Oakbrook Health And Rehabilitation
OAKBROOK HEALTH AND REHABILITATION in THORP, WI — inspection on January 29, 2026.
Found 3 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
Minimum Data Set (MDS) for 1 of 1 resident reviewed (R1).R1 had a Preadmission Screening and
admitted to the facility on [DATE].Surveyor reviewed R1's health record. PASARR 1 was completed upon admission dated 03/01/24. PASARR 2 was completed on 03/13/24.Surveyor reviewed R1's MDS assessments.
The annual MDS on 03/01/24 indicated R1 did not have a PASARR 1 completed. A correction was made to reflect that R1 did in fact have both PASARR 1 and 2 completed.Upon further review, the MDS assessments completed after the correction had the previous information stating R1 did not have either PASARR completed.On 01/28/26 at 2:46 PM, Surveyor interviewed Social Worker (SW) D. SW D stated PASARR level 1's are completed upon admission and if the resident will be there 30 days or less, SW D would send the information to the county. SW D stated if the resident would be there longer than 30 days, the PASARR 2 will be submitted right away. SW D stated SW D updates the MDS all the time when changes occur.
Surveyor showed SW D where the MDS assessments indicated no PASARRs were completed. SW D stated SW D would look into it.On 01/28/26 at 3:05 PM, Surveyor interviewed Clinical and Quality Consultant (CQC) E. CQC E stated there may be a glitch in the system that is pulling the old information from the MDS. CQC E stated there was a nurse working at the time that may have changed the information on the MDS back to the original information, but that nurse no longer worked there. CQC E stated CQC E stated it may not help at this time, but the facility would be working on fixing the issue so it would not continue to occur.
525472 01/29/2026
Oakbrook Health and Rehabilitation 206 W Prospect St Thorp, WI 54771
after a positive COVID test. DON B stated DON B would update Surveyor if DON B found any other
On 02/02/26, Nursing Home Administrator (NHA) A submitted additional information to Surveyor. A
dialog indicated RN I worked from 5:58 AM to 10:05 AM and 10:33 AM to 3:31 PM on 01/01/26.
The timecard indicates RN I worked from 5:57 AM to 6:18 AM on 01/02/26 which does not correlate with a positive test on 01/01/26.
Example 3 Facility's policy titled Standard and Transmission-Based Precautions revised date of 02/24 read in part, Change gloves, as necessary, during the care of a resident to prevent cross-contamination from one body site to another (i.e. when moving from a contaminated body site like the perineal area to a clean body site like the face). f.
Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces.
On 01/28/2026 at 9:10 AM, Surveyor observed Certified Nursing Assistant (CNA) C and CNA J provide R2 with personal care. R2 is on enhanced barrier precautions. CNA C applied a gown and gloves and entered R2's room. CNA C gathered R2's clothes. CNA C placed a clean washcloth in the bottom of the sink and ran water over the washcloth. CNA C did not use a basin in the sink for washing R2. CNA C took the washcloth from the bottom of the sink and applied bar soap to the washcloth. CNA C washed R2's peri area with the contaminated washcloth. CNA C and CNA J rolled R2 to the left, and CNA C used the same washcloth and washed buttocks and anal area. CNA C did not rinse the peri area and buttocks. CNA C dried the buttocks and applied a clean brief. CNA C did not remove gloves and continued to provide care to R2. CNA C placed a clean washcloth in the bottom of the sink and ran water over the washcloth. CNA C put bar soap on the washcloth and washed R2's right hand and applied hand brace.
Surveyor observed R2's hand brace appeared to be soiled on the palm portion of the brace. CNA C and CNA J transferred R2 to wheelchair using the Hoyer lift.
While transferring, R2's left hand held onto the Hoyer lift cross bar.
Surveyor observed the protective cover of the Hoyer lift cross bar appeared to be soiled. CNA C, with the same contaminated gloved hands, wet a toothette and squeezed the toothette with contaminated gloved hands and gave the toothette to R2 to cleanse mouth. CNA C, with the same contaminated gloved hands, got another toothette and squeezed the toothette with the same contaminated gloved hands. CNA C placed a washcloth in bottom of the sink and let the water run over the washcloth. CNA C, with the same contaminated gloves, took the wet washcloth and washed R2's face. CNA J wiped the Hoyer lift with sanitizing wipes and did not cleanse the protective cover of the cross bar.
Surveyor interviewed CNA C and CNA J asking when R2's hand brace is cleaned. CNA C and CNA J did not know when the brace was to be cleaned.
Surveyor asked if the cover of the cross bar gets cleaned or laundered. CNA J stated it looks a little dirty and did not know if there is a replacement or when the protective cover gets cleaned.
On 01/29/2026 at 11:20 AM, Surveyor interviewed Director of Nursing (DON) B about expectation during personal cares for R2.
Surveyor reviewed with DON B of the observation with CNA C providing R2 personal cares. DON B stated this is not the expectation of care being provided.
Education will be provided for staff. DON B stated a basin should have been used and the washcloths not put in the sink.
After washing the peri area with bar soap, the area should have been rinsed.
Gloves should be changed.
Toothette should not have been touched with the contaminated gloved hands.
525472 01/29/2026
Oakbrook Health and Rehabilitation 206 W Prospect St Thorp, WI 54771
Review of R36's hospital discharge orders documented on 01/13/26 order for doxycycline 50 mg daily for meibomian gland dysfunction.
With no end date.
Review of the facility's antibiotic stewardship line lists did not document R36 being prescribed antibiotics of doxycycline and Valtrex.On 01/29/2026 at 8:53 AM, Surveyor interviewed Director of Nursing (DON) B asking if R36's use of doxycycline and reason for use should be listed on the facility's antibiotic stewardship infection control line list. DON B stated anyone on an antibiotic is to be on the line list. On 01/29/2026 at 9:50 AM, Surveyor interviewed DON B asking if R36 should be listed on the antibiotic stewardship infection control line list for Valtrex and reason for use. DON B stated this must have been missed. On 01/29/2026 at 11:50 AM, Surveyor interviewed DON B about Valtrex for a stop date. DON B stated had just found the diagnosis listed for Valtrex was incorrect.
Surveyor asked if the information about the end date and reasons for both antibiotics should have been verified at the time of admission. DON B stated this information should have been found out at the time of admission.