Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Park Nursing And Rehab Center during CMS and state inspections, most recent first.
A resident with diabetes, venous insufficiency, neutropenia, obesity, and multiple lower-extremity wounds had physician orders for BID wound care to both feet and legs, bilateral tubi grips for edema, and routine Calmoseptine skin treatment. On one morning shift, the MAR showed these ordered treatments were not administered, and there was no documentation of provision or refusal of care. RNs and the DON confirmed that nurses are responsible for wound care and must sign out completed treatments in the EHR, including refusals, but no additional documentation was available for that shift.
A resident with dementia and other psychiatric diagnoses, who is rarely or never understood per MDS, was observed in a wheelchair with a nitroglycerin patch stuck to the wheelchair wheel, despite having no order for nitroglycerin. An RN confirmed the patch was dated from the prior day and stated that only one other resident on the unit had an order for such a patch, which should have been removed the previous night. Both the RN and the DON described the facility’s required process for nitroglycerin patch disposal—folding the patch in half and placing it in a sharps container or immediately removing it in trash—and acknowledged that the patch found on the wheelchair wheel was not disposed of according to facility policy or accepted professional principles.
The facility failed to implement an effective infection prevention and control program during concurrent outbreaks of influenza, RSV, and COVID-19. Several residents with confirmed respiratory infections, including those with severe cognitive impairment and significant comorbidities, had no physician orders for transmission-based precautions and no care plan interventions addressing their infections. Isolation signage was missing from rooms of infected residents, and visitors entered without performing hand hygiene or using PPE. The IP was absent, and the DON and ADON reported they could not access or interpret the EMR infection tracking system, were not systematically tracking infected or non-infected residents’ respiratory symptoms, and had not entered isolation or droplet precaution orders or related care plans for affected residents. Requested outbreak documentation, including line listings, an outbreak management plan, and ongoing symptom tracking, could not be produced, and EMR infection control records showed the outbreak status and contact tracking had not been updated for several days despite multiple residents and staff reporting respiratory symptoms. These failures resulted in an immediate jeopardy finding under F880 for infection control.
The facility failed to designate and employ a qualified IP and had no trained back-up to manage the infection prevention and control program during an active outbreak of COVID-19, influenza, and RSV. The Regional Nurse identified as the IP had a job description focused on overall operations rather than IP duties, and the DON and ADON, who assumed responsibility in the IP’s absence, reported they were not trained as IPs, lacked access to the EMR infection tracking system, and could not interpret infection data. Outbreak documentation, including line listings, an outbreak management plan, and respiratory symptom tracking for non-infected residents, was not available, and electronic infection tracking had not been updated for several days. A resident with a history of stroke, a resident with Parkinson’s disease, and a resident with atrial fibrillation and a recent fracture developed respiratory symptoms and tested positive for influenza, RSV, or COVID-19, while rooms of infected residents lacked isolation/PPE signage, a visitor entered without hand hygiene or PPE, and housekeeping staff were unaware of the infections or required precautions.
Two residents, one cognitively intact with respiratory and cardiac conditions and one severely cognitively impaired with hypertensive heart disease and generalized anxiety disorder, were subjected to verbally abusive statements by an RN. The intact resident reported that when she requested her ordered narcotic pain medication, the RN called her "addicted," and that she witnessed the RN tell another resident to "stop your damn crying" while administering eye drops. The cognitively impaired resident, for whom the facility is home, could not be interviewed. The facility’s investigation documented these reports but the Administrator later stated he did not believe abuse occurred, despite an existing abuse-prevention policy guaranteeing residents freedom from abuse by staff.
A resident was subjected to verbal abuse by a family member, including yelling, swearing, and the throwing of a hanger, as witnessed and reported by others. Despite these reports, facility staff did not interview the resident, implement protective interventions, report the incident, or conduct an investigation, in violation of the facility's abuse prevention policies.
A resident was subjected to verbal abuse by a family member, witnessed by another resident and a visitor, who reported the incident to Social Services. Despite facility policy requiring immediate reporting of suspected abuse, the allegation was not reported to authorities, and no interventions were implemented to protect the resident.
