Deficiencies (last 3 years)
Deficiencies (over 3 years)
12.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
167% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 5, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of verbal abuse by a family member towards a resident (R1) at Oak Park Nursing and Rehab Center.
Findings
The facility failed to implement policies and procedures to prevent abuse, neglect, and exploitation, did not report or investigate the abuse allegation timely, and did not put interventions in place to protect the resident from further abuse. The facility also failed to respond appropriately to the alleged violations and did not ensure reporting to proper authorities as required.
Complaint Details
The complaint involved verbal abuse of resident R1 by a family member (FM E) on 10/22/25. Witnesses R4 and RV D reported hearing yelling and profanity, and FM E throwing a hanger in R1's room. The facility was made aware but failed to investigate, report, or implement interventions to protect R1. The Social Services staff reported the incident to the previous Nursing Home Administrator but no further action was taken. The Nursing Home Administrator at the time of the survey acknowledged the failure to report and investigate the incident thoroughly.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Level of Harm - Minimal harm or potential for actual harm |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Respond appropriately to all alleged violations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
BIMS score: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SS C | Social Services | Reported the abuse allegation to the Nursing Home Administrator and provided information about the incident |
| NHA A | Nursing Home Administrator | Acknowledged failure to report, investigate, and implement interventions regarding the abuse allegation |
| NHA F | Previous Nursing Home Administrator | Received report of abuse from Social Services but did not ensure investigation or reporting |
Inspection Report
Routine
Deficiencies: 17
Sep 9, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident rights, safety, infection control, medication administration, food service, and other aspects of care.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' dignity and self-determination, inadequate cleanliness and housekeeping, failure to properly investigate and resolve grievances, failure to timely report and investigate abuse allegations, failure to provide required discharge documentation, inaccurate resident assessments, failure to provide appropriate treatment and care, inadequate supervision to prevent accidents, unsafe dialysis care, medication errors, improper medication storage, food service deficiencies, inadequate infection prevention and control program, and failure to document influenza vaccination.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Level of Harm - Immediate jeopardy to resident health or safety: 1
Level of Harm - Actual harm: 2
Deficiencies (17)
| Description | Severity |
|---|---|
| Failure to ensure residents' dignity and self-determination related to uncovered catheter bags and dirty wheelchairs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a safe, clean, comfortable and homelike environment including inadequate housekeeping and unclean wheelchairs. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to document thorough grievance investigations and resolve grievances as per facility policy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse and failure to report allegations of abuse to the state agency. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to respond appropriately to allegations of abuse and failure to remove alleged staff from resident care during investigation. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide required discharge documentation including bed hold notices for residents transferred to hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate Minimum Data Set (MDS) assessments reflecting residents' cognitive and fall status. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and care according to orders and resident preferences, including failure to monitor and respond to elevated pulse resulting in resident death. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to ensure a resident's environment remained free of accident hazards and provide adequate supervision to prevent accidents, including failure to identify root causes of falls and implement appropriate interventions. | Level of Harm - Actual harm |
| Failure to provide safe, appropriate dialysis care and services including lack of staff training and care plan interventions related to dialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure medication error rates are below 5%, including administration of medication outside prescribed window and crushing extended-release medication. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure drugs and biologicals are stored and labeled in accordance with professional standards, including expired medications and unlabeled food items. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food and drink are palatable, attractive, and served at safe and appetizing temperatures. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure meals and snacks are served at times in accordance with resident needs and preferences, including failure to provide nourishing snacks when there is more than 14 hours between evening meal and breakfast. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to procure food from approved sources and store, prepare, distribute, and serve food in accordance with professional standards, including unsealed and unlabeled food, dirty microwaves, and inconsistent temperature monitoring. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, including incomplete and inaccurate infection surveillance, failure to exclude symptomatic staff appropriately, failure to recognize and manage outbreaks, and failure to follow enhanced barrier precautions. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement policies and procedures for influenza and pneumococcal vaccinations, including failure to document resident education and vaccination administration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 7.14
Fall risk score: 75
Fall risk score: 80
Fall risk score: 25
BIMS score: 6
BIMS score: 7
BIMS score: 15
Medication administration time: 8.4
Medication administration error count: 2
Medication administration opportunities: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN H | Registered Nurse | Handled R45's catheter bag without gloves or hand hygiene |
| DON B | Director of Nursing | Interviewed regarding multiple deficiencies including catheter bag handling, infection control, falls, medication errors |
| LPN F | Licensed Practical Nurse | Observed crushing extended-release medication and interviewed about medication administration |
| RN X | Registered Nurse | Observed crushing extended-release medication |
| ADON N | Assistant Director of Nursing | Infection Preventionist, interviewed about infection control and outbreak management |
