Inspection Reports for
Generations at Oakton Arms
1665 Oakton Place, Des Plaines, IL, 60018
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% worse than Illinois average
Illinois average: 3.5 deficiencies/year
Deficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to Complaint 25810206/IL198128.
Complaint Details
Investigation unable to be completed due to subject of the complaint not residing at the facility.
Findings
The investigation was unable to be completed because the subject of the complaint did not reside at the facility.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Oct 20, 2025
Visit Reason
Annual Licensure Survey conducted to assess compliance with state regulations including disaster preparedness, personnel qualifications, employee orientation, physician assessments, service plans, and physical plant requirements.
Findings
The facility was found deficient in multiple areas including failure to involve residents in fire drills and document evacuation assistance, lack of proper CPR certification and demonstration for staff, incomplete employee orientation documentation, physician assessments signed by non-physicians, incomplete service plans especially regarding shower assistance and medication interventions, and failure to meet fire drill time constraints. These deficiencies pose substantial probability of harm to residents.
Deficiencies (6)
Failure to ensure residents are involved in fire drills and identification of residents needing assistance with evacuation; failure to complete resident emergency and evacuation orientation within 10 days of move-in.
Failure to ensure at least one direct care staff on duty at all times has valid CPR certification with demonstration of ability to perform CPR.
Failure to ensure proper documentation of employee orientation within 10 days of hire for two employees.
Failure to ensure residents' physician assessments were completed by a physician as required; assessments were signed by Advance Practiced Nurses.
Failure to follow shower assistance as stated on service plan for one resident and failure to include interventions for psychotropic and blood thinner medications in service plans for three residents.
Failure to meet time constraints for fire drills and failure to document resident participation and assistance needs during drills.
Report Facts
Fire drill duration: 13
CPR training without demonstration days: 29
CPR training without demonstration days: 25
CPR training without demonstration days: 26
CPR training without demonstration days: 13
Residents reviewed for physician assessment: 6
Residents with deficient physician assessment: 4
Residents reviewed for service plan: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Wellness Director | Named in CPR certification deficiency and physician assessment interview |
| E5 | Licensed Practical Nurse | Named in CPR certification deficiency |
| E11 | Certified Nursing Assistant | Named in CPR certification deficiency |
| E12 | Certified Nursing Assistant | Named in CPR certification deficiency |
| E13 | Caregiver | Named in CPR certification deficiency |
| E15 | Certified Nursing Assistant | Named in CPR certification deficiency |
| E16 | Certified Nursing Assistant | Named in CPR certification deficiency |
| E18 | Licensed Practical Nurse | Named in CPR certification deficiency |
| E19 | Certified Nursing Assistant | Named in CPR certification deficiency |
| E17 | Certified Nursing Assistant | Named in CPR certification deficiency |
| E20 | Caregiver | Named in CPR certification deficiency |
| E8 | Caregiver | Named in employee orientation and shower assistance deficiencies |
| E1 | Executive Director | Named in employee orientation and service plan interview |
| E10 | Maintenance Director | Named in fire drill deficiencies interview |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged staff to resident abuse involving a resident (R1) at the facility.
Complaint Details
The complaint investigation substantiated that a resident was physically and verbally abused by a nurse. The resident was injured and transported to the emergency room. The resident expressed fear and requested discharge against medical advice. The nurse was suspended pending investigation.
Findings
The facility failed to ensure a resident remained free from staff to resident abuse, resulting in physical injuries to the resident and an emergency room visit. The investigation included review of video footage and interviews, confirming an altercation between a nurse and the resident that escalated instead of being diffused.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical and verbal abuse. One resident sustained physical injuries after an altercation with a nurse, resulting in an emergency room visit and discharge request due to fear and dissatisfaction.
Report Facts
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Identified as abuse prohibition coordinator and involved in investigation. | |
| Social Service Director | Involved in employee orientation and interviewed regarding training. | |
| LPN Nurse (V4) | Nurse involved in the altercation with the resident. | |
| LPN Nurse (V5) | Nurse on duty who witnessed part of the incident and provided statements. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 25, 2025
Visit Reason
The investigation was conducted due to a complaint regarding failure to provide appropriate wound care treatment to a resident with necrotizing fasciitis, resulting in the resident calling 911 and being transported to the hospital.
