Inspection Reports for American House Oak Park

IL, 60302

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Deficiencies per Year

4 3 2 1 0
2024
2025
Severe High Moderate Low Unclassified
Inspection Report Complaint Investigation Deficiencies: 4 Aug 25, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of abuse and failure to uphold personnel standards at American House Oak Park.
Findings
The facility failed to ensure staff upheld standards of conduct, resulting in verbal and physical altercations between staff and residents, including an incident of abuse involving resident R1. The facility also failed to follow service plans for residents and did not report the abuse allegation to the state agency within the required timeframe.
Complaint Details
The complaint investigation involved allegations of physical and verbal abuse by staff member E6 towards resident R1 during incontinence care on 8/19/25. The incident included physical altercations and verbal insults. Staff E5 reported the incident but the facility failed to notify the state agency within 24 hours as required. Resident R1 was sent to the hospital with no trauma found. Staff involved were suspended. The investigation found failure to uphold standards of conduct and failure to follow service plans.
Deficiencies (4)
Description
Failure to ensure employees uphold their Standards of Conduct affecting one resident (R2).
Failure to follow service plan intervention for one resident (R1) resistive to care, resulting in combative behavior towards staff.
Failure to ensure a resident was free from abuse and follow Abuse Policy and procedure, affecting one resident (R1).
Failure to notify the Department within 24 hours of an allegation of abuse affecting one resident (R1).
Report Facts
Incident time: 1 Resident age: 59 Resident age: 95
Employees Mentioned
NameTitleContext
E5Resident AssistantNamed in abuse and conduct incident involving resident R1 and R2.
E6Certified Nursing AssistantNamed as alleged perpetrator of abuse towards resident R1 and involved in conduct issues with resident R2.
E3Memory Care DirectorProvided statements regarding resident R1's condition and staff conduct.
E7Certified Nursing AssistantWitnessed and reported staff altercation involving resident R1.
Z1Agency NurseCalled to assist with resident R2 and involved in incident report.
E4Business Office ManagerReported suspension of staff E5 and E6 due to argument in front of residents.
E2Wellness DirectorReported that abuse allegation was not timely reported to state agency.
Inspection Report Complaint Investigation Census: 56 Deficiencies: 3 Jun 29, 2025
Visit Reason
Complaint investigation triggered by allegations of physical abuse and failure to conduct background checks prior to employee start dates.
Findings
The facility failed to conduct required background checks prior to employee start dates for three employees, potentially affecting all 56 residents. Additionally, the facility failed to keep two residents free from physical abuse, resulting in one resident sustaining a black eye and another a skin tear. The facility also failed to timely report the abuse and did not remove involved staff from resident care promptly.
Complaint Details
Complaint investigation related to physical abuse allegations involving resident R1 who sustained a black eye and resident R4 who sustained a skin tear. The investigation included multiple staff interviews and review of incident reports. The abuse was substantiated, and involved staff were suspended or terminated. The facility failed to report the abuse within 24 hours as required.
Deficiencies (3)
Description
Failed to conduct health care worker background checks prior to employee start dates for three employees.
Failed to keep two residents free from physical abuse, resulting in one resident with a black eye and another with a skin tear.
Failed to timely report abuse to the Illinois Department of Public Health and failed to remove alleged perpetrator from resident care promptly.
Report Facts
Residents affected: 56 Employees with background check failures: 3 Date of incident: Jun 13, 2025 Date of report to IDPH: Jun 16, 2025 Date of skin tear incident: Jun 24, 2025
Employees Mentioned
NameTitleContext
E7Certified Nursing AssistantFailed background check prior to start date; reported physical abuse incident involving resident R1.
E14Certified Nursing AssistantFailed background check prior to start date; involved in incident with resident R4 resulting in skin tear.
E15Certified Nursing AssistantFailed background check prior to start date; involved in physical altercation with resident R1 resulting in resident injury; terminated following investigation.
E6Business Office Manager/HR DirectorProvided statements regarding background check policy and failures.
E1Senior Executive DirectorProvided statements regarding background check policy and abuse investigation.
E21Memory Care DirectorManaged investigation of abuse incidents and staff suspensions.
E2Clinical Specialist, LPNInvolved in abuse investigation and staff in-service.
E10Licensed Practical NurseObserved resident R1 post-injury and reported findings.
E22Agency LPNProvided care to resident R1 during night shift; documented observations of injury.
E14Certified Nursing AssistantInvolved in incident with resident R4 resulting in skin tear; did not report incident appropriately.
Inspection Report Plan of Correction Deficiencies: 2 Jun 29, 2025
Visit Reason
This document is a Corrective Action Plan submitted in response to a citation dated June 29, 2025, for American House Oak Park.
Findings
The document outlines specific corrective actions taken to address citations related to Healthcare Worker Background Checks and Resident Rights, including audits, education, monitoring compliance, and termination of staff involved in violations.
Deficiencies (2)
Description
Failure to ensure presence of Healthcare Worker Background Checks in employee files.
Violations of Resident Rights and Abuse and Neglect policies.
Report Facts
Citation numbers: Citation# 295.3040 / 295.6000 / 295.6010 Termination pay out hours: 72
Employees Mentioned
NameTitleContext
Paul P. ZappoliExecutive DirectorNamed as responsible person and signer of the Plan of Correction
Nataly MorenoBusiness Office ManagerResponsible for auditing employee files for Healthcare Worker Background Checks and received re-education
Mary Joyce FloresWellness DirectorResponsible for skin assessments and education on Resident Rights and Abuse and Neglect Policy
Stacey WilliamsResident AssistantTermination form and worker's compensation refusal form related to injury and termination
