Oakbrook Health And Rehabilitation

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

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.

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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

11/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oakbrook Health and Rehabilitation

206 W Prospect St Thorp, WI 54771

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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

their roommate.Resident #1's progress notes revealed an entry dated 08/17/2025 at 11:13 PM that indicated Resident #1 became loud and disruptive at bedtime, yelling and screaming out to their roommate to Shut up and Shut your mouth.Resident #1's progress notes revealed an entry dated 08/22/2025 at 5:33 AM that indicated Resident #1 continued to yell Shut up at their roommate because the roommate was talking. The note indicated Resident #1 did not like their roommate talking and continued to yell out.Resident #1's progress notes revealed an entry dated 08/24/2025 at 09:29 AM that indicated Resident #1 was yelling, being disruptive, and interfering with other residents' abilities to sleep. The progress note revealed Resident #1 stated they did not feel well, but refused to take their medications. The progress note revealed the facility called a family member to come to the facility to manage [Resident #1's] behaviors.Resident #1's progress notes revealed an entry dated 08/26/2025 at 6:38 AM that indicated Resident #1 yelled at their roommate throughout the shift, Shut up and Stop talking. The note indicated Resident #1 was educated that it was not appropriate to yell at people and that others were trying to sleep.

The note indicated Resident #1 stated, I don't care, I can't sleep with [the roommate] talking. The note indicated that staff had not heard the roommate talking.Resident #1's progress notes revealed an entry dated 08/27/2025 at 2:08 AM that indicated Resident #1 yelled, Shut up at their roommate, who was not talking. The note indicated Resident #1 was reminded that others were trying to sleep, but Resident #1 continued to yell out. The note indicated Resident #1 was taken to the television (TV) room for a period of time, and once their roommate fell asleep, Resident #1 was assisted back into bed.Resident #1's progress notes revealed an entry dated 08/27/2025 at 9:07 AM that indicated Resident #1 screamed at others and made disruptive sounds daily. Resident #1's Care Plan, printed on 10/21/2025, revealed no documented evidence of goals or interventions related to the resident's ongoing verbal behavioral symptoms. 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.

Event ID:

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If continuation sheet