F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on interview and record review the facility failed to have a PRN (as needed) psychotropic medication
stop date to 1 of 5 residents (R59) reviewed for unnecessary medications in the sample of 5.
The findings include:
R59's Physician Order Sheet (POS) dated 8/2023 show, R59 has an order of: start date- 8/10/23 Risperdal
Oral Tablet 0.25 MG (Risperidone) Give 0.25 mg by mouth every 12 hours as needed (PRN) for agitation
and insomnia.
On 8/15/23 at 9:15 AM, V2 (Director of Nursing-DON) said all psychotropic as needed medications should
have a 14 day stop date unless the physician renews the PRN meds. V2 said we will be working on this and
ensure all PRN psychotropic medications have a 14 day stop date.
The facility policy on Psychotropic Medications with a review date of 8/2023 show, all PRN psychotropic
medications will have an automatic stop date of 14 days unless specified by the medical provider.
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:
146105
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
146105
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Crest
2944 Greenwood Acres Drive
Dekalb, IL 60115
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 wash hands after providing pericare
to prevent the spread of infection to 1 of 5 residents (R58) reviewed for infection control in the sample of 5.
Residents Affected - Few
The findings include:
On 8/14/23 at 9:10 AM, V4 (Certified Nursing Assistant-CNA) toileted R58 and provided peri care after R58
had a bowel movement. V4 (CNA) then removed her soiled gloves but did not wash hands/did not perform
hand hygiene. Using her contaminated hands V4 took R58's toothbrush, applied tooth paste then handed
the toothbrush to R58 and gave R58 a cup of water. V4 then wheeled R58 and assisted R58 to his recliner
all doing these tasks without washing her hands.
On 8/15/23 at 8:50 AM, V5 (Registered Nurse) said staff should wash their hands prior to and after giving
care. V5 also said every time staff remove their gloves, they should perform hand hygiene to prevent the
spread of infection,
The facility Policy entitled Hand Hygiene with a revised date of 4/2020 show, it is the policy of this
organization to promote use of alcohol sanitizers and handwashing as the single most important means of
preventing the spread of infection. Examples of situation when hand hygiene is indicated before and after
direct resident contact (care, treatment).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146105
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
146105
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/15/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Crest
2944 Greenwood Acres Drive
Dekalb, IL 60115
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 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to offer the pneumococcal conjugate vaccines (PCV20) or the
pneumococcal polysaccharide vaccine (PPSV23) for 1 of 5 residents (R58) reviewed for vaccinations in the
sample of 5.
Residents Affected - Few
The findings include:
R58's face sheet shows he is an [AGE] year-old male admitted to the facility on [DATE] with diagnosis
including pneumonitis due to inhalation of food and vomit, atrial fibrillation, hypertension, and presence of
cardiac pacemaker.
R58's Immunization Report provided on 8/14/23 shows on 10/9/2015 he received Prevnar 13 (PCV13).
There were no other pneumococcal vaccinations recorded.
On 8/15/23 at 12:03 PM, V3 Assistant Director of Nursing (ADON) said R58 received Prevnar 13 in 2015,
he is eligible to receive the 2nd dose of the pneumococcal vaccine. It should've been offered on admission
and given if consented. Residents should receive the 2nd dose of the pneumococcal vaccine after one year
of receiving PCV13.
The CDC (Centers for Disease Control and Prevention) guidelines dated February 2013 shows states, the
CDC recommends pneumococcal vaccination for all adults 65 years or older. The tables below provide
detailed information .For adults 65 years or older who have only received PCV13, CDC recommends you
either: Give 1 dose of PCV20 at least 1 year after PCV13 or Give 1 dose of PPSV23 at least 1 year after
PCV13 .
The facility's Flu and Pneumonia Vaccines revised 2018, states, All residents living in licensed units will be
offered an annual flu vaccine in accordance with the recommendations of the Advisory Committee of the
Centers for Disease Control and with the approval of their physician and the resident's consent, (if resident
unable to make decision, legally responsible party will be consulted), unless they have had previous
reactions to the vaccine, are allergic to eggs, have a history of Guillain Barre Syndrome, or are ill .All
residents age [AGE] and older living in a licensed unit will be offered a pneumonia vaccine in accordance
with the recommendations of the Advisory Committee on Immunization Practices of the Centers for
Disease Control upon admission and with the approval of their physician, and with the resident's consent
.Administration of, refusal of, or medical contraindication of a pneumonia vaccine will be documented in the
resident's medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146105
If continuation sheet
Page 3 of 3
