Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Park Place Of Nakoma during CMS and state inspections, most recent first.
A CNA entered the kitchenette three times during mealtime to get resident drinks without wearing a hair restraint, despite hairnets being available outside the area. The CNA stated she knows hair restraints are required in the kitchen but does not always remember to wear one in the kitchenette. The DM and NHA both stated that all staff should wear a hair restraint any time entering the kitchen and kitchenettes.
Improper Disposal of Garbage and Refuse: Surveyors observed open dumpster lids, a bag of garbage outside the dumpsters, and food wrappers, gloves, and cardboard on the ground near the dumpsters. The DM and NHA both acknowledged that the lids should be down and that garbage should not be left outside or on the ground.
QAPI committee meetings did not consistently include the required members or occur at least quarterly. The facility’s QAPI records showed meetings where the Medical Director and Infection Preventionist were absent, and the NHA stated the facility did not meet quarterly in 2025 and only one quarterly QAPI meeting met the requirements.
A facility failed to ensure that residents who needed ADL help received required grooming and bathing assistance. Several residents were observed with long facial hair, and two residents reported missed showers or that staff had not offered shaving assistance. Records showed care plans and CNA Kardex entries for personal hygiene and bathing, but shaving was not addressed for the affected residents, and shower documentation showed repeated missed scheduled showers for one resident.
Failure to follow contact precautions for a resident with shingles. An LPN was observed entering and exiting the resident's room without PPE and sanitizing hands before entering and exiting, despite a contact precautions sign outside the room directing staff to wear gloves and a gown for room entry. The LPN stated PPE was only needed for direct care and said the resident's shingles might be scabbed over.
The facility did not provide accurate SNFABN notices to three residents whose Medicare Part A coverage had ended, so they were not informed of potential financial liability for noncovered services. An LPN stated the facility had no SNFABNs for the residents and had not been completing any SNFABNs.
The facility failed to follow its own discharge planning policy for three discharged residents by not completing required discharge summaries and, in one case, omitting a discharge goal from the care plan. The policy requires a discharge summary with a recap of the stay, a final status at discharge, and an individualized post‑discharge plan developed by the IDT with the resident and family, and that these documents be provided to the resident and filed in the medical record. For each of the three residents, the EMR showed a “Discharge Summary and Recap of Stay” assessment that was due and flagged in red as incomplete, and the DON confirmed these were not done as expected. One resident with progressive supranuclear palsy and palliative care needs had only a medication note on the discharge date with no summary; another with UTI, muscle weakness, cognitive communication deficit, and vascular dementia had a discharge summary entry that could not be opened and was acknowledged as not completed; and a third with a femur fracture and weakness was discharged home with home health services ordered but had no discharge summary documented and no discharge goal in the care plan.
A resident was allowed to self-administer a prescribed nasal spray without a documented assessment or care plan by the IDT or physician, as required by facility policy. Nursing staff left the medication at the bedside and acknowledged the resident's independent use, but there was no supporting documentation in the EMR.
A nurse, following instructions from an administrator, withdrew oxycodone tablets prescribed for one resident and administered them to another resident with a different physician order, resulting in a medication error. The incident involved residents with complex medical histories and occurred despite facility policy prohibiting the administration of medications ordered for one resident to another.
A resident with CHF did not receive daily weight monitoring as ordered by the physician, with significant gaps in documentation and inconsistent recording of refusals or physician notifications. Facility staff were unclear about responsibility for obtaining weights, and the resident experienced a substantial weight loss over three months without proper adherence to policy or orders.
A resident with multiple health conditions experienced severe, unplanned weight loss over several months. Despite physician orders for daily weights and notification requirements for significant changes, staff did not consistently obtain or document daily weights, nor did they notify the physician or NP of the weight loss or refusals. The DON confirmed these actions were not documented or communicated as required.
The facility failed to document vital signs and follow physician orders for several residents, leading to non-compliance with professional standards. Residents with conditions such as hypertension, diabetes, and cognitive impairments had missing records for vital signs and blood glucose checks, despite active orders. Interviews with staff revealed confusion about documentation processes.