| NHA A | Nursing Home Administrator | Interviewed regarding infection control, outbreak management, and immunizations |
| CNA D | Certified Nursing Assistant | Interviewed about dialysis care and snack offerings |
| CNA C | Certified Nursing Assistant | Interviewed about dialysis care |
| CNA E | Certified Nursing Assistant | Interviewed about dialysis care and snack offerings |
| RN W | Registered Nurse | Observed R37 eating pom poms, interviewed about wheelchair cleanliness and supervision |
| Activity Aide II | Activity Aide | Observed R37 rummaging and eating pom poms |
| CNA M | Certified Nursing Assistant | Interviewed about R37 rummaging and microwave cleaning |
| CNA FF | Certified Nursing Assistant | Interviewed about R37 rummaging and supervision |
| RN HH | Registered Nurse | Interviewed about R37 rummaging and supervision |
| HD CC | Housekeeping Director | Interviewed about laundry room cleanliness |
| LPN R | Licensed Practical Nurse | Interviewed about pulse monitoring for R74 |
| NP T | Nurse Practitioner | Interviewed about monitoring and treatment for elevated pulse |
| RN V | Registered Nurse | Interviewed about shift report and monitoring for R74 |
| MD Q | Medical Director | Interviewed about elevated pulse and expected nursing response |
| LPN Y | Licensed Practical Nurse | Reported finding R2 left in dining room and notified ADON |
| ADON N | Assistant Director of Nursing | Interviewed about grievance investigation and follow-up |
Inspection Report
Routine
Deficiencies: 7
Jul 16, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, environment, medication use, wound care, fall prevention, and infection control.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment; developing comprehensive care plans for medication use; providing appropriate treatment and care for non-pressure and pressure injuries; ensuring adequate supervision and safety to prevent falls; ensuring appropriate use and consent for psychotropic medications; and implementing an effective infection prevention and control program.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Facility did not ensure a safe, clean, comfortable, and homelike environment for 1 of 16 residents reviewed (R31) with housekeeping deficiencies including dust, debris, and uncleaned spills in resident's room. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not develop a comprehensive person-centered care plan for 2 of 5 residents (R9 and R42) reviewed for unnecessary medications, specifically for Melatonin use without proper sleep assessments or monitoring. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure residents received necessary treatment and services consistent with professional standards for 2 residents (R7 and R12) with non-pressure injuries; wounds were not comprehensively assessed weekly and documentation was inconsistent with physician assessments. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure residents received necessary treatment and services consistent with professional standards for 2 residents (R7 and R12) with pressure injuries; wounds were not comprehensively assessed weekly, staging was inconsistent with physician documentation, and depth measurements were missing. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure adequate supervision and safety to prevent accidents for 1 of 3 residents (R5) reviewed; fall interventions such as low bed and fall mat were not in place when resident was in bed. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure residents using psychotropic drugs had appropriate assessments, diagnoses, and consent for 2 of 5 residents (R9 and R42); antipsychotics were prescribed without appropriate indications and consents were not current. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to implement an effective infection prevention and control program; staff did not apply PPE appropriately and did not perform hand hygiene for the appropriate duration during treatment of a resident on Enhanced Barrier Precautions (R1). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for homelike environment: 17
Residents reviewed for unnecessary medications: 5
Residents reviewed with non-pressure injuries: 5
Residents reviewed with pressure injuries: 3
Residents reviewed for fall prevention: 17
Residents reviewed for psychotropic medication use: 5
Opportunities for hand hygiene observed: 8
Residents observed for Enhanced Barrier Precautions: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN-H | Registered Nurse | Named in wound care treatment and assessment deficiencies |
| RN C | Registered Nurse | Named in infection control and PPE use deficiency |
| CNA E | Certified Nursing Assistant | Named in fall prevention deficiency |
| DON B | Director of Nursing | Named in multiple findings including wound care, fall prevention, psychotropic medication, and infection control |
| NHA A | Nursing Home Administrator | Named in housekeeping and cleanliness deficiency |
| Ancillary Director G | Ancillary Director | Named in housekeeping and cleanliness deficiency |
| RNUM D | Registered Nurse Unit Manager | Named in medication and fall prevention deficiencies |
Inspection Report
Deficiencies: 1
Mar 27, 2024
Visit Reason
The inspection was conducted to assess medication administration practices and ensure residents are free from significant medication errors, specifically reviewing orders and administration of insulin for one resident (R1).
Findings
The facility failed to ensure that one resident (R1) was free from significant medication errors related to insulin administration. The insulin order was incomplete, lacking frequency instructions, and the facility administered insulin without proper clarification from the physician. The resident did not receive the prescribed Humalog insulin on multiple dates, and the facility did not identify or investigate these medication errors.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure residents are free from significant medication errors related to incomplete insulin orders and improper administration for one resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Medication administration dates missed: 4
Insulin administration frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Discussed medication error report and acknowledged failure to identify and investigate significant medication errors |
| Physician C | Physician whose office was to be contacted for clarification of insulin orders |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 23, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and thoroughly investigate an allegation of neglect involving resident R1.
Findings
The facility failed to immediately report an allegation of neglect to the State Survey Agency and did not conduct a thorough investigation into the allegation. Resident R1 reported being left in soiled bedding for several hours without assistance, and staff failed to respond appropriately or document the incident properly. The Nursing Home Administrator was unaware of key details until the investigation and acknowledged the investigation was not thorough.
