Resident #1's disruptive episodes began in mid-August and continued for at least ten days, according to progress notes reviewed by federal inspectors. On August 17 at 11:13 PM, the resident became loud and disruptive at bedtime, yelling and screaming at their roommate to "shut up" and "shut your mouth."
Five days later, the pattern persisted. At 5:33 AM on August 22, Resident #1 continued yelling "shut up" at their roommate because the roommate was talking. Progress notes indicated Resident #1 did not like their roommate talking and continued to yell out.
The disruptions escalated. On August 24 at 9:29 AM, staff documented that Resident #1 was yelling, being disruptive, and interfering with other residents' abilities to sleep. The resident stated they did not feel well but refused to take medications. Staff called a family member to come to the facility to manage the resident's behaviors.
Two days later, the overnight disruptions continued. At 6:38 AM on August 26, Resident #1 yelled at their roommate throughout the shift, screaming "shut up" and "stop talking." Staff educated the resident that it was not appropriate to yell at people and that others were trying to sleep.
Resident #1 responded: "I don't care, I can't sleep with [the roommate] talking."
Staff had not heard the roommate talking.
The following night brought more of the same. At 2:08 AM on August 27, Resident #1 yelled "shut up" at their roommate, who was not talking. Staff reminded the resident that others were trying to sleep, but Resident #1 continued to yell out. Staff took the resident to the television room for a period of time, and once their roommate fell asleep, assisted Resident #1 back into bed.
Later that morning at 9:07 AM, staff documented that Resident #1 screamed at others and made disruptive sounds daily.
Despite weeks of documented behavioral issues disrupting other residents' sleep, Resident #1's care plan contained no goals or interventions related to the ongoing verbal behavioral symptoms. The care plan, printed on October 21, showed no evidence the facility had developed strategies to address the nightly disruptions.
Licensed Practical Nurse L confirmed during an October 22 interview that Resident #1 had behaviors, was disruptive, and yelled out. The same day, the facility's Minimum Data Set Coordinator acknowledged that Resident #1 was not compliant with care and refused care.
The MDS Coordinator admitted Resident #1's care plan should have been updated with interventions related to the continuous behaviors of yelling.
The Medical Director, interviewed on October 23, stated that at minimum, interventions should have been care planned for all recurring behaviors and reassessed for effectiveness.
The Director of Nursing acknowledged that same day that Resident #1's care plan should have been updated with interventions related to the resident's behaviors. The Administrator made the same acknowledgment during their interview.
During the November inspection, the Social Services Director revealed a systemic problem. They stated they had determined there was an issue in their system with updating the Care Area Assessments that were checked on the MDS.
The facility's failure to develop behavioral interventions left other residents subjected to nightly disruptions for weeks. While staff documented each episode of yelling and screaming, they took no systematic approach to address the underlying behavioral issues or protect other residents from sleep disruption.
Federal inspectors cited Oakbrook Health and Rehabilitation for failing to ensure residents received care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The violation affected few residents but created potential for actual harm.
The inspection revealed a facility that documented problems extensively but failed to develop solutions. Staff knew Resident #1's behaviors were ongoing and disruptive to other residents' sleep, yet the care plan remained unchanged for months after the documented episodes began.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oakbrook Health and Rehabilitation from 2025-11-10 including all violations, facility responses, and corrective action plans.
Additional Resources
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