Complaint Details
The complaint was substantiated. The resident reported multiple requests for wound care that were ignored by nursing staff and wound care nurse. The resident independently removed the wound vac device and was not treated for 5 hours, leading to calling 911 and hospital transfer.
Findings
The facility failed to follow physician orders for negative pressure wound therapy and dressing for a resident, resulting in the resident not receiving wound treatment for 5 hours. Staff did not respond to the resident's requests for wound care, leading to the resident's condition worsening and eventual hospital transfer.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to physician orders and resident preferences. Specifically, the resident with necrotizing fasciitis did not receive timely negative pressure wound therapy and dressing, resulting in delayed care and hospital transfer.
Report Facts
Duration without wound treatment: 5
Medication dosage: 10
Negative pressure wound therapy setting: 125
Resident mental status score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V9 | Certified Nursing Assistant | Assigned to resident; unable to recall if wound therapy was connected and did not inform others of resident's request for wound care. |
| V6 | Nurse | Assigned to resident; unsure if wound care nurse was contacted or if resident was seen. |
| V14 | Social Service Director | Manager on duty; observed resident in pain and informed floor nurse of wound care request. |
| V15 | Front Desk Staff | Observed resident complaining about foot; paged wound care nurse but received no response. |
| V7 | Nurse | Assigned to resident evening shift; noted wound therapy disconnected and resident's request to go to hospital. |
| V13 | Wound Care Nurse | Saw resident once in morning; unaware of further wound care needs or requests. |
| V2 | Assistant Director of Nursing (ADON) | Described protocol for contacting wound care nurse and noted failure to follow as needed orders. |
| V16 | Wound Nurse Practitioner | Explained importance of negative pressure wound therapy and risks of noncompliance. |
Inspection Report
Routine
Deficiencies: 3
Date: Feb 10, 2025
Visit Reason
The inspection was conducted to assess compliance with facility policies and procedures related to housekeeping, feeding tube care, hydration, and overall resident care for four residents dependent on staff for daily living activities and enteral nutrition.
Findings
The facility failed to ensure consistent cleaning and sanitization of residents' rooms and medical equipment, proper feeding tube site care according to physician orders, and adequate hydration for a resident dependent on tube feeding. These failures affected four residents and resulted in minimal to actual harm, including hospitalization for dehydration.
Deficiencies (3)
F 0584: The facility failed to ensure rooms and medical equipment of residents dependent on staff were consistently cleaned and sanitized, with visible dust, stains, and uncovered syringes observed in four residents' rooms.
F 0684: The facility failed to follow physician orders for daily cleansing and dressing of feeding tube sites for four residents, with dressings missing, undated, or stained and scabs present.
F 0692: The facility failed to ensure a resident dependent on tube feeding received the recommended amount of fluids, resulting in dehydration, high blood sodium, hypotension, and hospitalization.
Report Facts
Residents reviewed for environment and care: 4
Date of inspection visit: Feb 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Confirmed observations, described responsibilities for equipment cleaning, and discussed communication failures related to hydration orders. |
| V3 | Registered Nurse | Observed and confirmed feeding tube site deficiencies and environmental cleanliness issues. |
| V4 | Licensed Practical Nurse | Observed feeding tube site deficiencies and confirmed lack of dressings or undated dressings. |
| V5 | Registered Nurse | Confirmed environmental cleanliness issues and feeding tube site care deficiencies. |
| V6 | Housekeeping Supervisor | Explained housekeeping responsibilities and staffing issues affecting cleaning. |
| V9 | Registered Dietitian | Provided nutrition assessments and recommendations for fluid increases that were not communicated effectively. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 16, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to properly transfer a resident, resulting in injury.
Complaint Details
The investigation was triggered by a complaint related to a fall of resident R1 during transfer. The complaint was substantiated as the facility failed to follow the resident's care plan and safety protocols, resulting in injury.
