Oak Forest Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Oak Forest Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Nov 8, 2024

  Based on record reviews, interviews with resident, staff, Nurse Practitioner (NP), and Medical Director, the facility failed to protect a resident from a significant medication error when on 10/18/24, Nurse #1, an agency nurse, administered the wrong medications to Resident #1. On 10/18/24, Nurse #1 administered Resident #1's prescribed medications during the morning medication pass and then later in the morning administered medications prescribed for Resident #2 to Resident #1. The wrongly administered medications included olanzapine (antipsychotic medication), lamotrigine (anticonvulsant medication), gabapentin (anticonvulsant medication), paroxetine (antidepressant medication), haloperidol (antipsychotic medication), and clonazepam (antianxiety medication). […]

• Immediate jeopardy, isolatedF760Jun 14, 2021

  Based on record review and staff interviews, the facility failed to prevent a significant medication error when a medication aide failed to identify residents which resulted in 2 residents receiving the other one's medications (Residents #97 and #64) resulting in medication induced shock for Resident #97 requiring hospitalization and intravenous medications and fluids for 2 of 5 sampled residents reviewed for medication administration (Residents #97 and #64). Immediate jeopardy began on 5/22/21 when, during medication administration on the 400 hall, Medication Aide #1 administered Resident #97's medications to Resident #64 and Resident #64's medications to Resident #97 and was removed on 6/10/21 when the facility implemented a credible allegation of immediate jeopardy removal. […]

• Actual harm, patternF689Nov 15, 2022

  Based on record review, staff interviews, and nurse practitioner interviews, the facility failed to provide care in a safe manner and/or implement fall safety interventions developed and care planned by its interdisciplinary team (IDT) for 4 of 5 residents (Residents #2, #335, #7 and #132) reviewed for falls. Resident #2 sustained a fall from his bed that resulted in a fracture of the left femur neck requiring open reduction and internal fixation (surgical intervention). Resident #335 sustained a fall from his bed that resulted in a non-displaced fracture to his right femur that was conservatively managed (no surgical intervention). […]

• Actual harm, isolatedF689Jun 12, 2025

  Based on observation, record review, and staff and Nurse Practitioner (NP) interviews, the facility failed to provide care in a safe manner when Resident #71 was rolled out of her bed during incontinent care hitting the floor. Resident #71 was sent to the Emergency Department (ED) and diagnosed with a fracture of her left distal (away from the center) clavicle, a closed fracture of the second rib on the left side, and a large left-sided scalp hematoma. The facility also failed to conduct smoking assessments when Resident #117 was not assessed for smoking. The deficient practice occurred for 2 of 4 sampled residents reviewed for supervision to prevent accidents (Resident #71 and Resident #117). Findings included: 1. […]

• Actual harm, isolatedF689Dec 18, 2023

  Based on record review, observations and staff interviews, the facility failed to provide care in a safe manner and failed to ensure fall mat was in place for 1 of 3 residents reviewed for accidents (Resident #1). Resident #1 sustained a fall from his bed after the Nurse Aide walked away after raising the height of the bed and failed to ensure the fall mat was placed next to his bed when she left to retrieve items from his closet. The fall resulted in a 6.5 centimeter laceration to the forehead, 2 centimeter laceration to the nose, 1.5 centimeter laceration to the upper lip, 1 centimeter laceration inside of the mouth, and an 8 millimeter parenchymal hematoma corresponding in location to a previous hematoma (Resident #1). […]