A facility failed to thoroughly investigate an alleged neglect incident involving a resident with multiple health issues. The resident's POA expressed concerns about inadequate attention during the resident's stay. Although the NHA initiated an investigation and communicated with the POA, they did not interview other residents, which was required by the facility's policy.
A resident with a complex medical history experienced significant medication errors due to the omission of multiple prescribed medications over a period. The facility's MAR showed numerous instances of unadministered medications without proper documentation or physician notification. Interviews with staff revealed a lack of understanding and adherence to medication administration policies, highlighting systemic issues in medication management and documentation.
The facility failed to ensure safe food handling practices, affecting all 14 residents. A cook's hair was not fully covered, and raw meat was improperly stored, risking cross-contamination. The Dietary Manager confirmed these issues and took steps to correct them.
The facility did not ensure medications were accurately labeled and disposed of when beyond expiration for several residents. An LPN administered insulin pens without open dates, and a medication cart contained undated medications, contrary to policy and manufacturer guidelines. The DON confirmed the medications should have been dated upon opening.
A resident with multiple diagnoses was transferred to the hospital without receiving a required written transfer notice. The notice should have included the date, reason, location of the transfer, appeal rights, and contact information for the State LTC Ombudsman. The absence of this notice was confirmed by a Corporate RN during an interview.
A facility did not provide a bed hold notice to a resident or their emergency contact when the resident was transferred to the hospital. The facility's policy requires written notice of bed hold policies to be given at least twice, but this was not done for a resident with multiple diagnoses, including acute kidney injury and pulmonary embolism. A Corporate RN confirmed the oversight during an interview.
A resident's CPAP machine was not cleaned according to the facility's policy, which required daily cleaning. The resident, with severely impaired cognition, could not recall seeing the CPAP mask cleaned. Staff interviews revealed confusion about cleaning responsibilities, with CNAs and LPNs unsure of their roles. The DON expected adherence to the policy but could not confirm the cleaning process.
A resident prescribed lamotrigine and oxycodone was not monitored for adverse reactions or side effects, contrary to the facility's Medication Therapy policy. The resident's medical record lacked documentation of such monitoring, and the Corporate RN confirmed the absence of side effect monitoring in the Medication Administration Record or care plan.
The facility failed to maintain proper infection control practices. An LPN did not sanitize a blood pressure cuff before or after use on a resident, and another LPN entered a resident's room on contact isolation precautions without wearing PPE. Both staff members acknowledged their oversights, and the DON confirmed the expectations for sanitization and PPE use.
The facility failed to ensure pneumococcal vaccinations were reviewed, offered, or administered for two residents. One resident's vaccination history was not reviewed, and they were not offered the PCV20 vaccine. Another resident, who had previously received PPSV23 and PCV13 vaccines, was not offered the PCV20 vaccine as per CDC guidelines. The Corporate RN acknowledged the facility's non-compliance with vaccination updates.
The facility failed to document and ensure the administration of updated COVID-19 vaccines to two residents. Despite previous vaccinations, there was no record of offering, declining, or administering the updated vaccines as per CDC and ACIP guidelines. A CRN acknowledged the facility's lapse in maintaining up-to-date COVID-19 vaccinations.
Failure to Wear Hair Restraint in Kitchenette
Penalty
Summary
The facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. During observation on 1/20/26 at 12:15 PM, Certified Nursing Assistant D entered the kitchenette three times to get resident drinks without wearing a hair restraint. Hairnets were observed to be available for all staff outside the kitchenette. CNA D stated she knows she needs to wear a hairnet when going into the kitchen and that she remembers to do so in the big kitchen, but not always when going into the kitchenette. The facility policy on Hair Restraints, dated 7/13/25, states that hair must be pulled back and properly restrained when working with exposed food, clean equipment, utensils, linens, and unwrapped single service and single use articles. The Dietary Manager and Nursing Home Administrator both stated that all staff should wear a hair restraint any time entering the kitchen and the kitchenettes.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Garbage and refuse were not disposed of properly in the facility’s kitchen area. During the initial walk-through, the surveyor observed dumpster lids left open, a bag of garbage outside the dumpsters, and food wrappers, gloves, and cardboard on the ground near the dumpsters. The facility’s policy stated that outside dumpsters provided by garbage pickup services would be kept closed and free of surrounding litter. The Dietary Manager acknowledged that the lids should be down and that garbage should not be left outside the dumpsters, and the Nursing Home Administrator later stated that the dumpster lids should be down and garbage should not be left on the ground.
