Inspection·February 13, 2025

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedure for housekeeping by not ensuring the rooms and medical equipment of residents who are totally dependent on staff for care and assistance with activities of daily living, were consistently and adequately cleaned and sanitized. This failure applies to four of four residents (R1, R2, R3, R4) reviewed for environment. Findings include: 1. R1 is a [AGE] year-old male with a diagnoses history present on admission of Brain Damage due to Oxygen Deprivation, Bacterial Infection, Epilepsy, Congestive Heart Failure, Stage 4 Pressure Ulcers, Acute Kidney Failure, UTI's, Trach Use, and Feeding Tube Use who was admitted to the facility 07/27/2024. On 02/10/2025 at 10:29 AM Observed multiple dresser drawers near R1's bed open and a mild odor present. On 02/10/2025 at 10:54 AM Observed R1's oxygen machine with visible dust and particles. V5 (Registered Nurse) was present and verbally confirmed the observation and stated the oxygen equipment should be clean. Observed a clean dressing dated 02/10/2025 sitting on R1's dresser near the foot of his bed. Observed R1's respiratory equipment with visible dust in the crevices on the top of the machine. V5 verbally confirmed the observation and wiped away some of the dust to further confirm that the area was unclean. V5 stated there shouldn't be any visible dust on the respiratory equipment. Observed a brown substance spilled over on multiple areas of R1's feeding tube monitor and pole. Observed R1's dresser near the foot of his bed with multiple uncovered and exposed plastic syringes. V5 stated that one of the syringes was for stool collection and the other is for feeding tube flushing and they should both be covered and stored properly. Observed a refrigerator in R1's room with visible dust and particles on the creviced exterior and with visible residue in multiple areas of the exterior. V5 stated the refrigerator exterior surface should be clean and free of visible matter. Observed multiple dresser drawers open. V5 agreed that R1's drawers should be closed and stated it only takes a moment to close them. 2. R2 is a [AGE] year-old female with a diagnoses history of Partial Paralysis following Brain Related Bleeding, Feeding Tube Placement, Protein Calorie Malnutrition, and Dysphagia (Difficulty Swallowing Foods) who was admitted to the facility 01/23/2025. On 02/10/2025 at 11:22 AM Observed R2's oxygen machine with visible dust and particles, a large mat next to the right side of her bed with multiple visible stains and residue, R2's respiratory (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 8 Event ID: 145626 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 145626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Generations Oakton Pavillion 1660 Oakton Place Des Plaines, IL 60018 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)