Oak Park Place Of Janesville

F-F677: ADL's (activities of daily living) for dependent residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 18 525728 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32513

Residents Affected - Few Based on interview and record review the facility must provide pharmaceutical services to meet the needs for 1 (Resident R6) of 8 sampled residents. Resident R6 did not receive his Trazadone per Resident R6's preference and physician's orders resulting in a timing error.

Review of Resident R6's Admission Record located in the Profile tab of the EMR. revealed Resident R6 was admitted to the facility on [DATE REDACTED] 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 Resident 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 Resident 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 [Resident R6's] medications.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 18 525728 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32513

Residents Affected - Few Based on interviews and record reviews, the facility failed to maintain a complete and accurate medical

record for 2 (Resident R1 and Resident R4) of 8 sample residents. The facility failed to ensure the daily Medicare and/or Skilled Charting documentation contained skin/wound documentation for Resident R1. In addition, the daily Medicare and/or Skilled Charting assessments were not completed daily, as required for Resident R4. This failure placed the residents at risk of unmet care needs.

Findings include:

Example 1

Review of Resident R1's Admission Record located in the Profile tab of the electronic medical record (EMR) revealed, Resident R1 was admitted to the facility on [DATE REDACTED] with diagnoses which included T-cell Lymphoma (a rare type of cancer), skin cancer, and diabetes.

Review of the admission Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 11/29/24 revealed that Resident R1 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated he was cognitively intact and had no skin issues.

Review of the Skin/Wound assessments, dated 11/14/24 and located in the Skin/Wound tab in the EMR, revealed the following identified wounds and pressure ulcers.

-Stage four (a full-thickness loss of tissue with exposed muscle, tendon, or bone) on the sacrum.

-An unstageable pressure ulcer (a full thickness-loss of tissue with the wound bed containing necrotic tissue (dead tissue) on the scrotum.

-A deep-tissue injury on the heels.

Review of the daily Medicare and/or Skilled Charting documentation (a required document for all residents who have Medicare/Insurance as their primary payor source) located in the Assessments tab of the EMR, revealed no documentation regarding Resident R1's skin/wounds on the 11/14/24, 11/15/24, 11/16/24, 11/17/24 and 11/18/24 Medicare and/or Skilled Charting forms.

In addition, a review of the Nursing Progress Notes located under the Progress Notes tab of the EMR did not contain documentation regarding Resident R1's skin or pressure wounds.

During an interview on 01/10/24 at 10:36 AM, the Assistant Director of Nursing (ADON) was asked what the expectation was regarding completing the daily Medicare and/or Skilled Charting by the nursing personnel.

The ADON stated, Anything out of the ordinary is to be documented on the Medicare and/or Skilled Charting or the Nursing Progress Notes. The ADON was shown the Medicare and/or Skilled Charting forms for the above dates and the lack of documentation regarding the skin/wounds. The ADON stated, I was not aware that the nurses' had not documented the wounds, they definitely should have.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 18 525728 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Example 2

Level of Harm - Minimal harm or Review of Resident R4's Admission Record located in the Profile tab of the EMR revealed Resident R4 was admitted to the potential for actual harm facility on [DATE REDACTED] with diagnoses that included colon cancer, stage 3 ulcers, and diabetes.

Residents Affected - Few Review of the admission MDS located in the MDS tab of the EMR with an ARD of 12/25/24 revealed Resident R4 had

a staff assessed BIMS of moderately independent, had one stage 3 pressure ulcer, one deep-tissue injury, and was on intravenous antibiotic therapy for a wound infection.

Review of the Medicare and/or Skilled Charting located in the Assessments tab of the EMR, revealed on 12/25/24, 12/30/24, 01/04/25, 01/05/25 and 01/09/25 there was no documentation that nursing personnel had documented Resident R4's care.

During an interview on 01/10/25 at 12:20 PM, the ADON was asked what the expectation was regarding the daily Medicare and/or Skilled Charting documentation. The ADON stated, The 'Medicare and/or Skilled Charting' documentation is to be done daily and updated with any new issue the resident develops.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 18 525728

F-F725: Sufficient Staffing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 18 525728 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 32513 potential for actual harm Based on interview and record review the facility failed to consistently assess and monitor pressure ulcers Residents Affected - Few and wounds. In addition, the facility failed to inform the provider upon admission and when wound care was refused for 1 of 2 residents (Resident R4) reviewed for wounds out of 8 sampled residents.

Findings include:

Review of the facility's policy and procedure titled, Wound Care, dated October 2010, revealed . DOCUMENTATION .The following information should be recorded in the resident's medical record .The type of wound care given .The date and time the wound care was given .The position in which the resident was placed .The name and title of the individual performing the wound care .Any change in the resident's condition .All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound .How the resident tolerated the procedure .Any problems or complaints made by the resident related to the procedure .If the resident refused the treatment and the reason(s) why .The signature and titled of the person recording the data .REPORTING .Notify the supervisor if the resident refuses the wound care .Report other information in accordance with facility policy and professional standards of practice .

Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed Resident R4 was admitted to the facility on [DATE REDACTED] 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 Resident R4 had a Brief Interview of Mental Status (BIMS) score that was staff assessed as moderately independent. In addition, Resident 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 Resident 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 18 525728 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 -Ceftriaxone (an antibiotic medication given intravenously) 2 grams one time a day for Diabetic Foot Infection for 14 days. Start Date: 12/21/24 End Date: 01/04/24. Level of Harm - Minimal harm or potential for actual harm Review of a Health Status Note, dated 12/20/24 and located in the Progress Notes tab of the EMR, revealed Resident will not allow staff to change wound dressings. Resident stated, 'If they aren't bleeding, they do not Residents Affected - Few need to be changed.' LPN [Licensed Practical Nurse] educated resident that wound dressings need to be changed PRN [as needed] especially when they are soiled and leaking. The resident stated, 'I don't care, it's not needed.' LPN attempted another time to change wound dressings and resident still refused dressing changes Will continue to monitor and educate.

The Health Status Note did not show documentation that the provider was notified of Resident R4's continued refusal to have wound dressings changed.

Review of the Nursing Progress Note, dated 12/21/24 and located in the Progress Notes tab of the EMR, revealed Resident took his bandage off of his head and writer attempted to rebandage head and resident started to yell at writer and said he does not need a bandage on his head if it's not bleeding. Resident is refusing to use call light and attempting to self-transfer (sic) himself in his room.

Review of a Nursing Progress Note, dated 12/21/24 and located in the Progress Notes tab of the EMR, revealed Has open areas largest being the top of his head, area on top of head cleansed and Medi honey applied. According to the admission Physician Orders, dated 12/20/24, for the scalp wound, Silvadene was to be applied and not Medi-honey.

Review of the 12/26/24 Skin and Wound Evaluation assessment form, dated 12/26/24 and located in the Assessments tab in the EMR, revealed the Director of Nursing (DON) had measured and assessed the wounds (six days after admission). The following wounds were documented:

-A deep-tissue injury, pressure located on the right medial Achillies heel of unknown duration which measured 1.8 x 2.4 cm (centimeters).

-Dry, pink areas on left buttock of unknown duration.

-An abrasion to a kneecap of unknown duration which measured 1.4 x 0.9 cm.

-A pressure ulcer, stage 3 (full-thickness loss of tissue), left mid foot which measured 2.6 x 4.7 x 1.9 cm of unknown duration.

-Burn which measured 11.6 x 11.2cm.

In addition, there was no documentation on the Skin and Wound Evaluation to show that the provider had been updated on the wounds.

Review of the Nursing Progress Notes did not show any additional documentation regarding the wounds.

Review of the Physician Orders located in the Orders tab of the EMR revealed, Ceftriaxone 2 grams intravenously was to be continued from 01/04/25 to 01/18/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 18 525728 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Review of the January 2025 Treatment Administration Record (TAR) located in the Orders tab of the EMR, revealed between 01/01/25 and 01/10/25, Resident R4 refused wound care two times, was in the hospital one time Level of Harm - Minimal harm or and accepted wound care two out of five opportunities. potential for actual harm There was no documentation in the Nursing Progress Notes to show the provider had been updated and was Residents Affected - Few aware of Resident R4's refusal to have wound care performed.

During an interview on 01/11/25 at 8:45 AM, the Regional Clinical Nurse was asked why there was no assessment and monitoring for Resident R4's wounds. The Regional Nurse stated, The DON keeps a spreadsheet on wounds however, when I contacted the DON regarding her wound documentation, she did not return my call. It's safe to say, the assessment and monitoring of the wounds was not done. As for lack of Provider notification, it's safe to say that wasn't done either.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 18 525728 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Level of Harm - Minimal harm or potential for actual harm 32513

Residents Affected - Many Based on interviews, record review, and document review, the facility failed to ensure sufficient nurse staffing to provide nursing and related services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 4 of 4 residents and/or representatives (Resident R8), Family Member (FM1) FM2, and FM3 out of a census of 20 residents.

Findings include:

1. Review of the Facility Assessment, provided by the Administrator, revealed the assessment was updated

on 08/24/24. The total number of beds available was 35. The average daily census was 19 for short-stay residents and zero for long-term residents. The average number of residents that were admitted to the facility per day was one to two on weekdays and zero to one on the weekends. The average number of resident discharges was zero to one per day.

In addition, the Facility Assessment revealed that there are six full-time Registered Nurses (RN)s, three full-time Licensed Practical Nurses (LPN)s and 25 full-time Certified Nurse Aide (CNA) positions available. Based on condition/acuity, and census the following was the number of staff necessary for care of the residents: one Nurse Manager on the first shift; one RN/LPN on each shift and on weekends/holidays; and one to three CNAs on first and second shift and one to two CNAs on the third shift. In addition, there were one to three CNAs on the weekends.