A resident who was cognitively intact was subjected to verbal abuse by a family member, witnessed by another resident and a visitor. The incident was reported to Social Services and the administrator, but the facility did not conduct a thorough investigation, interview the resident, or implement interventions to ensure safety. The event was not reported to authorities as required by policy.
A resident under Enhanced Barrier Precautions did not receive proper infection control during wound care due to a nurse's failure to secure PPE and perform adequate hand hygiene. The nurse's gown repeatedly fell off, and the resident's foot contacted the nurse's mask and clothing, risking contamination. Interviews revealed gaps in staff training and adherence to infection control protocols.
A resident with intact cognition reported concerns about the cleanliness of her room, which was observed to have dust, debris, and stains on various surfaces, as well as a dark brown spill and spatter that remained unaddressed for several days. The Ancillary Director and facility leadership acknowledged the failure to maintain a clean environment, despite the resident's occasional refusal of chemical cleaners.
The facility failed to create comprehensive care plans for two residents prescribed Melatonin for insomnia, despite lacking a diagnosis of sleep disorders. Both residents received Melatonin daily without proper sleep assessments or evaluations of sleep hygiene. Interviews with staff confirmed the absence of necessary care plans and assessments, leading to the deficiency.
The facility failed to provide consistent and comprehensive wound care assessments for two residents with non-pressure injuries. One resident's wounds were not assessed weekly, and there were discrepancies in wound classification between the facility and external providers. Another resident's new wound was not fully assessed until days later. Technical limitations and inconsistent documentation practices contributed to the deficiency.
The facility failed to provide adequate care and documentation for two residents with pressure injuries. One resident had multiple pressure injuries that were not comprehensively assessed weekly, with inconsistencies in staging between the facility and the Wound Physician. Another resident developed pressure injuries that were misidentified as moisture-associated skin damage, and assessments lacked depth measurements. The facility's failure to follow its policy for weekly assessments and accurate documentation led to inadequate care.
A resident at high risk for falls did not have prescribed safety interventions, such as a low bed and fall mat, in place due to a printing error in the CNA care plan. The CNA was unaware of the resident's fall risk, leading to the absence of necessary precautions until the issue was identified by a surveyor.
Two residents were prescribed antipsychotic medications without appropriate diagnoses or updated consents. One resident received Quetiapine for dementia, and another was given Risperidone for anxiety, both of which are not appropriate indications. Additionally, the consent for an antidepressant was outdated, violating the facility's policy requiring updated consents every 15 months.
Failure to Provide and Document Ordered Wound and Skin Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered wound care and skin treatments and to document them according to policy for one resident. The facility’s wound care policy requires documentation of the date and time wound care is given, any refusals and reasons, and the signature and title of the person recording the data. The resident was admitted with multiple significant diagnoses, including type 2 diabetes with diabetic polyneuropathy, neutropenia, venous insufficiency, and obesity, and had multiple wounds on both feet and lower extremities. The physician’s orders included Calmoseptine ointment to the buttocks, groin, and folds every morning and at bedtime and after each toileting episode; bilateral high tubi grips on in the morning and off at bedtime for edema; and multiple specific wound care treatments to the left foot toes, left lower extremity, right foot, and right lower extremity, all to be completed twice daily and as needed. On the morning shift of 1/18/26, the Medication Administration Record showed that these ordered treatments were not administered. There was no documentation that the Calmoseptine, tubi grips, or any of the ordered wound care treatments for the resident’s left foot toes, left lower extremity, right foot, or right lower extremity were provided during that shift. Interviews with multiple RNs and the DON confirmed that nurses are responsible for conducting wound treatments and dressing changes and that, when treatments are completed, they are expected to be signed out in the electronic health record, including documentation if a resident refuses treatment. No further documentation was provided to account for the missing wound care treatments on that morning shift.
