Oakbrook Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jul 15, 2025

  Based on interview, record review, and review of facility policy, the facility failed to provide appropriate supervision for Resident (R)1, resulting in R1 successfully eloping from the facility on 06/22/25.On 07/15/25 at 1:51 PM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations had caused or was likely to cause serious injury, serious harm, serious impairment, or death.On 07/15/25 at 1:55 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility that IJ existed as of 6/22/25. The IJ was related to 42 CFR 483.25 - Free of Accident Hazards/Supervision/Devices.On 07/15/25 at 4:17 PM, the facility provided an acceptable IJ Removal Plan. […]

• Actual harm, isolatedF693Feb 11, 2025

  Based on review of the facility policy, record review, observations, and interviews, the facility failed to ensure Resident (R)281 received prescribed tube feeding for 1 of 1 resident receiving tube feeding. This failure caused R281's blood sugar levels to drop, warranting additional orders needing to be obtained to increase his blood sugar to an acceptable level. Findings include: Review of the facility policy titled, Enteral and Parenteral Feedings, with a complete revision of May 5, 2023 revealed Nutritional complete enteral (tube) feedings may be indicated for residents who are unable to obtain adequate nutritional intake orally or whose clinical condition demonstrates that enteral feedings are unavoidable. Obtain a physicians order for all enteral feedings. […]

• Actual harm, isolatedF697Feb 11, 2025

  Based on review of the facility policy, record review, observation, and interview, the facility failed to ensure Resident (R)58 was free from significant pain for 1 of 2 residents reviewed for pain. Findings include: Review of the facility policy with a complete revision date of May 5, 2023 titled, Pain Management revealed that Pain can be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Pain is whatever the experiencing person says it is, existing whenever the experiencing person it does. Negative verbalizations and vocalizations, groaning, crying, whimpering or screaming. Facial expressions, grimacing, frowning, fright or clenching the jaw. […]

• No harm, potential for more than minimal, widespreadF727May 5, 2026

  Based on interviews, record review, and facility policy, the facility failed to ensure adequate Registered Nurse (RN) coverage for 4 of 31 days in October 2025; 7 of 30 days in November 2025; and 3 of 31 days in December 2025, totaling 14 days during these 3 months/quarters. This failure has the potential to affect all resident quality of care outcomes that residents experience. Findings include: Record review of facility policy titled Leadership Policies and Procedures, Staffing last revised 11/01/17 revealed The facility's leadership will provide sufficient staff to successfully implement patient/resident focused functions. […]

• No harm, potential for more than minimal, widespreadF761May 5, 2026

  Based on review of the facility policy, observations, and interviews, the facility failed to remove expired medications, and label open medications in 3 of 4 medication carts and 1 of 2 medication rooms. Review of the facility policy, Pharmacy Services Policies and Procedures: Section 8 - Medication Storage with a revision date of 04/17/24, revealed, 7. Once any multi-dose packaged medication or biological is opened, nursing will mark multi-dose products (e.g. inhalers, insulin, ophthalmics, otics, and the like) with the date opened and follow the manufacturer/supplier guidelines with respect to expiration dates, and 12. Outdated, contaminated, or deteriorated medications. […]