Findings
The facility failed to ensure proper transfer techniques and appropriate footwear for resident R1, which led to a fall causing a neck fracture and hospitalization. The staff did not use a required gait belt despite the resident's care plan and assessment indicating maximal assistance needed during transfers.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents. Specifically, staff did not use a gait belt during transfer of resident R1 who required maximal assistance, and R1 was wearing inappropriate slippers, resulting in a fall and acute C7 spinous process fracture.
Report Facts
Date of resident discharge to hospital: Jan 10, 2025
Date of survey completion: Jan 16, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | V3 authored progress note describing transfer incident | |
| Certified Nursing Assistant | V4 involved in transferring resident R1 during fall incident | |
| Director of Nursing | V2 stated expectation of gait belt use during transfer | |
| Primary Physician | V7 commented on fracture type and fall risk |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 4, 2024
Visit Reason
The inspection was conducted following a complaint regarding inadequate catheter care and failure to timely obtain urine specimens, which led to a resident's severe urinary tract infection and hospitalization.
Complaint Details
The complaint was substantiated. The investigation found failures in catheter care and urine specimen collection that led to a resident's severe UTI and hospitalization. The grievance form was incomplete, and staff failed to document or act timely on clinical signs and lab orders.
Findings
The facility failed to provide appropriate catheter care, timely obtain urine specimens, document urine output, and respond to signs of urinary tract infections for two residents with indwelling catheters. These failures resulted in one resident requiring emergency treatment and hospitalization for severe UTI with sepsis.
Deficiencies (1)
F 0690: The facility failed to obtain urine specimens timely, document catheter output, provide catheter care, and identify/respond to UTI signs for 2 of 3 residents with indwelling catheters, resulting in one resident's hospitalization for severe UTI with sepsis.
Report Facts
Urine output documentation omissions: 20
Non-volume urine output entries: 31
WBC count: 26.7
WBC count: 11.82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Named in relation to investigation and statements about catheter care responsibilities. |
| V3 | Assistant Director of Nursing | Provided statements on catheter care standards and investigation details. |
| V5 | Registered Nurse | Provided expert statements on UTI signs and catheter care. |
| V7 | Licensed Practical Nurse | Discussed urine specimen collection and documentation practices. |
| V9 | Nurse Practitioner | Provided clinical insight on UTI symptoms and treatment expectations. |
| V12 | Licensed Practical Nurse | R1's nurse on day of hospitalization; failed to document resident's status. |
| V16 | Certified Nursing Assistant | Reported resident's condition changes and communication with nursing staff. |
| V18 | County Public Guardian | Reported concerns about resident care and catheter condition. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 22, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide a recliner wheelchair to a dependent resident who expressed a desire to get out of bed and interact with the environment.
Complaint Details
The complaint was substantiated as the facility failed to provide a recliner wheelchair to resident R12 after hospice services ended, limiting the resident's mobility and ability to get out of bed.
Findings
The facility failed to provide a recliner wheelchair to resident R12 after hospice services were discontinued, resulting in the resident remaining in bed despite expressing a desire to get up. Staff acknowledged the lack of wheelchair provision and the facility policy expects residents to have wheelchairs as needed.
Deficiencies (1)
F 0688: The facility failed to provide appropriate care to maintain or improve range of motion and mobility by not providing a recliner wheelchair to resident R12 after hospice services were discontinued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V21 | Certified Nursing Assistant | Named in observation of care and wheelchair provision failure for resident R12. |
| V16 | Registered Nurse | Commented on lack of wheelchair provision for resident R12 after hospice discontinuation. |
| V20 | Assistant Director of Nursing | Expressed expectation that resident R12 should have a wheelchair. |
| V2 | Director of Nursing | Stated facility policy to provide wheelchairs to all residents as needed. |
| V1 | Administrator | Presented facility policy on residents' rights. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 23, 2024
Visit Reason
The investigation was conducted following a fall incident involving a high-risk resident (R1) who fell out of an unlocked wheelchair in an unsupervised dining room on 05/31/2024.
Complaint Details
The complaint investigation was substantiated. The resident (R1) fell out of an unlocked wheelchair in an unsupervised dining room, sustaining bruising and a cut above the left eye requiring four sutures and hospital evaluation.
Findings
The facility failed to ensure the wheelchair locking mechanism was engaged and failed to provide adequate supervision for a high-risk resident, resulting in the resident falling and sustaining injuries requiring hospital evaluation and sutures. Staff interviews and record reviews confirmed the wheelchair was only partially locked and no staff supervised the resident in the dining room at the time of the fall.
Deficiencies (1)
F 0689: The facility failed to ensure the wheelchair locking mechanism was fully engaged and failed to supervise a high-risk resident in the dining room, resulting in a fall with injury requiring hospital treatment.
Report Facts
Sutures placed: 4
Fall risk score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V10 | Activity Aide | Transported resident R1 to dining room and failed to lock both wheelchair wheels. |
| V11 | Licensed Practical Nurse (LPN) | Directed activity aide to place R1 in dining room and provided first aid after fall. |
| V12 | Registered Nurse (RN) | Observed fall, provided first aid, and called 911. |
| V2 | Director of Nursing | Investigated fall incident and provided information on staff training. |
| V14 | Activity Director | Provided information on activity aides' training and supervision practices. |
| V1 | Administrator | Responded to incident and discussed staff education and supervision. |
Inspection Report
Routine
Census: 20
Deficiencies: 1
Date: Jun 3, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically compliance with transmission-based precautions and hand hygiene practices.
Findings
The facility failed to follow physician orders for transmission-based precautions for one resident and failed to perform proper hand hygiene and use of personal protective equipment (PPE) by staff, increasing the risk of infection spread.
Deficiencies (1)
F 0880: The facility failed to follow physician orders for transmission-based precautions for resident R8 and failed to perform hand hygiene and use PPE properly, risking the spread of infectious microorganisms.
Report Facts
Census on floor: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 | Registered Nurse | Provided information on isolation precautions and PPE requirements for resident R8 |
| V3 | Infection Prevention Nurse | Explained PPE protocol related to droplet and contact isolation signs |
| V2 | Director of Nursing | Stated expectations for staff to follow PPE signs for residents on isolation |
| V5 | Certified Nursing Assistant | Observed failing to perform hand hygiene and PPE use when entering resident R8's room |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 20, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding a resident (R2) who fell from his wheelchair at the nurse's station, resulting in injury. The visit aimed to assess the circumstances of the fall and the facility's supervision and fall prevention practices.
Complaint Details
The investigation was triggered by a fall incident on 11/20/2023 involving resident R2, a high fall risk individual. The fall was not directly witnessed by staff, though some staff heard the fall. The resident sustained injuries requiring hospital evaluation and sutures. The complaint was substantiated with findings of inadequate supervision and lack of a formal monitoring policy.
Findings
The facility failed to adequately supervise a high fall risk resident, resulting in the resident falling from a wheelchair and sustaining a laceration requiring sutures. Staff accounts conflicted on whether the fall was witnessed, and observations revealed residents in the dining room were often unsupervised. The facility lacked a formal policy on monitoring high fall risk residents.
Deficiencies (1)
F0689: The facility failed to ensure adequate supervision to prevent accidents, resulting in a high fall risk resident falling from a wheelchair and sustaining actual harm requiring hospital treatment.
Report Facts
Fall Risk Assessment Score: 20
Number of prior falls: 12
Date of fall incident: Nov 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V9 | Certified Nursing Assistant (CNA) | Assigned CNA for resident R2 during the fall incident; provided care and was involved in supervision. |
| V10 | Licensed Practical Nurse (LPN) | Nurse on duty during the fall incident; provided first aid and called for hospital transfer. |
| V2 | Director of Nursing | Provided statements regarding the fall incident, supervision policies, and resident history. |
| V7 | Registered Nurse (RN) | Provided assessment of resident R2's fall risk and supervision needs. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 19, 2024
Visit Reason
The inspection was conducted following complaints related to resident safety and catheter care at the facility.
Complaint Details
The investigation was triggered by complaints regarding a resident fall and improper catheter care. The fall was substantiated with findings of inadequate supervision and mattress missettings. The catheter care complaint was substantiated with findings of improper catheter bag placement and unsecured tubing.