Improper Disposal of Nitroglycerin Patch Found on Resident’s Wheelchair
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper disposal of a nitroglycerin transdermal patch in accordance with professional standards and facility policy. During observation in the dining area, a surveyor saw a resident seated in a wheelchair with an oval, paper-tape-like object stuck to the wheelchair wheel. On closer inspection, the object was identified as a nitroglycerin patch labeled with a date of 2/3. Review of the resident’s physician orders confirmed that this resident did not have an order for nitroglycerin. The resident’s diagnoses include dementia, major depressive disorder, and schizophrenia, and the most recent MDS indicated that a BIMS could not be completed because the resident was rarely or never understood. When interviewed, an RN stated that only one resident on the unit had an order for a nitroglycerin patch and that the ordered patch would have been removed the previous night. The RN described the facility’s expected disposal process for nitroglycerin patches as folding the patch in half so the medicated sides adhere together and then placing it in a sharps container or wrapping it in gloves, placing it in the resident’s trash, and immediately removing the trash. The RN acknowledged that the patch found on the wheelchair wheel had not been properly disposed of. The DON similarly stated that nitroglycerin patches should be folded on themselves and placed in a sharps container and agreed that the patch observed on the wheelchair wheel was not properly disposed of, indicating noncompliance with the facility’s medication disposal policy and accepted professional principles.
Failure to Implement Effective Infection Control During Concurrent Influenza, RSV, and COVID Outbreaks
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program during concurrent outbreaks of influenza, RSV, and COVID-19, affecting residents, staff, and visitors. The facility did not ensure appropriate physician orders or care plans were in place for multiple residents with confirmed respiratory infections, including influenza, RSV, and COVID. For one resident with a history of stroke and severe cognitive impairment who tested positive for both influenza and RSV, there were no orders addressing management of these infections and no care plan interventions, despite documented respiratory symptoms and positive lab results. This resident’s room lacked any droplet precaution signage, and a visitor entered and exited the room multiple times without performing hand hygiene or using PPE, with staff confirming the absence of signage indicating required precautions. Another resident with Parkinson’s disease and severe cognitive impairment developed respiratory symptoms and later tested positive for influenza. Although a nurse’s note referenced discussion with the NP about Tamiflu and isolation time frames, the comprehensive physician order set contained no orders for transmission-based precautions, and the care plan did not address influenza management. This resident, who had an active order for Tamiflu, also had no droplet precaution signage on the room door. A third resident with dysphagia and a history of sepsis tested positive for influenza, yet had no related physician orders for infection management or TBP and no care plan addressing influenza. A fourth resident, cognitively intact and positive for COVID, had droplet precaution orders in place but no corresponding care plan for COVID management. A fifth resident with vascular dementia and dysphagia tested positive for COVID, but had no droplet precaution orders until several days after symptom onset and no care plan addressing COVID. The facility’s leadership and infection control infrastructure were also deficient. The designated IP was not present in the facility during key survey dates and was unavailable for interview. The DON reported that she and the ADON were responsible for infection control when the IP was absent but stated they could not access or interpret the EMR infection tracking system and had only basic infection control training. The DON acknowledged she was not tracking residents with influenza, RSV, or COVID in an organized manner and was not tracking respiratory symptoms in non-infected residents. She also confirmed that isolation and droplet precaution orders and related care plans had not been entered for residents on droplet precautions for influenza, COVID, and RSV, and that symptom tracking for respiratory illness in all residents had not been occurring prior to a later date. When surveyors repeatedly requested outbreak documentation, including line listings, an outbreak management plan, and evidence of respiratory symptom tracking, the facility could not provide an outbreak management plan or documentation showing systematic tracking of non-infected residents. Infection control documentation from the EMR showed the outbreak status had not been updated for several days, and contact tracking had not been documented beyond its initial entry, despite multiple residents and staff reporting respiratory symptoms during the outbreak. The Administrator and DON were unable to produce an outbreak management plan for the concurrent influenza and COVID outbreaks when interviewed. The DON stated she did not know why droplet precaution signage was missing from the doors of infected residents and reiterated that her expectation was that such signage should be present. A Regional Nurse Consultant confirmed that his expectation for outbreak management included appropriate documentation