Oak Park Place of Nakoma: Quality Care Standards - WI
The resident, identified in inspection records only as R9, had just arrived from the hospital and was reporting pain at 9 out of 10. Records show she received a dose of oxycodone at 6:52 PM on August 8, 2025. What those records didn't reflect until a routine audit three days later was where the medication actually came from: two 5-milligram tablets pulled from a different resident's controlled drug supply.
R9's prescription called for 10-milligram tablets. The resident the tablets were taken from, R8, had a separate order for 5-milligram tablets. The orders were not the same.
RN2, the nurse who administered the medication, told inspectors she remembered checking the dosage but couldn't recall the specifics. "I pulled the medication oxycodone at 1900 on 08/08/25," she said, showing a photo she had taken on her personal phone of R8's controlled drug record. She said she knew oxycodone could cause drowsiness, respiratory distress, mood changes, and nausea. She said she had never done this before.
She also said she hadn't acted alone. Before pulling the medication, she spoke with ADM2, the administrator on duty, who was handling the situation by phone. "I asked if it was going to be a problem and [ADM2] said that it would be okay," RN2 told inspectors. "I realized that it was a medication error, but my Administrator said it was going to be okay, so I trusted her."
The Director of Nursing told inspectors she had been out of town when it happened. ADM2 called her, she said, and she told the administrator there wasn't much she could do from where she was. RN2 was the only nurse in the building.
The facility's five-day investigation report, signed August 19, documented the error. The response: education was provided to RN2, and the controlled drug record pages were spiral-bound so they could no longer be removed from a binder.
R9 had been reporting severe pain. The family was upset. And the one nurse in the building was left to solve it with a phone call and someone else's prescription.
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 only as R9, had just arrived from the hospital and was reporting pain at 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.