JANESVILLE, WI - Federal inspectors identified significant deficiencies at Oak Park Place of Janesville during a January 11, 2025 inspection, including failures to properly monitor and treat wounds and insufficient nursing staff to meet resident needs.
Critical Wound Care Management Failures
Inspectors documented serious breakdowns in wound care protocols for a resident with multiple severe injuries. The resident was admitted with a stage 3 pressure ulcer, deep-tissue injury, scalp burn, and underlying bone infection requiring daily intravenous antibiotics.
Documentation revealed the resident repeatedly refused wound care treatments, telling staff "If they aren't bleeding, they do not need to be changed" and "I don't care, it's not needed." Despite the facility's policy requiring supervisor notification when residents refuse wound care, no evidence showed medical providers were informed of these refusals.
The facility's documentation showed significant gaps in wound assessment and monitoring. Initial wound measurements were not recorded upon admission, and the first comprehensive wound evaluation did not occur until six days later. During this assessment, staff documented multiple wounds including an 11.6 x 11.2 cm burn and a 2.6 x 4.7 x 1.9 cm stage 3 pressure ulcer.
Further complicating care, nursing staff administered incorrect wound treatments. Medical orders specified Silvadene cream for the scalp burn, but staff applied Medi-honey instead. Between January 1-10, 2025, the resident refused wound care twice and only accepted treatment twice out of five scheduled opportunities.
Medical Implications of Wound Care Failures
Proper wound care is essential for preventing serious complications, particularly for residents with compromised healing capacity. Stage 3 pressure ulcers involve full-thickness tissue loss and require consistent monitoring to prevent progression to stage 4 ulcers, which can involve muscle and bone damage.
When wound dressings remain unchanged, bacterial contamination increases significantly. For residents receiving intravenous antibiotics for bone infections, as in this case, untreated wounds can become additional infection sources. The combination of diabetes, pressure ulcers, and bone infection creates a particularly high-risk scenario where delayed healing and systemic complications are common.
Standard medical protocols require daily wound assessment documentation, including measurements, drainage characteristics, and healing progress. Provider notification of treatment refusals ensures appropriate medical intervention and care plan modifications when necessary.
Staffing Shortages Compromise Care Quality
The inspection revealed widespread staffing deficiencies affecting resident care across all shifts. The facility's own assessment indicated needs for one nurse and one to three certified nursing assistants (CNAs) per shift, but actual staffing fell significantly short.
Critical gaps included multiple shifts with no licensed nurse coverage. On January 10, the second shift operated from 6:00 PM to 10:00 PM without any registered nurse or licensed practical nurse present. The overnight shift the same night had no licensed nursing coverage, relying only on a certified medication technician and one CNA.
Residents and families directly reported the impact of understaffing. One resident waited 22 minutes for call light response when requesting bathroom assistance. Family members described wait times up to 45 minutes for toilet assistance, resulting in incontinence incidents.
"Call lights are not answered timely, and he ends up wetting himself because it's taken too long," one family member reported. Another stated, "There are so many call lights going on during the night and the CNAs are working like crazy to get them answered, but there isn't enough staff."
Staff Acknowledge Insufficient Resources
Multiple staff members confirmed inadequate staffing levels during interviews. One CNA explained, "We are only two CNAs today but was supposed to have three. We have to answer the call lights first, get showers done, make sure everyone is fed, there just isn't enough time."
The facility's Assistant Director of Nursing directly acknowledged the problem, stating, "I agree, there just isn't enough staff for the residents." An occupational therapist noted that post-hospital residents have particularly high care needs, commenting, "These residents are in a state of transition from being in the hospital and their needs can be much. No, I think they could use more help."
Agency nurses filling staffing gaps reported being too busy with medication administration and treatments to assist with call lights, further reducing available care capacity.
Additional Issues Identified
The inspection documented additional concerns including communication breakdowns between nursing leadership, with the Regional Clinical Nurse stating the Director of Nursing did not return calls regarding wound documentation practices. The facility's wound care spreadsheet system appeared inadequately maintained, contributing to assessment gaps.
Federal regulations require nursing homes to maintain sufficient staffing to ensure resident safety and achieve optimal physical and mental well-being. The documented deficiencies indicate systemic failures in both clinical care protocols and staffing management that directly impacted resident care quality and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Park Place of Janesville from 2025-01-11 including all violations, facility responses, and corrective action plans.
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