such as line listings, a functioning outbreak management plan, symptom tracking for staff and residents, and family notification of infection and outbreak status, but the facility lacked this documentation. The combination of missing orders and care plans for infected residents, absent or unclear isolation signage, lack of organized surveillance and tracking, and limited infection control oversight led to the determination of immediate jeopardy related to infection control. The facility’s own policies required prompt identification and management of communicable disease outbreaks, defined thresholds for declaring an outbreak, and assigned responsibilities to the administrator, IP, DON, and staff for surveillance, initiation of transmission-based precautions, and communication with health authorities and families. Policies also required that when residents are placed on transmission-based precautions, appropriate notification be placed on the room entrance door and chart, and that visits to residents on influenza precautions be scheduled and controlled with instruction on hand hygiene and PPE. Despite these written policies, the facility did not implement them during the concurrent outbreaks, as evidenced by the lack of isolation signage, absence of documented TBP orders and care plans for multiple infected residents, and failure to maintain up-to-date outbreak tracking and symptom surveillance. Staff symptom logs provided to surveyors showed multiple employees, including activity aides, housekeepers, CNAs, and an RN, reporting respiratory or flu-like symptoms over several days during the outbreak period. However, there was no evidence that this information was integrated into a broader outbreak management or surveillance system. The EMR infection control management system showed that outbreak status had not been evaluated or updated for several days, and contact tracking documentation had not been continued after its initial entry. These inactions, combined with the absence of a functioning outbreak management plan and the lack of systematic tracking of both infected and non-infected residents, contributed directly to the identified deficiency in the facility’s infection prevention and control program. Overall, the deficiency centers on the facility’s failure to operationalize its infection control policies and CDC-based guidance during simultaneous outbreaks of influenza, RSV, and COVID. This included not ensuring that residents with confirmed infections had appropriate physician orders and individualized care plans, not posting required isolation signage, not maintaining organized surveillance and outbreak tracking, and not having adequately trained and available infection control leadership to manage the situation. These documented failures led surveyors to determine that immediate jeopardy existed under F880 for infection control.
Failure to Designate Qualified Infection Preventionist and Manage Respiratory Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to designate and employ a qualified Infection Preventionist (IP) to develop, implement, and monitor the infection prevention and control program, including during an active outbreak of COVID-19, influenza, and RSV. The facility identified a Regional Nurse as the IP, reportedly working 20 hours per week, but the Regional Nurse’s job description focused on overall facility operations and only generally referenced following established infection control procedures. The facility lacked a qualified back-up IP, and the designated IP was not present in the facility and unavailable for interview during multiple days of the survey while the outbreak was ongoing. During the IP’s absence, the DON and ADON reported they were responsible for managing the infection control program and the current outbreak, but both confirmed they were not trained as IPs, could not interpret the IP’s information, and could not act on her behalf. They also stated they did not have access to the EMR Infection Tracking Program and would not be able to read or understand the information even if they obtained access. The surveyors requested outbreak-related documentation multiple times, including staff and resident line listings, an outbreak management plan, and evidence of respiratory symptom tracking for non-infected residents, but the facility could not provide an outbreak management plan or documentation showing tracking of non-infected residents. Infection control documentation from the facility’s PCC Infection Control Management System showed that outbreak status had not been evaluated, tracked, or updated for several days, and contact tracking documentation had not been updated since the date it was initiated. The deficiency also included specific resident-level findings and infection control lapses. One resident with a history of stroke developed respiratory symptoms and later tested positive for both influenza and RSV, another resident with Parkinson’s disease developed respiratory symptoms and tested positive for influenza, and a third resident with atrial fibrillation and a recent pubic bone fracture developed respiratory symptoms and tested positive for COVID-19. Surveyors observed that required isolation/PPE signage was not posted outside the rooms of residents with RSV and/or influenza. A visitor entered and exited one such resident’s room multiple times without performing hand hygiene or donning PPE, and housekeeping staff reported they were unaware of the residents’ infectious status or required PPE and confirmed there were no signs at the doorways directing them on precautions.