Findings
The facility failed to ensure adequate supervision to prevent a resident's fall and failed to properly secure a resident's urinary catheter bag, increasing risk of infection. Both incidents involved failure to follow established care policies and procedures.
Deficiencies (2)
F 0689: The facility failed to ensure a resident's safety when providing care to prevent a fall for 1 of 3 residents reviewed. The resident slid off the bed while being bathed due to inadequate supervision and improper mattress settings.
F 0690: The facility failed to ensure a resident's urinary catheter bag was kept off the floor and the catheter tubing was properly secured for 1 of 3 residents reviewed. The catheter bag was found resting on the floor and tubing was unsecured, risking infection.
Report Facts
Residents reviewed for safety: 9
Residents reviewed for falls: 3
Residents reviewed for catheters: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V11 | Certified Nursing Assistant | Involved in resident fall incident and care |
| V9 | Registered Nurse | Involved in resident fall incident and catheter care |
| V2 | Director of Nursing | Conducted investigation after resident fall |
| V4 | Certified Nursing Assistant | Provided statement on catheter bag care |
| V5 | Certified Nursing Assistant | Provided statement on catheter bag care |
| V3 | Licensed Practical Nurse | Assisted with resident repositioning and catheter care |
Inspection Report
Routine
Deficiencies: 2
Date: Jan 2, 2024
Visit Reason
The inspection was conducted to assess compliance with care standards related to pressure ulcer prevention and maintenance of range of motion for residents.
Findings
The facility failed to implement effective pressure ulcer prevention measures for one resident, including improper use of a pressure relief mattress. Additionally, the facility failed to provide necessary therapy and interventions to prevent decline in range of motion for another resident, resulting in a contracture.
Deficiencies (2)
F 0686: The facility failed to ensure a pressure relief mattress was operated correctly, affecting one resident with pressure sore prevention needs. Multiple layers of sheets under the resident prevented proper mattress inflation and deflation.
F 0688: The facility failed to provide necessary services and interventions to prevent decline in range of motion, resulting in a contracture of the right hand for one resident. The resident was not provided a prescribed right-hand splint or passive range of motion therapy as ordered.
Report Facts
Resident weight: 156
Wound measurements: 3
Wound measurements: 8.2
Wound measurements: 2.7
Wound measurements: 7.7
Wound measurements: 0.1
Wound measurements: 1.9
Wound measurements: 6.3
Wound measurements: 6
Wound measurements: 0.2
Duration of PROM therapy documented: 15
Duration of splint application documented: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 | Wound Care Coordinator | Provided statements about pressure relief mattress settings and care |
| V10 | Wound Care Physician | Documented wound assessments and treatments for resident R2 |
| V12 | Covering Wound Care Physician | Provided statements about mattress settings and wound care |
| V8 | Restorative Aide | Documented PROM therapy and splint application for resident R1 |
| V7 | Restorative Nurse | Provided information about restorative therapy program and assessments |
| V9 | Rehabilitation Director | Reviewed occupational therapy evaluations and provided statements on therapy needs for resident R1 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 8, 2023
Visit Reason
The investigation was conducted due to concerns about the facility's failure to follow its Accident/Incidents Reporting policy and Fall Prevention and Management policy, specifically regarding incomplete incident reporting, lack of documentation, failure to assess and monitor residents after falls, and failure to notify physicians and families promptly.
Complaint Details
The complaint investigation found substantiated failures in incident reporting, documentation, monitoring, notification, and fall prevention practices related to residents R1 and R2. The failures caused actual harm, including delayed treatment and hospitalization of R1 for a left femoral neck fracture.
Findings
The facility failed to complete incident reports, document progress notes, assess and monitor residents for changes after falls, notify physicians and families immediately, and implement fall prevention interventions or update fall care plans for residents. These failures resulted in delayed treatment and hospitalization of a resident with a fractured femoral neck.
Deficiencies (1)
F 0689: The facility failed to complete an incident report, document progress notes, assess and monitor for changes, and notify physician and family immediately after a fall incident involving resident R1. Fall prevention interventions were not implemented and fall care plans were not updated for residents R1 and R2.