Complaint Details
The complaint involved resident R1 who reported being neglected on 1/6/24 when a CNA did not return to assist her after removing her breakfast tray, leaving her in a soiled bed for approximately 3 hours. The family member was present and had to intervene to get help. The facility failed to report the allegation immediately and did not conduct a thorough investigation, missing key witness interviews and documentation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to thoroughly investigate an allegation of neglect. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 6
Residents with allegation: 1
Date of incident: Jan 6, 2024
Date of report: Jan 8, 2024
Date of survey: Jan 23, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Interviewed regarding the incident and investigation; acknowledged lack of thorough investigation and delayed awareness of key facts. |
| NM RN C | Nurse Manager Registered Nurse | Interviewed about resident R1's care concerns and reporting. |
| CNA D | Certified Nursing Assistant | Assigned to resident R1 on 1/6/24; failed to return to assist resident after removing breakfast tray. |
| CNA E | Certified Nursing Assistant | Provided care to resident R1 after family intervention; reported incident and apologized to resident. |
| LPN F | Licensed Practical Nurse | Interviewed; did not recall any incident report regarding R1's personal care on 1/6/24. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 31, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's provision of pharmaceutical services, specifically regarding timely administration of medications to residents.
Findings
The facility failed to ensure timely administration of medications for 2 out of 3 sampled residents, resulting in multiple medication errors. Medication administration times frequently exceeded the facility's policy window of one hour before or after the scheduled time.
Complaint Details
The visit was complaint-related, focusing on medication administration errors for residents R1 and R4. The Director of Nursing confirmed that medications should be administered within one hour before or after the scheduled time and acknowledged late medication administration as errors.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide pharmaceutical services including timely administration of all drugs and biologicals to meet the needs of residents R1 and R4. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration errors: 2
Medication administration times: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding medication administration expectations and errors |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 23, 2023
Visit Reason
The inspection was conducted based on a complaint investigation regarding the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident with pressure injuries/ulcers.
Findings
The facility did not ensure that a resident with pressure injuries received necessary treatment and services consistent with professional standards to prevent infection. Specifically, RN C failed to perform appropriate hand hygiene during wound care, including not washing hands before and after glove use and using wound care supplies that had fallen on the floor.
Complaint Details
The complaint investigation found substantiated deficiencies related to inadequate wound care and hand hygiene practices by RN C, including failure to perform hand hygiene before and after glove use, use of wound care supplies that fell on the floor, and improper handling of wound dressings. RN C acknowledged the failures during interview and indicated he had received training but did not comply with hand hygiene protocols. The Director of Nursing confirmed proper hand hygiene practices and that items should not touch the floor.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including inadequate hand hygiene by RN C during wound care. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 4
Residents affected: 1
Date of wound treatment order: Apr 28, 2023
Time of observation: 930
Time of interview RN C: 945
Time of interview DON B: 1142
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Named in deficiency for failure to perform appropriate hand hygiene during wound care |
| DON B | Director of Nursing | Interviewed regarding hand hygiene practices and wound care standards |
Inspection Report
Routine
Census: 25
Deficiencies: 5
Apr 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident environment cleanliness, resident assessments, activities of daily living assistance, activity programming, and pressure injury care.
Findings
The facility failed to maintain a clean and homelike environment for residents, did not complete required quarterly assessments for one resident, failed to provide adequate assistance with activities of daily living for several residents, did not provide an ongoing and meaningful activity program for residents, and failed to provide appropriate pressure injury care and prevention for two residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Level of Harm - Actual harm: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility did not ensure a safe, clean, comfortable, and homelike environment; housekeeping services were inadequate for 4 of 25 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not complete quarterly Minimum Data Set (MDS) assessment for 1 of 19 sampled residents (R38). | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not ensure residents unable to perform ADLs received necessary assistance for nutrition, grooming, and hygiene for 5 of 19 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to provide an ongoing, individualized, and meaningful activity program to support residents' physical, mental, and psychosocial well-being for 3 of 19 sampled residents and 1 supplemental resident. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not provide care consistent with professional standards to prevent pressure injuries from developing or worsening for 2 of 5 residents reviewed for pressure injuries. | Level of Harm - Actual harm |
Report Facts
Residents affected: 4
Residents affected: 1
Residents affected: 5
Residents affected: 4
Residents affected: 2
Residents present during inspection: 25
Pressure injury measurement: 2.3
Pressure injury measurement: 1.5
Pressure injury measurement: 1.3
Pressure injury measurement: 1.5
Pressure injury measurement: 1.3
Pressure injury measurement: 2
Pressure injury measurement: 4.49
Pressure injury measurement: 4.47
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Regional Nurse, Wound Care Certified Nurse | Provided wound care assessment and staging for R66's pressure injury |
| RN D | Registered Nurse | Performed wound care treatment and initial assessment for R66 |
| DON B | Director of Nursing | Provided information on wound care policies and expectations |
| CNA N | Certified Nursing Assistant | Interviewed regarding housekeeping and resident assistance |
| AD L | Activity Director | Provided information on activity programming and attendance |
| AA M | Activity Assistant | Provided information on activity attendance and resident preferences |
| INHA A | Interim Nursing Home Administrator | Provided information on MDS completion and activity attendance monitoring |
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