Brianna KingResident AssistantTermination form indicating termination due to no show or quitting after day 1
Inspection Report Plan of Correction Deficiencies: 2 Feb 6, 2025
Visit Reason
This document is a Plan of Correction submitted in response to a citation dated February 6, 2025, regarding failure to ensure residency requirements and service plan compliance for one resident who developed pressure ulcers.
Findings
The facility failed to ensure residency requirements were met for one resident who developed stage III and stage II pressure ulcers that progressed to stage VI, and failed to include outside wound care services in the resident's service plan. Corrective actions and monitoring plans were outlined to address these issues.
Deficiencies (2)
Description
Failed to ensure residency requirement was followed for one resident who developed stage III pressure ulcer and stage II pressure ulcer progressed to stage VI.
Failed to ensure that outside services and intervention for wound care were included in the service plan for one resident.
Report Facts
Citation number: 184173
Employees Mentioned
NameTitleContext
Paul P. ZappoliExecutive DirectorNamed as responsible person for corrective actions and signer of the Plan of Correction
Katrina AleckRWDInstructor for in-service training on residency requirements and wound care
Oseloka OkonkwoTeam member involved in in-service training
Inspection Report Complaint Investigation Deficiencies: 2 Feb 5, 2025
Visit Reason
The inspection was conducted as a complaint investigation survey (IL184173/2590248) to determine compliance with residency requirements and service plan regulations following concerns about a resident with progressing pressure ulcers.
Findings
The facility failed to comply with residency requirements by allowing a resident with stage III and progressing pressure ulcers to remain without appropriate services or higher level of care. Additionally, the service plan did not include necessary wound care interventions or outside services despite the resident's documented wounds and physician orders.
Complaint Details
The complaint investigation was substantiated. The resident (R1) developed multiple pressure ulcers progressing in severity, and the facility failed to provide appropriate care or transfer to a higher level of care as required.
Severity Breakdown
Type 2 Violation: 1 Type 3 Violation: 1
Deficiencies (2)
DescriptionSeverity
Failure to ensure residency requirements were met for a resident with stage III and progressing pressure ulcers.Type 2 Violation
Failure to include outside wound care services and interventions in the resident's service plan.Type 3 Violation
Report Facts
Resident age: 93 Pressure ulcer stages: 4 Antibiotic dosage: 450 Dates of wound onset: Pressure ulcers onset dates: 1/17/2024, 1/30/2024, 2/3/2024, 2/15/2024
Employees Mentioned
NameTitleContext
Executive DirectorNoted resident was moved out due to need for higher level of care and acknowledged missing home health services in service plan
Regional NurseReviewed resident notes and confirmed wounds and need for higher level of care
Director of NursingNotified and changed wound dressing upon noticing wound size change
Nurse PractitionerNotified of skin tear and issued wound care orders
Inspection Report Plan of Correction Deficiencies: 1 Jan 15, 2025
Visit Reason
This document is a Plan of Correction submitted in response to a citation dated January 15, 2025, for American House Oak Park.
Findings
The facility failed to address an issue where a resident service plan did not properly account for the resident hiding or misplacing the call pendant. The Plan of Correction outlines auditing current service plans, updating plans for residents missing interventions, re-educating staff, and monitoring compliance over the next twelve weeks.
Deficiencies (1)
Description
Failed to address one of three sampled residents' service plans where the resident hides or misplaces the call pendant.
Report Facts
Citation number: 183477 Dates for achieving compliance: 02/28/2025, 03/07/2025, 02/16/2025, 05/23/2025 and ongoing
Employees Mentioned
NameTitleContext
Paul P. ZappoliExecutive DirectorSigned letter and named as responsible person for re-education and monitoring compliance
Inspection Report Complaint Investigation Deficiencies: 1 Jan 13, 2025
Visit Reason
The inspection was conducted as an original investigation of Complaint 2590011 / IL 183477 regarding the facility's failure to address a resident's ongoing issue with hiding or misplacing a call pendent.
Findings
The facility failed to address in the service plan of one sampled resident (R1) the ongoing problem of the resident hiding or misplacing the call pendent. Interviews with the resident's daughter and facility staff confirmed the issue has persisted for several months, but the service plan dated 7/23/24 did not include any interventions to address this problem.
Complaint Details
Original investigation of Complaint 2590011 / IL 183477. The complaint concerned the facility's failure to address a resident's call pendent issue in the service plan. The complaint was substantiated based on record review and interviews.
Severity Breakdown
Type 3 Violation: 1
Deficiencies (1)
DescriptionSeverity
Failure to address in the service plan the ongoing problem of a resident hiding or misplacing the call pendent.Type 3 Violation
Employees Mentioned
NameTitleContext
E1Executive DirectorConfirmed ongoing problem with resident's call pendent and lack of service plan interventions.
E2Memory Care DirectorConfirmed ongoing issue with resident's call pendent and explained it as part of dementia disease process.
Z1Resident's daughter who reported the call pendent issue.
Inspection Report Plan of Correction Deficiencies: 2 Dec 12, 2024
Visit Reason
This document is a Corrective Action Plan submitted in response to a citation dated December 12, 2024, for American House Oak Park.
Findings
The plan outlines corrective actions to address deficiencies related to initial health evaluations for direct care and food service employees, and signed service plans for residents. It includes auditing current employee files and resident service plans, re-education of staff, and ongoing monitoring to ensure compliance.
Deficiencies (2)
Description
Missing initial health evaluation and tuberculosis (TB) testing for employees.
Residents' service plans missing required signatures.
Report Facts
Citation number: 2953030 Citation number: 2954010
Employees Mentioned
NameTitleContext
Paul P. ZappoliExecutive DirectorSigned the plan of correction and responsible for some corrective actions

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