Report Facts
Fall incident reports for R1 in 2023: 9
Fall incident reports for R2 in 2023: 7
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 4, 2023
Visit Reason
The visit was conducted to investigate an allegation of verbal and physical abuse by a Certified Nurse Assistant (CNA) towards a resident (R1) at the facility.
Complaint Details
The complaint investigation was triggered by an allegation that a CNA verbally abused and physically assaulted a resident by throwing the resident's legs into bed and using inappropriate language. The allegation was reported to the Administrator, police were notified, and the CNA was suspended. The investigation was ongoing but unable to substantiate abuse at the time of the report.
Findings
The investigation found that a CNA forcibly grabbed and threw the resident's legs into bed and used inappropriate language. The resident complained of mild shoulder pain but had no injuries on assessment. The CNA was suspended pending investigation and police were involved.
Deficiencies (1)
F 0600: The facility failed to protect a resident from verbal and physical abuse by a CNA who forcibly grabbed and threw the resident's legs into bed and used inappropriate language. This affected one resident who complained of mild shoulder pain.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V4 | Certified Nurse Assistant (CNA) | Named in verbal and physical abuse allegation |
| V5 | Certified Nurse Assistant (CNA) | Witnessed the abuse incident |
| V1 | Administrator | Reported and managed the abuse investigation |
| V2 | Director of Nurses (DON) | Involved in investigation and resident care |
| V6 | Licensed Practical Nurse (LPN) | Conducted resident assessment and escorted CNA out |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow fall prevention policies and provide appropriate pain management for a resident with dementia who experienced a fall resulting in injury.
Complaint Details
The complaint investigation focused on the fall incident of resident R1 on 8/12/2023, the facility's failure to implement effective fall prevention measures, and inadequate pain management following the fall. The resident suffered a displaced left femur fracture and sepsis. The investigation included interviews with staff and family, record reviews, and assessment of facility policies.
Findings
The facility failed to implement and reevaluate fall prevention interventions for a high-risk resident, resulting in a fall causing a displaced left femur fracture and sepsis. Additionally, the facility failed to provide adequate pain management post-fall, despite family and staff reports of the resident's pain.
Deficiencies (2)
F 0689: The facility failed to follow fall prevention policy to develop, implement, and reevaluate interventions for a resident with dementia and high fall risk, resulting in a fall causing a displaced left femur fracture.
F 0697: The facility failed to provide appropriate pain management after a fall for a resident with dementia, resulting in the resident not receiving pain medication despite complaints and family notification.
Report Facts
Deficiencies cited: 2
Fall risk assessment score: 2
Corrected fall risk assessment score: 10
Medication dosage: 500
Medication dosage: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Certified Nurse Assistant | Reported resident's fall and complaints of pain multiple times to nursing staff. |
| V3 | Nurse | Assessed resident post-fall, did not administer pain medication despite complaints. |
| V6 | Care plan/Minimum Data Set Coordinator | Developed fall risk care plan and discussed fall interventions. |
| V11 | Director of Nursing | Acknowledged that pain medication should have been given to the resident. |
Inspection Report
Routine
Deficiencies: 5
Date: Aug 25, 2023
Visit Reason
Routine inspection to assess compliance with resident rights, pressure ulcer care, catheter care, pharmaceutical services, and other regulatory requirements at Generations Oakton Pavillion.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during medication administration, lack of accessibility to state inspection survey results for residents, improper pressure settings on alternating pressure air mattresses for residents at risk of pressure ulcers, failure to keep catheter collection bags off the floor, and incomplete controlled medication receipt documentation.
Deficiencies (5)
F 0550: The facility failed to treat one resident with respect and dignity by administering insulin in the dining room without privacy.
F 0577: The facility failed to make State inspection survey results available and accessible to residents, affecting five residents.
F 0686: The facility failed to properly set alternating pressure air mattresses according to resident weight for four residents, risking pressure ulcer development.
F 0690: The facility failed to keep an indwelling catheter collection bag off the floor for one resident, posing an infection risk.
F 0755: The facility failed to complete controlled drug receipt/record/disposition forms upon receipt of medications for two medication carts affecting five residents.