2. Review of the Nurse Staffing Schedule provided by Human Resources (HR) revealed the following staffing from 01/09/25 to 01/11/25:

a. 01/09/25: First Shift (6:00 AM to 2:00 PM): one RN for eight hours and two CNAs for eight hours. One CNA, who was scheduled but called off and did not work.

Second Shift (2:00 PM to 10:00 PM): One RN for four hours and one LPN for four hours. There were three CNAs for eight hours.

Third Shift (10:00 PM to 6:00 AM): One LPN for eight hours, one CMT (Certified Medication Technician) and one CNA for eight hours.

b. 01/10/25: First shift: one RN for eight hours; one staffing agency LPN for eight hours due to the regularly scheduled LPN having called off, and two CNAs as the third CNA did not show up for work.

Second shift: One staffing agency LPN for four hours. There was no RN or LPN identified to have worked from 6:00 PM to 10:00 PM. There were two CNAs for eight hours.

Third shift: No RN or LPN was identified to have worked in the skilled unit from 10:00 PM to 6:00 AM. There was one CMT for eight hours and one CNA for eight hours.

c. 01/11/25: First shift: One staffing agency RN for eight hours and two CNAs for eight hours. One CNA had called off and did not work.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 18 525728 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Second shift: One staffing agency RN for four hours, one staffing agency LPN for four hours and three CNAs for eight hours. Level of Harm - Minimal harm or potential for actual harm Third shift: one staffing agency LPN for eight hours, one CMT for eight hours, and one CNA for eight hours.

Residents Affected - Many 3. During an observation and interview on 01/11/25 at 9:45 AM, the call light was observed to have been activated. Resident R8 was asked why she turned on her call light. Resident R8 stated, I need to go to the bathroom. Resident R8 was asked if her call light was answered timely. Resident R8 stated, No, it does take a long time, but they do work their butts off, but it does take a long time. During a continuous observation of Resident R8's call light response time, the light was answered in 22 min.

Review of the admission Minimum Data Set (MDS) located in the MDS tab of the electronic medical record (EMR) with an Assessment Reference Date (ARD) of 11/19/24 revealed Resident R8 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated she was cognitively intact.

4. During an interview on 01/09/25 at 1:27 PM, FM1 stated, After dinner and up to around 8:00 PM, there just isn't enough staff. Sometimes it takes up to 45 minutes to get assistance to use the toilet.

During an interview on 01/10/25 at 1:10 PM, FM2 was asked if there was enough staff to meet Resident R5's needs. FM2 stated, No, there isn't. Call lights are not answered timely, and he ends up wetting himself because it's taken too long.

During an interview on 01/11/25 at 9:25 AM, FM3 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.

5. During an interview on 01/10/25 at 1:29 PM, CNA1 was asked if there were enough staff to care for the residents. CNA1 stated, No, there isn't. CNA1 further stated, We are only two CNAs today but was supposed to have three. We have to answer the call lights first, get the showers done, make sure everyone is fed, there just isn't enough time.

During an interview on 01/10/25 at 2:15 PM, the Occupational Therapist (OT) was asked if she felt there was enough staff to meet the needs of the residents. The OT stated, 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.

During an interview on 01/10/25 at 2:43 PM, the Assistant Director of Nursing (ADON) was asked if she felt there was enough staff to meet the needs of the residents. The ADON stated, I agree, there just isn't enough staff for the residents.

During an interview on 01/11/25 at 9:54 AM, Registered Nurse 2 (RN-staffing agency) stated, I have only worked here one other time. RN2 was asked if she helped answer call lights. RN2 stated, No, I don't have time as I am too busy with passing medications and doing treatments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 18 525728 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 During an interview on 01/11/25 at 10:05 AM, CNA2 stated, I work in the Memory Care Unit but was pulled down to the skilled area today. CNA2 was asked how she got everything done when there were only two Level of Harm - Minimal harm or CNAs working. CNA2 stated, We just try and go with flow. I have a pager and when I hear the call light go potential for actual harm off, I will try and answer it.

Residents Affected - Many During an interview on 01/11/25 at 10:10 AM, CNA3 was asked if she felt there was enough staff to meet the needs of the residents. CNA3 stated, We just try and make sure everyone is fed, toileted, their beds are made, and the call lights are answered, it's a lot of work. CNA3 was asked if she worked in the skilled area regularly. She stated, No, I was pulled from the Assisted Living area to work here today.

During an interview on 01/10/24 at 4:00 PM, the Administrator and Regional Clinical Nurse were asked if there was enough staff to meet the residents' needs. The Administrator stated, Our staffing numbers exceed

the State of Wisconsin minimum requirements. The Regional Nurse then stated, It appears that we are not utilizing the staff effectively.

Cross-reference: