Oak Park Place of Nakoma: Medication Rights Lapses - WI
The resident, identified in inspection records as R9, had just arrived from the hospital and was reporting pain at a 9 out of 10. The nurse, RN2, pulled two 5-milligram oxycodone tablets from the supply belonging to R8, a different resident, and administered them to R9 at 6:52 PM on August 8, 2025. R9's prescription called for 10-milligram tablets. R8's prescription called for 5-milligram tablets. The orders were not the same.
RN2 told inspectors she called Administrator ADM2, who was handling the situation over the phone. "I asked if it was going to be a problem," RN2 said, "and [ADM2] said that it would be okay." RN2 said she would not have given the medication otherwise. "I trusted her."
She knew the risks. When asked about the effects of narcotic pain medication, RN2 listed them without hesitation: drowsiness, respiratory distress, mood changes, nausea. She said she had never done this before with other residents and, at the time, did not think of it as a medication error. "I was trying to solve a crisis," she said. "The patient just came from the hospital and the family was upset."
The Director of Nursing told inspectors she was out of town when it happened and learned about it from ADM2 by phone. RN2 was the only nurse in the building that night.
The error wasn't caught until August 11, three days later, during a routine audit. A five-day investigation report, signed August 19 by a Regional Registered Nurse, confirmed what had happened.
The facility's response was education for RN2 and a change to how controlled drug records are stored — the pages are now spiral bound instead of kept in a binder.
R9 received twice the prescribed opioid dose while reporting near-maximum pain. Whether that combination caused any harm to R9 is not addressed in the inspection record.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Park Place of Nakoma from 2025-12-23 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Oak Park Place of Nakoma in Madison, WI was cited for violations during a health inspection on December 23, 2025.
The resident, identified in inspection records as R9, had just arrived from the hospital and was reporting pain at a 9 out of 10.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.