F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observation, interview and record review the facility failed to ensure resident rooms were cleaned
routinely for 5 of 6 residents (R1, R6, R11, R12 and R13) reviewed for clean, comfortable and homelike in
the sample of 23.The findings include:On 1/23/26 at 9:30 AM, there were no housekeepers seen on the
first floor.At 10:01 AM, V14 (Receptionist) was going into resident rooms and emptying their garbage
cans.On 1/23/26 at 11:57 AM, R11's bathroom toilet was filled with toilet paper and stool. R11's bathroom
smelled of stool. V13, Certified Nursing Assistant (CNA) said that R11's toilet has been in that state for at
least three weeks.On 1/23/26 at 12:04 PM, R12's garbage bin in her room did not have a trash bag in it.
The garbage bin in the bathroom did not have a trash bag in it as well. R12's room floor was sticky and had
splatter marks of an unknown substance throughout the floor. R12 said that she does not remember when
the last time was that her floor was cleaned and the spots have been on her floor for at least a month. R12
said that her biggest concern is that when they empty her garbage, they do not put another garbage bag in
the bin. R12 said that she does not get her room cleaned daily. On 1/23/26 at 12:04 PM, R13's garbage bin
was filled above the rim. R13 said that they do not clean her room daily and her main concern is that her
garbage can get really full and they do not empty it. R13 said that it has been a long time since they
cleaned her room. On 1/23/26 at 10:15 AM, R1 showed a picture of the garbage bin in her bathroom. The
garbage bin was filled above the rim and there was what appeared to be incontinence briefs in the bin. R1
said that she does not use incontinence briefs, but her previous roommate did and she moved out a while
ago. R1 said her garbage had been full since Sunday and on Thursday evening, she finally had to ask an
aide to get rid of it for her. R1 said that housekeeping does not come and clean her room daily nor empty
her garbages.On 1/23/26 at 9:00 AM, R6 said, Housekeeping has gotten bad. We used to have our rooms
cleaned every day. Now there is no cleaning for a week at times.On 1/23/26 at 12:14 PM, V1 (Administrator)
said that he is currently managing housekeeping due to not having a manager. V1 said that resident rooms
should be cleaned daily. On 1/23/26 at 12:40 PM, V14 (Receptionist) said that she used to be a
housekeeper. V14 said that all resident rooms should be cleaned daily and should include emptying the
garbage, cleaning high touch surfaces, sweeping and mopping the floors and cleaning the bathroom. V14
said that she was helping with emptying garbages and spot cleaning this morning since there was not a
housekeeper but then she had to go back to her reception duties. On 1/23/26 at 11:40 AM, V13 (Certified
Nursing Assistant) said all rooms do not get cleaned daily. V13 said that she asked the housekeeper if all
rooms are cleaned daily and she said that it is more of a lottery on what rooms get cleaned per day.
October 2025 Resident Council Minutes show, Resident stated concerns floors occasionally being sticky
after mopping.Residents stated concerns with dining room not being cleaned after meals and
activities.November 2025 Resident Council Minutes show, Residents stated concern with dining room not
being cleaned after meals and activities.December 2025 Resident Council Minutes show, Residents would
like
(continued on next page)
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
Page 1 of 3
Event ID:
145338
Printed: 05/15/2026
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
145338
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/23/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oakwood Rehab and Nursing Center
512 East Ogden Avenue
Westmont, IL 60559
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 0584
to request additional garbage bins for their bedrooms/restrooms.A routine resident room housekeeping
policy was requested and was not provided.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145338
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
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
145338
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/23/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oakwood Rehab and Nursing Center
512 East Ogden Avenue
Westmont, IL 60559
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview and record review the facility failed to ensure staff wore personal protective
equipment when caring for residents who are positive for COVID-19 to prevent to spread of infection for 6 of
9 residents (R14-R18 and R20) reviewed for infection control in the sample of 23.The findings
include:1.The facility provided COVID Isolation List shows that R20 is on isolation due to being COVID
positive. The facility's COVID positive line list shows that R20 tested positive on 1/15/26.On 1/23/26 at
10:01 AM, there was a sign on R20's door that said that she was on contact/droplet Isolation. V14
(Receptionist) was in R20's room. V14 had gloves, gown and a surgical mask on. V14 exited the room with
her personal protective equipment still on and disposed of her gown and gloves in a housekeeping cart. 2.
The facility provided COVID Isolation List shows that R14 is on isolation due to being COVID positive. The
facility's COVID positive line list shows that R14 tested positive on 1/18/26. R17 and R18 are not on the
COVID Isolation List.On 1/23/26 at 10:26 AM, R14, R17 and R18 were in the dialysis room. R14 did not
have a mask on. V15 (Dialysis Tech.) and V16 (Dialysis Registered Nurse) were in the room with R14, R17
and R18. V15 had a surgical mask on. V16 had a surgical mask and gown on. On 1/23/26 at 11:50 AM, V15
said that R14 is no longer on isolation. V15 said that R14 was dialyzed in another room for 8 days when he
was on isolation for being positive for COVID-19. V16 said that residents are dialyzed in a separate room if
they are positive for COVID-19 and personal protective equipment (PPE) of gloves, gown and surgical
mask are used when providing care to them. V16 said that they use their regular glasses as eye
protection.3. The facility provided COVID Isolation List shows that R16 is on isolation due to being COVID
positive. The facility's COVID positive line list shows that R16 tested positive on 1/14/26.On 1/23/26 at
11:00 AM, R16 was in the dialysis room. V15 was providing care to R16. V15 had a surgical mask and
gloves on. 4. The facility provided COVID Isolation List shows that R14 and R15 are on isolation due to
being COVID positive. The facility's COVID positive line list shows that R14 and R15 tested positive on
1/18/26.On 1/23/26 at 11:40 AM, R14 and R15's door did not have a sign indicating that they were on
contact/droplet isolation but did have a sign that showed what PPE should be used and how to use it. V13
(Certified Nursing Assistant) entered R14 and R15's room. V13 only had a surgical mask on. R14 and R15
were both in the room. On 1/23/26 at 11:40 AM, V13 said that she does not know if R14 and R15 are on
isolation. V13 said that one person told her that they were and one person told her that they were not. On
1/23/26 at 12:28 PM, V2 (Director of Nursing) said that if a resident tests positive for COVID-19, they are
placed on contact/droplet isolation for 10 days. V2 said that a sign is placed on the resident's door to alert
staff that they are on isolation. V2 said that staff should apply gloves, gown, N95 mask and a face shield
before entering the room. V2 said that staff should remove all of their PPE before exiting the room. V2 said
that residents that are COVID positive are still able to go to dialysis but they have to wear a surgical mask if
they are out of their room. The facility's PPE and Source Control Policy shows, If a resident is suspected or
confirmed to have COVID-19, HCP (Health Care Personnel) must wear an N95 respirator, eye protection,
gown and gloves.The facility's Acute Respiratory Illness Management Policy shows, Apply appropriate
transmission-based precautions (TBP).Residents who are placed in TBP for acute respiratory infection
should remain in their rooms except for medically necessary purposes. If they must leave their room, they
should practice physical distancing and wear a facemask for source control.The facility provided Viral
Respiratory Pathogens Toolkit shows that residents with COVID-19 should be placed on contact/droplet
isolation for 10 days.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145338
If continuation sheet
Page 3 of 3