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Complaint Investigation

Oakbrook Health And Rehabilitation

November 10, 2025 · Thorp, WI · 206 W Prospect St
Citations 2
CMS Rating 4/5
Beds 58
Provider ID 525472
Healthcare Facility
Oakbrook Health And Rehabilitation
Thorp, WI  ·  View full profile →
Inspection Summary

OAKBROOK HEALTH AND REHABILITATION in THORP, WI — inspection on November 10, 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

FF0600
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

using a raised voice. CNA P stated that telling a resident to shut up would be considered abuse.During an interview on 11/10/2025 at 9:40 AM, CNA F stated that if a resident told another resident to shut up, it was considered abusive. CNA F stated she had heard Resident #1 tell their roommate to shut up.During an interview on 11/10/2025 at 10:15 AM, the Director of Nursing (DON) stated verbal and emotional abuse included name calling, making derogatory remarks, and yelling at someone to get out of the way.

The DON stated if a resident was being told to shut up, it could be considered harassment.

During an interview on 11/10/2025 at 11:10 AM, the Administrator stated both residents were highly confused, and she did not know if they were really hearing what was being said.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Oakbrook Health and Rehabilitation

206 W Prospect St Thorp, WI 54771

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 10/22/2025 at 12:51 PM, Licensed Practical Nurse (LPN) L stated Resident #1 had behaviors, was disruptive, and yelled out.

During an interview on 10/22/2025 at 1:19 PM, the Minimum Data Set (MDS) Coordinator stated that Resident #1 was not compliant with care and refused care.

The MDS Coordinator acknowledged Resident #1's care plan should have been updated with interventions related to continuous behaviors of yelling.

The Medical Director (MD) was interviewed on 10/23/2025 at 9:12 AM.

The MD stated that at minimum interventions should have been care planned for all re-occurring behaviors and reassessed for effectiveness.

During an interview on 10/23/2025 at 10:11 AM, the Director of Nursing acknowledged that Resident #1's care plan should have been updated with interventions related to the resident's behaviors.

The Administrator was interviewed on 10/23/2025 at 10:37 AM.

The Administrator acknowledged Resident #1's care plan should have been updated with interventions related to their behaviors.

During an interview on 11/10/2025 at 1:49 PM, the Social Services Director stated they had determined there was a problem in their system with updating the CAAs that were checked on the MDS.

Facility ID:

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 THORP, 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 OAKBROOK HEALTH AND REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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