Oak Park Oasis

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to follow their policy to provide Discharge Instructions and Medications to one resident (Resident R1)upon her planned transfer from the facility to another skilled facility. This failure affected 1 of 3 residents reviewed for discharge/transfers.The findings include:Resident R1 admitted to the facility on [DATE REDACTED] and discharged to another facility on 8/9/25.On 8/13/25 at 12:06PM V3, Restorative Nurse, said Resident R1 had a planned discharge, I was working the cart. V3 said Resident R1's family came and got her. V3 said the Secretary at the front desk told them to speak with a nurse, but the family just took Resident R1. V3 said

they did not speak with me. V3 said only the secretary saw the family. At 12:54PM V3 said the admitting facility called me around 12:31PM on 8/9/25, V3 checked her phone for times. V3 said that is when I became aware Resident R1 had left. V3 said they called when Resident R1 arrived saying no medications were sent with Resident R1.

V3 said I faxed the paper work to the facility after they called. The family said they spoke with me, but then said I thought it was you. V3 said she didn't know when Resident R1 left so no medication was sent or discharge instructions were given. V3 said she had see Resident R1 sometime after 9:00AM on 8/925 when she administered medications. V3 said Resident R1 was in her room with her suitcase. On 8/13/25 at 2:00PM V5, LPN, said when a resident is a planned discharge we review the discharge instructions and medications with them. We send them the instructions, medication list, and any referrals they might have with them.Resident R1's progress notes dated 8/8/25 states Resident R1 requested to be transferred to another facility. Resident R1's family will transport. On 8/9/25 progress notes at 12:02PM states writer notified via phone that Resident R1 arrived to accepting facility. Nurse did not speak to the family, medication did not go with Resident R1 at the time she left the facility.A Transfer Discharge Report dated 8/8/25 was presented. Resident R1 transferred to another nursing home. Medications are listed. A Discharge Planning Review dated 8/8/25 was presented stating will be returning to the facility she came from before facility.No document presented for Resident R1 has a signature on the day of discharge. No Discharge Instructions with Resident R1 or representative signature was presented.Facility Discharge/Transfer of Resident policy dated 11/18 states in part, purpose to provide safe departure from the facility period to provide for continuity of care and treatment. Provide additional health education or medication instruction information for resident or family as indicated. Have resident or sponsor signed personal inventory of effects form. Heat transfer form accurately and completely including vital signs. Assist resident into wheelchair and escort to vehicle if necessary or assist attendance with transport. Document discharge summary. Include notes on specific instructions given such as medications to resident and responsible parties.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Park Oasis

625 North Harlem Oak Park, IL 60302

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm

of floor.The facility fall policy dated 2/28/14 states the standard fall safety precautions for all residents in part states the residents environment will be kept clear of clutter Which would affect ambulation and remove hazards.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Park Oasis

625 North Harlem Oak Park, IL 60302

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records reviewed the facility failed to ensure staff followed the facility practice of nurses not leaving the unit at the end of a shift without a relief. This failure resulted in the unit not having a nurse on unit for at least 1 hour. This failure has the potential to affect 36 residents residing on the unit.The findings include:On 8/13/25 at 12:06PM V3, Restorative Nurse, said on the second floor there is normally 2 nurses, 1 on main unit and 1on pavilion unit. V3 said 8/9/25 there was a call off for day shift I was notified at 8:45AM that there was a missing nurse on 2 main. V3 said I took over the cart about 9:15AM. V3 said I found out because I was coming in as Manager on Duty. V3 said I didn't clock in or out that day. V3 said the off going nurse is supposed to wait until the next nurse comes in before leaving. V3 said V12, LPN, called in. V3 said when I got to the facility the staff told me there was no nurse on 2 main. V3 said the call ins go to the DON or ADON. V3 said the unit was without a nurse for about 2 hours. V3 said CNAs can't pass medications. V3 said I don't even know what time I finished the morning medication pass, we had a code, reports of an alleged smoking violation I had to look into, and the Manager on Duty responsibilities.On 8/13/25 at 1:59PM V7, CNA, said we are supposed to call in 4 hours before our shift. We call into the DON to notify her.On 8/13/25 at 2:00PM V5, LPN, said we give verbal report to the oncoming nurse and we do a narcotic count with them. V5 said we are not supposed to leave the shift without a relief.On 8/13/25 at 12:42PM V6, Administrator, said I was made aware when V3 notified me on 8/9/25 that there was not a nurse for the 2nd floor unit. V6 said V3 took the cart. V3 said calls offs are to go to the on call person and DON. V6 said it is not the facility practice for the nurses to leave before a relief arrives. On 8/14/25 at 9:50AM V6 said we are

a skilled nursing facility, we provide nursing care 24 hours a day.On 8/14/25 at 8:02AM V10, LPN, said I was not told there was a call off for the morning of 8/9/25. I was not asked to stay over on 8/9/25.On 8/14/25 at 12:45PM V14, Director of Nursing, said V12 text me last minute on 8/9/25. V14 said it was 6:50something in the morning when she text. V14 said I didn't even hear the text, I didn't know V12 wasn't

in the building until V3 notified me. V14 said if I had known, I would have come in and had the nurse wait for me. V14 said call off should be 4 hours before the shift, staff should call the on call number. V14 said this is told to them at hire and is in the handbook. At 12:57PM V14 presented the unit census for 8/9/25 and said

the unit has 36 assigned residents for the nurse.Review of time cards includes 8/9/25 V11 clocked in at 7:33AM; V13, LPN, clocked in at 6:51AM; V9, LPN, clocked in at 6:59AM. V12 is designated absent on 8/9/25. V10 clocked out the morning of 8/9/25 at 7:32AM.Review of Controlled Substances Check Form dated 8/9/25 unit 2 Main has no day shift on nurse or off nurse signature.The facility attendance policy in part states it is an employee's responsibility to notify their supervisor promptly of their absence for any scheduled work day. Employees should call at least 4 hours in advance of their scheduled start times.The Facility assessment dated [DATE REDACTED] identifies on day shift (1st shift) 4 nurses will provide direct care to the residents.

Event ID:

Facility ID:

If continuation sheet