Failure to Protect Residents From Verbal Abuse by RN
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a registered nurse, contrary to its abuse prevention policy that guarantees residents the right to be free from abuse by anyone, including staff. One resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including acute and chronic respiratory failure and heart disease, reported that during the night she requested her ordered narcotic pain medication and the RN responded by referring to her as "addicted." The same resident also reported that on the previous evening she witnessed the RN administering eye drops to another resident and telling that resident to "stop your damn crying" when the resident cried during the procedure. The second resident involved, whose diagnoses included hypertensive heart disease and generalized anxiety disorder and who had a BIMS score of 6 indicating severe cognitive impairment, was described as considering the facility her home and could not be interviewed due to poor cognition. The facility’s own incident reporting and investigation documentation reflected that an investigation into potential verbal abuse of both residents was initiated after the cognitively intact resident reported these events. During a subsequent interview with surveyors, the cognitively intact resident reiterated that she felt verbally abused when called "addicted" and believed the other resident was verbally abused when told to stop her "damn" crying. The Administrator later stated he did not feel either resident was abused and characterized the situation as a "he said/she said" matter, despite the facility’s policy requiring protection from abuse.
Failure to Implement Abuse Prevention Policies Following Family Member's Verbal Abuse
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for one resident. Specifically, after being made aware that a family member verbally abused a resident—including yelling, swearing, and throwing a hanger in the resident's room—the facility did not take steps to protect the resident from further abuse, did not report the incident, and did not conduct an investigation as required by their abuse prevention policy. Witnesses, including another resident and a visitor, reported the incident to Social Services, describing the family member's behavior as abusive and distressing. Despite these reports, the facility did not interview the resident involved, citing the family member's status as activated power of attorney and their instruction that staff could not speak to the resident without their presence. Staff acknowledged the incident could be considered abuse and confirmed that no interventions or plans were put in place to ensure the resident's safety. The facility also failed to report or thoroughly investigate the allegation, contrary to their own policies and federal requirements.
Failure to Timely Report Alleged Abuse by Family Member
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse involving a resident and a family member was reported to the appropriate authorities within the required timeframe. On the date of the incident, a family member was observed by another resident and a visitor yelling, using profanity, and throwing a hanger in the resident's room. Both witnesses reported the incident to the facility's Social Services staff, who in turn reported it to the previous Nursing Home Administrator. Despite the facility's policies requiring immediate reporting of suspected abuse to local, state, and federal agencies, the allegation was not reported as required. The resident involved was cognitively intact, as indicated by a recent BIMS score. Staff did not interview the resident about the incident due to instructions from the family member, who was the activated power of attorney, that staff could not speak to the resident without her present. No interventions or plans were implemented to ensure the resident's safety or to prevent further abuse, and the facility did not report the allegation to the appropriate agencies as mandated by policy and regulation.
Failure to Investigate and Report Alleged Abuse by Family Member
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported and thoroughly investigated according to state law and facility policy. On 10/22/25, an allegation of verbal abuse by a family member toward a resident was reported to the facility. Witnesses, including another resident and a visitor, described hearing and seeing the family member yelling, using profanity, and throwing a hanger in the resident's room. Both witnesses reported the incident to Social Services, who in turn reported it to the previous Nursing Home Administrator. Despite these reports, the facility did not conduct a thorough investigation, did not interview the resident involved, and did not obtain written witness statements as required by policy. The resident involved was cognitively intact, as indicated by a recent BIMS score of 13. Staff cited the family member's status as activated power of attorney as a reason for not interviewing the resident, stating that the family member required to be present for any staff interaction with the resident. No interventions or plans were implemented to ensure the resident's safety or to prevent further abuse, and the incident was not reported to the appropriate authorities as required by federal and state regulations. The facility's inaction was confirmed by both Social Services and the current Nursing Home Administrator during interviews.