Report Facts
Residents affected: 1
Residents affected: 5
Residents affected: 4
Residents affected: 1
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Provided statements on insulin administration privacy, mattress settings, catheter care, and medication receipt policies. |
| V19 | Licensed Practical Nurse | Observed administering insulin without privacy. |
| V11 | Activity Director | Commented on resident council meetings and accessibility of survey results. |
| V10 | Assistant Director of Nursing | Discussed mattress pressure settings. |
| V13 | Family Member | Reported mattress pressure setting issues. |
| V8 | Registered Nurse | Confirmed mattress pressure setting with family member. |
| V42 | Registered Nurse/Nursing Supervisor | Reported correct mattress pressure settings. |
| V15 | Wound Care Coordinator | Commented on mattress checks. |
| V26 | Wound Care Physician | Provided wound evaluation summary. |
| V30 | Certified Nursing Assistant | Observed catheter bag on floor. |
| V23 | Licensed Practical Nurse | Observed incomplete controlled medication forms. |
| V24 | Licensed Practical Nurse | Observed incomplete controlled medication forms. |
Inspection Report
Deficiencies: 1
Date: May 22, 2023
Visit Reason
The inspection was conducted to assess compliance with pressure ulcer care and prevention protocols for residents, specifically focusing on individualized care plans.
Findings
The facility failed to follow the individualized plan of care for pressure ulcer interventions by not turning and repositioning a resident every two hours as required. This failure affected one resident with a pressure ulcer, potentially impacting wound healing.
Deficiencies (1)
F 0686: The facility failed to provide appropriate pressure ulcer care by not turning and repositioning a resident every two hours as specified in the care plan. This affected one of three residents reviewed for pressure ulcer prevention.
Report Facts
Wound measurement: 5.1
Wound measurement: 7.3
Wound tissue composition: 20
Wound tissue composition: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Mentioned as V5 who last repositioned resident at 9:30am | |
| Wound Treatment Nurse | Mentioned as V2 who applied wound treatment and provided wound care details |
Inspection Report
Deficiencies: 0
Date: Apr 16, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for a nursing home inspection.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 9
Date: Jul 22, 2022
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory standards including care planning, medication administration, infection control, and safety.
Findings
The facility failed to update care plans after falls, administer medications per physician orders, maintain grooming standards, implement restorative care interventions, ensure effective fall prevention measures, stabilize urinary catheters, properly account for controlled substances, maintain safe medication refrigerator temperatures, and follow infection prevention and control protocols including transmission-based precautions.
Deficiencies (9)
F 0657: Facility failed to update care plans for four residents after fall incidents as required by policy.
F 0658: Facility failed to ensure medication administration per physician orders for one resident, including nurse not staying to observe medication intake.
F 0677: Facility failed to provide nail care for one resident despite repeated requests.
F 0688: Facility failed to implement care plan interventions for splint application to prevent contractures for one resident.
F 0689: Facility failed to ensure wheelchair alarms were functioning and attached for two residents at risk for falls.
F 0690: Facility failed to stabilize the indwelling urinary catheter tubing for one resident, increasing risk of injury.
F 0755: Facility failed to properly account for controlled substances for seven residents and failed to notify physician or document late medication administration for one resident.
F 0761: Facility failed to maintain and document safe refrigerator temperatures for medications in all medication rooms.
F 0880: Facility failed to disinfect medical equipment and medication trays between residents, failed to change gloves and perform hand hygiene, and failed to maintain isolation precautions for a COVID-positive resident.
Report Facts
Fall incidents: 31
Residents reviewed for medication administration: 31
Residents reviewed for grooming and hygiene: 31
Residents reviewed for limited range of motion: 31
Residents reviewed for catheter care: 31
Residents reviewed for infection control: 31
Controlled substances discrepancies: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Named in multiple findings including care plan updates, medication administration, fall prevention, infection control |
| V9 | Registered Nurse | Named in medication administration and infection control deficiencies |
| V11 | Minimum Data Set Coordinator | Named in care plan update findings |
| V16 | Licensed Practical Nurse | Named in infection control and medication administration findings |
| V26 | Housekeeper | Named in infection control deficiency related to COVID isolation protocol |
| V10 | Licensed Practical Nurse | Named in controlled substances count discrepancy |
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