitor one of two sampled residents (Resident 2) after a fall incident. This deficient practice placed the resident at risk of not receiving appropriate care and services and the potential to result in undetected pain or injury after a fall incident.