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) and inadequate hand hygiene practices by a Registered Nurse (RN) during the treatment of a resident. The resident, who was under Enhanced Barrier Precautions due to conditions including Type 2 Diabetes Mellitus with Diabetic Neuropathy and Peripheral Vascular Disease, required specific infection control measures during wound care. However, the RN did not secure the gown properly, leaving it open in the back, and repeatedly allowed it to fall off the shoulders during the procedure, compromising the protective barrier. Throughout the treatment, the RN failed to maintain proper hand hygiene, performing handwashing for significantly less than the recommended 20 seconds. The RN's gown frequently fell off, and at one point, the resident's foot with an old dressing touched the RN's N95 mask, stethoscope, and clothing, leading to potential contamination. Despite these issues, the RN continued the procedure without addressing the gown's fit or the contamination risk. Interviews with the RN and the Director of Nursing (DON) revealed a lack of awareness and adherence to proper infection control protocols. The RN admitted the gown did not fit properly and had not reported this issue to the DON. Additionally, there was a discrepancy in the understanding of the required duration for hand hygiene, with the RN and DON providing incorrect information. These lapses in infection control practices highlight deficiencies in staff training and adherence to established policies, potentially compromising resident safety.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, identified as R31, as evidenced by multiple observations of unclean conditions in her room. R31, who has intact cognition with a BIMS score of 15 out of 15, expressed concerns about the cleanliness of her room. Observations by the surveyor on multiple occasions revealed dust-coated window blinds, debris and stains on window sills, dust on shelving, dried liquid stains on the bedside table, and debris on the floor. Additionally, a dark brown spill and spatter were noted under the bed and on the wall behind the bed, as well as near the door and the dirty linen collection bin. The Ancillary Director acknowledged that the room should have been cleaned more frequently and that the dark brown spill/spatter should have been addressed immediately. It was noted that R31 sometimes refused the use of chemical cleaners, but alternative cleaning methods such as using a dust cloth or soap and water were not employed. The Nursing Home Administrator and Director of Nursing also confirmed that the room should not have remained in such a state for six days and that housekeeping should have been maintaining cleanliness regularly.
Failure to Develop Comprehensive Care Plans for Residents on Melatonin
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents who were prescribed Melatonin for insomnia, despite neither having a diagnosis of insomnia or any other sleep disturbance disorders. Resident 9, with diagnoses including cerebral infarction, unspecified dementia, anxiety disorder, and major depressive disorder, was receiving Melatonin daily without a documented sleep assessment or evaluation of sleep hygiene. Similarly, Resident 42, diagnosed with Alzheimer's disease and dementia, was also receiving Melatonin daily without an up-to-date sleep assessment or evaluation of sleep hygiene. The facility's care plans for both residents lacked documentation regarding the use of Melatonin for insomnia and did not include monitoring of sleep hygiene or the medication's effectiveness. Interviews with facility staff, including the Registered Nurse Unit Manager and the Director of Nursing, revealed an acknowledgment of the deficiency. Both staff members indicated that the residents should have had care plans related to sleep, including monitoring of sleep hygiene and the effectiveness of Melatonin. Additionally, they acknowledged that sleep assessments should be conducted quarterly or at least annually, but these assessments were not completed for the residents in question. The lack of a comprehensive care plan and failure to conduct necessary assessments led to the deficiency identified by the surveyors.
Inconsistent Wound Care Documentation and Assessment
Penalty
Summary
The facility failed to ensure that residents received necessary treatment and services consistent with professional standards of practice, specifically for two residents with non-pressure injuries. One resident, with a history of multiple medical conditions including peripheral vascular disease and chronic osteomyelitis, had several non-pressure injuries that were not comprehensively assessed weekly. The documentation for the location and etiology of these injuries was inconsistent between the facility and the Wound Physician. The facility's records often lacked depth measurements, and there were periods where no weekly assessments were documented. Additionally, there was confusion regarding the classification of wounds as pressure or non-pressure, leading to conflicting documentation between the facility and external wound care providers. Another resident developed a non-pressure injury that was not comprehensively assessed until several days after its initial documentation. The resident, who had a history of diabetes and other significant health issues, was noted to have a new blister and an open area near the rectum, which was not fully assessed until seen by the Wound Physician. The facility's process for wound assessment was hindered by technical limitations, such as a camera system that did not measure wound depth, and there was a lack of manual documentation to compensate for these limitations. The facility's failure to conduct comprehensive and consistent wound assessments, along with discrepancies in wound classification and documentation, contributed to the deficiency. The nursing staff, including a registered nurse who was not wound care certified, did not consistently review or align their documentation with that of the Wound Physician or the wound clinic, leading to ongoing issues in the management and treatment of the residents' wounds.
