Oakpark Healthcare Center

In the surveyor’s words

From the most serious findings on record at Oakpark Healthcare Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF605Apr 9, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF656Apr 9, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF755Apr 9, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF761Apr 9, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF812Apr 9, 2026

  Based 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. Findings: 1. During a concurrent observation and interview on 4/7/2026 at 10:41 a.m. with the Dietary Service Manager (DSM) in the dry storage room, the shelves in the refrigerator had rust with amber discoloration. […]