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Complaint Investigation

Oak Park Place Of Janesville

January 11, 2025 · Janesville, WI · 700 Myrtle Way
Citations 2
CMS Rating 2/5
Beds 35
Provider ID 525728
Healthcare Facility
Oak Park Place Of Janesville
Janesville, WI  ·  View full profile →
Inspection Summary

OAK PARK PLACE OF JANESVILLE in JANESVILLE, WI — inspection on January 11, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF677
Minimal harm or Few Based on interview and record review the facility must provide pharmaceutical services to meet the needs affected

Review of R6's Admission Record located in the Profile tab of the EMR. revealed R6 was admitted to the facility on [DATE] with diagnoses that included a left leg fracture, Parkinson's disease, and dementia.

Review of the admission MDS located in the MDS tab of the EMR with an ARD of 11/15/24 revealed R6 had a BIMS score of 13 out of 15 which indicated he was cognitively intact and was administered an antidepressant medication during the seven-day observation period.

Review of the Physician Orders located in the Orders tab of the EMR revealed Trazadone (an antidepressant medication) 50mg.

Give one tablet my mouth in the evening at 1800 [6:00 PM].

Start Date: 12/28/24.

Review of the Special Precautions on the banner located on the undated Face Sheet, revealed .Meds to be given between 6:30-7:00 PM d/t (due to) preference to go to bed around 7pm .

During an interview on 01/10/25 at 2:25 PM, FM1 stated, He did not get medication on time last night for his Parkinson's. It was supposed to be given to him between 6:30 PM and 7:00 PM but, it was after 7:30 PM. He was sleepier this morning. FM1 was asked if she had mentioned her concerns to the staff. FM1 stated, Yes, I spoke to the Regional Nurse about it, and he stated he would take care of it.

During an interview on 01/11/25 at 9:25 AM, FM1 was asked if R6's medication was given between 6:30 PM and 7:00 PM. FM1 stated, No he didn't. FM1 stated that an agency nurse was on duty last night who did not know what to do and did not give the medication until 7:15 PM. FM1 further stated, He did not even get his afternoon medications until 7:15 PM either. FM1 was asked if she had informed the Regional Nurse regarding this issue.

She stated, Yes, I did. He gave me his phone number personally if there was an issue with the timing of [R6's] medications.

During an interview on 01/11/25 at 10:30 AM, the Regional Clinical Nurse confirmed that R6's medications had been administered late. He stated, My expectation is the medications are to be administered, according to the special precautions banner.

525728

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 525728 B.

Wing 01/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Park Place of Janesville 700 Myrtle Way Janesville, WI 53545

Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed R4 was admitted to the facility on [DATE] with diagnoses that included pressure ulcers, a scalp burn, colon cancer, and osteomyelitis (a bone infection) of the left ankle and foot.

Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 12/25/24 revealed R4 had a Brief Interview of Mental Status (BIMS) score that was staff assessed as moderately independent. In addition, R4 had one stage 3 pressure ulcer, one deep-tissue injury and a scalp wound due to a burn he sustained at home and was administered intravenous antibiotics daily during the observation period.

Review of the Nursing Admission Form, dated 12/20/24 and located in the Assessments tab of the EMR, revealed documentation of R4's wound and skin issues.

However, there were no measurements or assessments of the wounds documented.

Review of the admission Physician Orders located in the Orders tab of the EMR, revealed:

-Wound Care to Shallow Leg Ulcers (LEFT): cleanse w/ normal saline.

Change 3x weekly & PRN [as needed].

Cover with Mepilex/foam dressing.

Dated 12/21/24.

-Wound Care to Lateral LEFT Foot: change dressing 3x/weekly & PRN.

Flush with normal saline.

Exufiber AG onto wounds.

Cover with Mepilex/foam dressing.

Dated 12/21/24.

-Wound Care to Scalp: BID flush w/ normal saline.

Apply Silvadene onto some dampened gauze (use saline to dampen).

Cover surface with ABD pad(s).

May use silicone tape or cohesive wrap to hold dressing in place.

Two times per day.

Dated: 12/21/24.

525728

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 525728 B.

Wing 01/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Park Place of Janesville 700 Myrtle Way Janesville, WI 53545

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in JANESVILLE, WI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from OAK PARK PLACE OF JANESVILLE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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