Inadequate Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for two residents with pressure injuries. One resident, identified as R7, had multiple pressure injuries, including a Stage 4 pressure injury to the left heel, a Stage 4 pressure injury to the left lateral foot, and a Stage 3 pressure injury to the left first toe. The facility did not comprehensively assess these wounds weekly, and there were inconsistencies in the documentation of the staging of the pressure injuries between the facility and the Wound Physician. The facility's documentation often lacked depth measurements, and the staging was not accurate according to the Wound Physician's assessments. Another resident, identified as R12, developed a Stage 2 pressure injury to the sacrum, which was not comprehensively assessed until a week later when seen by the Wound Physician. The facility's documentation incorrectly identified the wound as moisture-associated skin damage (MASD) rather than a pressure injury, as documented by the Wound Physician. Additionally, R12 developed a Stage 2 pressure injury to the right thigh, which was also not comprehensively assessed until several days later. The facility's documentation continued to misidentify the etiology of the wounds, and there were no depth measurements recorded. The facility's failure to accurately assess and document the pressure injuries led to a lack of consistent and appropriate care for the residents. The facility's policy required weekly assessments of pressure injuries, but this was not consistently followed. The use of a camera for wound assessments was cited as a reason for missing depth measurements, but manual measurements were not taken when the camera was not functioning. The discrepancies between the facility's documentation and the Wound Physician's assessments contributed to the deficiency in care provided to the residents.
Failure to Implement Fall Risk Interventions for a Resident
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures to prevent accidents for a resident identified as R5, who was at high risk for falls. R5 had a history of transient cerebral ischemic attack, essential tremor, and dementia with severe cognitive impairment. The care plan for R5 included interventions such as a low bed and a fall mat to mitigate the risk of falls. However, during an observation, it was noted that these interventions were not in place while R5 was in bed. The bed was not in the lowest position, and the fall mat was not next to the bed, contrary to the care plan requirements. The deficiency was further highlighted when a CNA, responsible for R5's care, was unaware of the fall risk interventions due to a printing error in the CNA care plan sheets. The CNA care plan did not list R5 as a fall risk, leading to the absence of necessary safety measures. Upon inquiry, the CNA found the fall mat in R5's bathroom and placed it next to the bed, and subsequently lowered the bed to the correct position. The RN and RNUM confirmed the oversight, attributing it to a printing error that omitted the fall interventions from the CNA care plan sheets for that day.
Inappropriate Use of Psychotropic Medications and Lack of Consent
Penalty
Summary
The facility failed to ensure that residents using psychotropic drugs had appropriate assessments, diagnoses, and consent, affecting two residents. One resident, identified as R9, was prescribed Quetiapine Fumarate, an antipsychotic, for dementia, which is not an appropriate indication for such medication. This resident was admitted with diagnoses including cerebral infarction, unspecified dementia, anxiety disorder, and major depressive disorder. The facility's policy on psychotropic medication use requires that medications be clinically indicated to treat a specific condition, which was not adhered to in this case. Another resident, R42, was prescribed Risperidone, an antipsychotic, for anxiety, and Citalopram, an antidepressant, without active consent. R42 was admitted with Alzheimer's disease, dementia, and anxiety disorder, but did not have a diagnosis of insomnia or sleep disturbance disorders. The consent for Citalopram was outdated, having been signed over 15 months ago, and the facility's policy requires consents to be updated every 15 months. Interviews with the Registered Nurse Unit Manager and the Director of Nursing confirmed the lack of appropriate diagnosis and consent for the antipsychotic medications prescribed to these residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madison Health And Rehabilitation Center | 1.7 mi | — | 8 | 0 |
| Oakwood Village East Health And Rehab Center | 4.9 mi | — | 2 | 1 |
| Capitol Lakes Health Center | 5.4 mi | — | 11 | 1 |
| Avina Of Sun Prairie | 6.7 mi | — | 10 | 0 |
| Sun Prairie Senior Living | 7.4 mi | — | 2 | 0 |
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