Oak Brook Health Care Center

In the surveyor’s words

From the most serious findings on record at Oak Brook Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF678Feb 8, 2023

  Based on observation, interview, and record review, the facility failed to provide basic life support, including CPR, to residents requiring emergency care prior to the arrival of emergency medical personnel. There were no staff on the 11p-7a shift certified to provide CPR on 5 of 25 dates reviewed from [DATE] through [DATE]. ([DATE], [DATE], [DATE], [DATE], and [DATE]) On [DATE] at 8:30 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. […]

• Immediate jeopardy, isolatedF757Mar 9, 2023

  Based on observation, interview, and record review the facility failed to ensure the drug regimen was free from unnecessary medication for 1 of 4 residents reviewed for antibiotic medications. (Resident #1.) The facility failed to: 1. Ensure Resident #1 was not given medications that caused him to experience a serious allergic reaction. 2. Ensure Resident # 1's physician orders and MAR were reviewed prior to administration of a new medication. 3. Ensure they followed their medication administration policy. Resident #1 experienced an adverse drug interaction to (Bactrim) a medication his clinical records indicated he was allergic to. An Immediate Jeopardy (IJ) situation was identified on 03/07/23 at 5:05 p.m. […]

• No harm, potential for more than minimal, patternF576Jun 17, 2026

  Based on interview and record review, the facility failed to ensure residents were provided reasonable access to receive their mail in a timely manner for 1 of 8 confidential residents (Confidential Resident #1) reviewed for resident rights. The facility failed to implement a system to distribute incoming mail daily and ensure residents promptly received their mail. This failure could place residents at risk of a delay in residents' personal correspondence, financial information, or other time-sensitive materials. The findings included: During a confidential group interview at an undisclosed date and time, Confidential Resident #1 indicated they did not receive their package that was delivered on a Saturday. […]

• No harm, potential for more than minimal, patternF677Jun 17, 2026

  Based on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of five residents (Resident # 5, Resident #25) reviewed for quality of life. The facility failed to ensure Resident #5 and Resident #25 received showers and facial hair care. This failure could place residents at risk for poor hygiene, dignity issues, and a decline in quality of life. Findings included: 1. A record review of a face sheet dated 06/17/2026 indicated Resident #25 was a [AGE] year-old female who admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF755Jun 17, 2026

  Based on observation, interview, and record review, the facility failed to ensure medications were prepared and administered in a manner that prevented medication errors for 4 of 4 licensed nurse medication carts (Cart #1, Cart #2, Cart #3 and Cart #4) observed for controlled medications storage. The facility failed to Ensure MA (B) did not sign the controlled substance count sheets for the end of their shift at the beginning of their shift on Cart #1 and Cart #2, on 6/16/2026The facility failed to Ensure LVN C did not sign the controlled substance count sheets for the end of her shift at the beginning of her shift on Nurses Cart #3 and Cart #4, on 6/16/2026 These failures could place residents at risk of creating the potential for medication diversion, administration of incorrect… […]