Oak Park Place Of Nakoma
Oak Park Place of Nakoma in Madison, WI — inspection on December 23, 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.
Inspection Findings
Review of R6's assessments located under the Assessments tab of the EMR, revealed that R6 was not assessed for self-administration of medications.Review of all progress notes under the Progress Notes tab in the EMR, revealed that 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 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 R6 and interview on 12/23/25 at 7:46 AM, while Registered Nurse (RN) 1 was pulling the morning medications to administer to 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, 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, 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. 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.
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
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/23/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Park Place of Nakoma
4327 Nakoma Rd.
Madison, WI 53711
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 12/22/25 at 4:34 PM, RN2 stated, I did give medication from another patient to give to 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 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 [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.
Facility ID: