The resident's family member told federal inspectors that Oak Park Place of Janesville failed to follow the facility's own protocol requiring the man's Trazodone to be administered between 6:30 and 7:00 PM. Instead, the medication wasn't given until 7:15 PM on January 9, well past the resident's preferred bedtime of 7:00 PM.
"He was sleepier this morning," the family member told inspectors during a January 10 interview, explaining that the late medication affected the resident's next-day condition.
The resident, identified as R6 in inspection documents, was admitted to the facility with a left leg fracture, Parkinson's disease, and dementia. His physician had ordered 50 milligrams of Trazodone, an antidepressant medication, to be given at 6:00 PM each evening starting December 28, 2024.
But the facility's own special precautions banner specified an even narrower window: medications were to be given between 6:30 and 7:00 PM "due to preference to go to bed around 7pm."
The family member said she had already raised concerns about medication timing with the Regional Nurse, who promised to "take care of it." When the problem persisted, she contacted him again.
"He gave me his phone number personally if there was an issue with the timing of [the resident's] medications," she told inspectors.
The timing violation extended beyond the evening dose. The family member reported that the resident "did not even get his afternoon medications until 7:15 PM either."
During a January 11 interview, the Regional Clinical Nurse confirmed the medication delays occurred. "My expectation is the medications are to be administered, according to the special precautions banner," he told inspectors.
The medication violation was part of broader documentation failures discovered during the January 11 complaint inspection. Federal inspectors found that nursing staff had failed to maintain complete medical records for multiple residents, putting them at risk of unmet care needs.
One resident with T-cell lymphoma, skin cancer, and diabetes had severe wounds that went completely undocumented in required daily charting. The man had a stage four pressure ulcer on his sacrum exposing muscle, tendon, or bone, plus an unstageable pressure ulcer on his scrotum containing dead tissue, and a deep-tissue injury on his heels.
Despite these serious wounds identified in November assessments, nursing staff failed to document any skin or wound care in the required Medicare skilled charting forms for five consecutive days: November 14, 15, 16, 17, and 18. The wounds also went unmentioned in nursing progress notes.
"Anything out of the ordinary is to be documented on the Medicare and/or Skilled Charting or the Nursing Progress Notes," the Assistant Director of Nursing told inspectors. When shown the blank forms, she admitted: "I was not aware that the nurses' had not documented the wounds, they definitely should have."
A second resident with colon cancer, stage 3 ulcers, and diabetes experienced similar documentation gaps. This resident was receiving intravenous antibiotic therapy for a wound infection, yet nursing staff failed to complete required daily skilled charting on December 25, December 30, January 4, January 5, and January 9.
The Assistant Director of Nursing confirmed that the Medicare skilled charting "is to be done daily and updated with any new issue the resident develops."
Both documentation violations and the medication timing failure received minimal harm citations from federal inspectors, indicating actual harm that was not immediate jeopardy but could have led to more serious consequences.
The inspection occurred in response to a complaint, though the specific nature of the complaint was not detailed in the publicly available report. Oak Park Place of Janesville is located at 700 Myrtle Way and serves residents requiring various levels of care.
The facility's failure to follow its own medication timing protocols for a Parkinson's patient highlights how staffing issues with agency nurses can directly impact resident care. The family member's need to obtain the Regional Nurse's personal phone number suggests ongoing concerns about medication management at the facility.
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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.