Oakwood Rehab: Fall Linked to Supervision Gap - IL
It didn't. The resident fell.
Federal inspectors cited Oakwood Rehab and Nursing Center following a complaint inspection on April 27, 2026, finding the facility failed to implement fall prevention measures for a resident whose care plan identified monitoring as a core part of keeping her safe. The citation was classified as causing actual harm.
Staff described the resident, identified in inspection records only as R2, as someone who slides down in her wheelchair and requires constant reminding to sit back. A nurse said she conducts rounds four to five times per shift specifically because of this. CNAs said they try to keep the woman in the dining room where staff can watch her, sometimes putting on movies to encourage her to stay.
But on the day she fell, the part-time aide finished helping her in the bathroom, and the resident asked to stay in her room and watch television. The aide left. She told inspectors she wasn't sure what time it was when she left, and that after the fall she was told the resident needed to be kept in the hallway where staff could see her. "I don't really know about the care specifics with the residents," she said.
Inspectors found no documentation in R2's nursing notes or care plan recording her preference to stay in her room, no record of discussions with her power of attorney or family about alternative fall prevention approaches, and nothing showing the facility had communicated her specific fall risks to staff responsible for her care that day.
The facility's own safety policy, revised in March 2025, calls for communicating specific interventions to all relevant staff and assigning responsibility for carrying out those interventions. The aide working with R2 the day she fell said she thought she could look things up in the computer if she needed to, but wasn't sure the information would be there.
It wasn't.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oakwood Rehab and Nursing Center from 2026-04-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Oakwood Rehab and Nursing Center in WESTMONT, IL was cited for violations during a health inspection on April 27, 2026.
The citation was classified as causing actual harm.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.