Oak Park Place Of Nakoma

F 0554

Allow residents to self-administer drugs if determined clinically appropriate.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, record review, and facility policy review, the facility failed to ensure residents were assessed for self-administration of medications for one of four residents (Resident (R) 6) reviewed for self-administration of medications out of 12 sample residents. Findings include:Review of the facility's policy titled, Administering Medications, last revised April 2019, revealed the policy statement, Medications are administered in a safe and timely manner, and as prescribed and Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.Review of Resident R6's admission Record located under the Profile tab of the electronic medical record (EMR) revealed Resident R6 was admitted to the facility

on [DATE REDACTED] with diagnoses that included fibromyalgia, anxiety disorder, chronic kidney disease stage 3A, and hypertension.Review of Resident R6's care plan, dated 12/16/25 and located under the Care Plan tab of the EMR, revealed .has demonstrated a decreased ability to perform activities of daily living (ADLs) related to impaired mobility. Interventions in place, dated 12/16/25, included .currently requires set-up assist by one staff with eating.wears glasses, and wears hearing aids. Review of Resident R6's assessments located under the Assessments tab of the EMR, revealed that Resident R6 was not assessed for self-administration of medications.Review of all progress notes under the Progress Notes tab in the EMR, revealed that Resident R6 was not assessed for self-administration of medications.Review of the orders located under the orders tab of the EMR revealed no orders related to self-administration of medication. Review of the Medication Administration Record (MAR) located under the orders tab of the EMR, revealed Resident R6 had a physician's order for Ipratropium Bromide Nasal Solution 0.06 % (Ipratropium Bromide (Nasal)) two spray in both nostrils three times a day for seasonal allergic rhinitis, start date 12/16/25.During an observation for medication administration for Resident R6 and interview on 12/23/25 at 7:46 AM, while Registered Nurse (RN) 1 was pulling the morning medications to administer to Resident R6, RN1 stated, I don't have the nasal spray in the cart because usually the other nurses leave the nasal spray in the resident's room because she can do it by herself.

During this observation, Resident R6 picked up the nasal spray from a white box located on top of her bedside table and administered the nasal spray in front of RN1.During an observation and interview on 12/23/25 at 8:02 AM, when asked what the white bottle was on her bedside table, Resident R6 stated, that's my nasal spray. They leave it there because I have been using nasal spray for a long time and I can do it on my own. Resident R6 proceeded to demonstrate how she had to hold the right nostril closed as she sprayed in the left nostril and then she demonstrated how to spray in the right nostril.During an interview on 12/23/25 at 3:50 PM, the Director of Nursing (DON) stated that when a resident was able to administer their own medications, this would be documented in the assessments tab of the EMR, it will also be care planned, and they had an Interdisciplinary Team (IDT) meeting progress note stating that the resident was able to self-administer their own medications.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Park Place of Nakoma

4327 Nakoma Rd.

Madison, WI 53711

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

on 08/08/25, for oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) (a narcotic pain medication). Give one tablet by mouth every four hours as needed, for pain.Review of Resident R9's MAR located under the Orders tab of

the EMR, revealed that Resident R9 was administered the narcotic pain medication, oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) Give one tablet by mouth every four hours as needed for pain, on 08/08/25 at 6:52 PM. This record also revealed that Resident R9 had a pain level of 9/10, indicating that Resident R9 was experiencing strong/severe pain at that time.Review of the five-day investigation report that was signed on 08/19/25 by

the Regional Registered Nurse (RRN) and provided by the facility, revealed that on 08/11/25, during a routine audit, it was discovered that two 5MG Oxycodone tablets were withdrawn from Resident R8's medication card and these two tablets were administered to Resident R9. This investigation further revealed that the two Oxycodone physician orders for the two residents were not the same. Resident R8 had an order for five milligram Oxycodone tablets and Resident R9 had an order for ten milligram Oxycodone tablets. This investigation further revealed that Administrator (ADM) 2 gave instructions to RN2 to remove two Oxycodone tablets from Resident R8's supply and administer these two Oxycodone tablets to Resident R9. During an interview on 12/22/25 at 4:34 PM, RN2 stated, I did give medication from another patient to give to Resident R9. I do remember that the patient I borrowed from, they don't use their pain medication on a daily basis. I had this other patient that was in big pain, and the family was not happy. When asked if she checked if the dosage of the two orders were the same, RN2 stated, Yes, I did check definitely. Oxycodone 5 milligram tablets I pulled but I really cannot remember now what exactly

the dosage was. When asked if she knew the effects of narcotic pain medication, she stated, drowsiness, respiratory distress, mood changes, and nausea. RN2 further stated, I have never done this before with other residents. When asked what prompted her to do what she did, she stated, when I spoke with [ADM2],

she was trying to solve a crisis over the phone. I asked if it was going to be a problem and [ADM2] said that

it would be okay. (RN2 pulled out her personal telephone and showed a picture of a section of Resident R8's 'Controlled Drug Use Record') while she stated, I pulled the medication oxycodone at 1900 on 08/08/25.

When asked if she would consider this action a medication error, she stated, Well, in my honest opinion, I thought I was trying to solve a crisis, the patient just came from the hospital and the family was upset, at

the time I didn't think that it was a medication error, because I was trying to solve a problem because the patient was in big pain. I realized that it was a medication error, but my Administrator [ADM2] said it was going to be okay, so I trusted her. I don't mean to blame her [ADM2], but she told me it was going to be okay, otherwise, I wouldn't have given the medication to [Resident R9].During an interview on 12/23/25 at 3:49 PM,

the Director of Nursing (DON) stated, there was a new admit and I was not in the building at the time it happened. [ADM2] called me and I told her there was not much I could do from where I was at. I was out of town. [RN2] was the only nurse in the building because the census was enough for one nurse. Education was provided to [RN2] to prevent this from happening again and the Controlled Drug Use Record pages are now spiral bound and no longer kept in a binder.

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Facility ID:

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