QAPI Committee Did Not Meet Required Membership or Quarterly Frequency
Penalty
Summary
The facility did not ensure the required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly in 2025. The facility’s QAPI policy stated that the committee meets monthly, and the facility’s QA Team Members list included the Administrator, DON, Dietary Manager, Therapy Director, Maintenance Director, Regional Nurse/Infection Preventionist, and Medical Director. However, review of the QAPI binder showed a 7/9/25 sign-in sheet with the Dietary Manager, Social Services/Activities, Regional Nurse/Infection Preventionist, MDS Coordinator, DON, Therapy Director, and Administrator, and the Medical Director was not included. A 9/18/25 QAPI sign-in sheet showed the Administrator, DON, MDS Coordinator, Dietary/Environmental Services Director, Maintenance Director, and Director of Rehabilitation, but the Medical Director and Infection Preventionist were not included. During interview, the NHA stated the Medical Director was not included in the QAPI meeting, the Medical Director and Infection Preventionist were not included in the QAPI meeting, and the facility failed to meet quarterly in 2025. The NHA also stated that during the meetings not all required members were present and that the facility held only one quarterly QAPI meeting that met the requirements during 2025.
Failure to Provide Required ADL Assistance for Grooming and Bathing
Penalty
Summary
The facility did not ensure that residents who were unable to independently perform ADLs received the necessary assistance to maintain grooming, personal hygiene, and bathing needs. Based on observation, interview, and record review, four residents were identified with unmet ADL support needs involving facial shaving and, for two residents, missed showers. The facility policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene, including bathing, dressing, grooming, and oral care. R2 was admitted with diagnoses including hip fracture, weakness, major depressive disorder, and dementia. The most recent MDS showed a BIMS of 13, and the resident required staff assistance for toileting, bathing, and personal hygiene. The care plan and CNA Kardex addressed personal hygiene and oral care but did not address shaving, and there was no documentation that shaving was completed. Surveyors observed R2 in bed on multiple occasions with whiskers approximately 1/2 inch long, and when asked, R2 stated a preference to be clean shaven. R19 was admitted with diagnoses including cerebral infarction, muscle weakness, dementia, and anxiety disorder. The MDS showed a BIMS of 3 and indicated substantial to maximal assistance was needed for bathing and personal hygiene. The care plan and CNA Kardex addressed personal hygiene and oral care but did not address shaving, and there was no documentation that shaving was completed. Surveyors observed R19 with whiskers approximately 1/4 to 1/2 inch long on multiple days, and R19 stated a preference to be clean shaven. R23 was admitted with diagnoses including a right lower leg bimalleolar fracture, muscle weakness, and hypertension. The resident’s MDS indicated dependence for bathing and supervision or touching assistance for personal hygiene. The care plan and CNA Kardex specified showers on Tuesdays and Fridays and included bathing and personal hygiene assistance, but the task documentation showed multiple missed showers, with only two showers documented over the reviewed period. R23 told the surveyor that no one had asked about shaving, that they preferred to be clean shaven, and that they believed they had only had one shower since admission. R34 was admitted with diagnoses including stroke, history of liver transplant, hypertension, and type 2 diabetes mellitus. The care plan and CNA Kardex stated that R34 required extensive physical assist with showering twice weekly and set-up assist for personal hygiene and oral care, but the task documentation did not show the shower schedule and only one shower was documented. Surveyors observed R34 with facial whiskers approximately 1/2 inch long, and R34 stated that staff had not asked about shaving, that they preferred to be clean shaven, and that they typically shaved every 2 to 3 days at home.
Failure to Follow Contact Precautions for Resident With Shingles
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 resident reviewed for transmission-based precautions. R3 had an order dated 1/2/26 to implement contact precautions for shingles to the right buttocks and right lower back/flank every shift, and a contact precautions sign was posted outside the bedroom stating that everyone must clean their hands before entering and when leaving the room, and that providers and staff must put on gloves and a gown before room entry and discard them before room exit. On 1/20/26, a surveyor observed an LPN entering and exiting R3's bedroom without any PPE and sanitizing hands before entering and exiting. The surveyor observed the contact precautions sign and PPE outside the room. The LPN stated that R3 had shingles and that staff only needed to wear PPE when providing direct care, and said she was not providing direct care. The LPN also stated the shingles had been going on since last week and might be scabbed over, and said she would wear a gown, gloves, and mask if providing direct care. On 1/22/26, the NHA stated staff should follow contact precautions signs and recommendations.
Failure to Provide SNFABN Notices for Residents Losing Medicare Coverage
Penalty
Summary
The facility failed to provide accurate Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) forms to residents whose Medicare Part A coverage had ended, resulting in a failure to notify them of potential financial liability for services not covered. Record review and interview showed that three residents, R21, R38, and R39, each had Medicare coverage end on different dates, but none were provided SNFABN letters regarding financial liability. On 1/21/26, the LPN/Regional MDS Nurse Coordinator stated the facility had no SNFABN forms for these residents and that the facility had not been completing any SNFABNs. The LPN also stated this issue was identified after the entrance conference with surveyors.
Failure to Complete Required Discharge Summaries and Goals for Three Discharged Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Discharge Summary and Plan policy for three residents reviewed for discharge planning. The policy, dated 10/2022, requires that when a discharge is anticipated, staff complete a discharge summary including a recapitulation of the resident’s stay, a final summary of status at discharge, and an individualized post‑discharge plan developed by the interdisciplinary team with the resident and family. The policy also requires that an evaluation of discharge needs, the post‑discharge plan, and the discharge summary be provided to the resident and filed in the medical record. For all three residents (R1, R2, and R3), the electronic medical record in Point Click Care showed a “Discharge Summary and Recap of Stay” assessment that was due and highlighted in red as overdue or not completed, and the DON confirmed these discharge summaries were not completed as expected on the day of discharge. R1, admitted for a respite stay with diagnoses including progressive supranuclear palsy and palliative care needs, had a care plan focus on preparing for discharge, but on the discharge date the only progress note entry was a medication entry with the word “discharged” and no discharge summary was present. R2, admitted with diagnoses including UTI, muscle weakness, cognitive communication deficit, and vascular dementia, was discharged to a private residence, but the “Discharge Summary and Recap of Stay” assessment in the record was highlighted in red and could not be opened, and the DON stated this meant it was not completed. R3, admitted with a left femur neck fracture and weakness and discharged home with home health PT and OT ordered, had progress notes on the day of discharge documenting pain monitoring and analgesic orders but no discharge summary or mention of discharge, and the care plan dated 12/10/25 did not include a discharge goal. The DON acknowledged that discharge summaries should be completed on the day of discharge and that residents’ care plans should include a discharge goal, which was not done for these residents.
Failure to Assess and Document Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for self-administration of medications as required by facility policy. The policy states that residents may self-administer medications only if the attending physician, in conjunction with the interdisciplinary care planning team, determines the resident has the decision-making capacity to do so safely. Review of the resident's electronic medical record, care plan, assessments, progress notes, and physician orders revealed there was no documented assessment or care plan addressing the resident's ability to self-administer medications. No orders related to self-administration were found, and there was no evidence of an interdisciplinary team meeting or progress note documenting this capability. Despite the lack of assessment and documentation, the resident was observed self-administering a prescribed nasal spray medication in her room, with the medication being left at her bedside for her use. The resident confirmed during interview that she had been self-administering the nasal spray independently for a long time, and nursing staff acknowledged that the medication was routinely left in the resident's room for her to use on her own. The DON stated that such practices should be documented in the assessments, care plan, and IDT meeting notes, but this was not done for this resident.
Medication Borrowing Results in Failure to Meet Professional Standards
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards and facility policy, resulting in a medication ordered for one resident being administered to another. Specifically, a registered nurse withdrew two oxycodone 5 mg tablets from one resident's medication supply and administered them to a different resident, despite each resident having distinct physician orders for their pain medication. This action was taken after the nurse consulted with the facility administrator, who approved the borrowing of medication, even though the facility's policy explicitly prohibits administering medications ordered for one resident to another unless permitted by state law and approved by the director of nursing services. The incident involved two residents with significant medical histories. One resident had diagnoses including pain in the left knee and hip, diabetes, and cognitive communication deficit, and had an order for oxycodone 5 mg to be given as needed. The other resident, who received the borrowed medication, had diagnoses such as spinal stenosis, muscle weakness, chronic embolism, and severe pain at the time of administration, with a physician's order for oxycodone 10 mg as needed. The medication administration records and controlled drug use records confirmed that the medication was not administered as prescribed and that the nurse documented the borrowing of medication in the records. Interviews with the nurse and facility leadership revealed that the nurse acted under the direction of the administrator, who was attempting to address a situation involving a resident in severe pain and a dissatisfied family. The nurse acknowledged that she did not initially consider the action a medication error, as she believed she was resolving an urgent issue, but later recognized it as such. The director of nursing was not present at the facility during the incident and was informed after the fact.
Failure to Monitor Daily Weights for CHF Resident
Penalty
Summary
Nursing personnel failed to follow physician orders and facility policy regarding daily weight monitoring for a resident diagnosed with congestive heart failure (CHF). The resident had clear orders from both the nurse practitioner and physician for daily weights to monitor CHF, with instructions to notify the provider if there was a significant weight change. However, the medical record and weight logs showed that weights were not obtained daily as ordered, with large gaps between recorded weights. The Medication Administration Record (MAR) indicated weights were sometimes completed, refused, held, or marked as 'other/see progress notes,' but the actual weight record only showed sporadic entries. Over a three-month period, the resident experienced a significant weight loss of 43.4 lbs, yet daily monitoring was not consistently performed or documented. Interviews with facility staff, including the Director of Nursing (DON) and Physical Therapy Director (PTD), revealed confusion and lack of clarity regarding responsibility for obtaining weights. The DON acknowledged awareness of the daily weight order and agreed that refusals and physician notifications should be documented, but could not provide evidence that refusals or physician notifications were consistently recorded. The PTD denied that therapy staff were responsible for weighing residents, despite a progress note suggesting otherwise. The facility's own policies required prompt notification of significant changes in condition and documentation of refusals, but these were not followed in this case.
Failure to Monitor and Report Severe Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status and did not consult with the resident's physician regarding significant weight loss for one resident. The resident, who had diagnoses including a lumbar fracture, CHF, cognitive communication deficit, and type 2 diabetes, experienced a severe weight loss of 15.3% over two months. Physician orders required daily weights due to CHF, with instructions to notify the nurse practitioner if there was a weight gain or loss of 3 lbs. in a day or 5 lbs. in a week. However, the medical record and MAR showed that weights were not consistently obtained daily as ordered, with some days marked as refused, held, or referencing progress notes. The resident's weight dropped from 280 lbs. to 238 lbs. over three months, a loss of 43.4 lbs., which is classified as severe. The Director of Nursing (DON) confirmed awareness of the daily weight order and acknowledged that the physician should have been notified of the severe weight loss and refusals. There was no documentation that the physician or nurse practitioner was updated about the weight loss or refusals, nor was there evidence that the risks and benefits of refusing weights were explained to the resident. The facility's policy required immediate notification of the dietician and physician for significant weight changes, but these steps were not documented or followed in this case.
Failure to Document Vital Signs and Follow Physician Orders
Penalty
Summary
The facility failed to ensure that the services provided by nursing personnel met professional standards of quality for five residents. Specifically, the facility did not complete physician orders for daily vital signs for residents R5, R8, R9, R10, and R1. The facility's policy requires that vital signs be documented daily, and any abnormalities be reported to a physician. However, the records show multiple instances where vital signs were not recorded as ordered. Resident R5, who was admitted with conditions including a periprosthetic fracture and hypertension, had several days where vital signs were not documented. Similarly, resident R8, admitted with osteomyelitis and hypertension, also had missing vital sign records on multiple days. Resident R9, with severe cognitive impairment and a history of stroke, and resident R10, with metabolic encephalopathy and atrial fibrillation, both had numerous days where vital signs were not recorded, despite active orders for daily monitoring. Resident R1, admitted with cellulitis and diabetes, had orders for frequent blood glucose checks and daily vital signs. However, there were gaps in the documentation of these checks, and the Medicare charting was not completed daily as required. Interviews with the Director of Nursing and an LPN revealed a lack of clarity regarding the documentation process, with blank boxes on the Medication Administration Record indicating potential non-compliance with physician orders.
Incomplete Investigation of Alleged Neglect
Penalty
Summary
The facility failed to ensure a thorough investigation of alleged neglect for a resident, identified as R3, during their stay from November 1 to November 4, 2024. R3's Power of Attorney (POA) expressed concerns about possible neglect, stating that R3, who was unable to move their arms or legs, did not receive adequate attention. The Nursing Home Administrator (NHA) initiated an investigation and maintained communication with the POA, but did not interview other residents to determine if there were additional concerns or allegations. The facility's policy requires all possible incidents of abuse, neglect, or mistreatment to be identified and investigated, which was not fully adhered to in this case. R3 was admitted with multiple diagnoses, including respiratory failure, heart disease, and major depressive disorder. The POA reported to the hospital that R3 felt neglected, which prompted the hospital to inform the facility. Although the NHA collected statements from staff and communicated with the POA, the investigation was deemed incomplete as it did not include interviews with other residents. The POA later clarified that the term 'neglect' was used to express concern over the level of attention R3 received, rather than an accusation of neglect. Despite this clarification, the facility did not conduct a comprehensive investigation as required by their policy.
Resident Medication Errors Due to Omission and Documentation Failures
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as evidenced by the omission of multiple medications over a period in December and January. The resident, who was admitted on December 20, 2024, had a complex medical history including conditions such as cellulitis, hyperlipidemia, paroxysmal atrial fibrillation, type 2 diabetes mellitus with diabetic neuropathy, epilepsy, chronic pain, hypertension, portal vein thrombosis, benign prostatic hyperplasia, and a history of transient ischemic attack and cerebral infarction. The resident's discharge medication list included critical medications for managing these conditions, such as insulin glargine, semaglutide, zonisamide, apixaban, levetiracetam, mycophenolate, tacrolimus, and ursodiol, among others. The Medication Administration Record (MAR) for the resident documented numerous instances where medications were not administered as prescribed. The chart codes indicated that some medications were marked with a '9', meaning 'other/see progress notes', but there were no corresponding progress notes to explain the omissions. Additionally, some medications had blank entries on the MAR, which staff were unable to explain. Interviews with the LPN and DON revealed a lack of clarity and understanding regarding the documentation codes and procedures for handling medication omissions, indicating a breakdown in communication and adherence to the facility's medication administration policies. The surveyor's interviews with the LPN and DON highlighted a lack of awareness and understanding of the facility's procedures for documenting and addressing medication errors. The DON acknowledged that medications should be administered as ordered and that any unavailability should be addressed by checking the automatic dispensing unit or contacting the pharmacy. However, the failure to document reasons for medication omissions and the lack of physician notification suggest systemic issues in medication management and documentation practices within the facility.
Improper Food Handling and Storage Practices
Penalty
Summary
The facility failed to ensure safe food handling practices, which had the potential to affect all 14 residents. During a kitchen tour, a cook was observed with a hat and hair net that did not fully cover their long hair, contrary to the Wisconsin Food Code and the facility's Hair Restraints policy. The Dietary Manager confirmed that the cook's hair should have been fully covered and provided a larger hair net. Additionally, raw meat was improperly stored in the walk-in cooler, posing a risk of cross-contamination. Raw ground hamburger and boneless chicken breasts were stored on the same shelf without equipment to prevent dripping, and sweet potatoes were stored alongside raw chicken. The facility's Food Storage policy and a sign in the cooler outlined proper storage arrangements, which were not followed. The Dietary Manager acknowledged the improper storage and rearranged the items to comply with the guidelines.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure medications were accurately labeled and disposed of when beyond the expiration date for several residents. During a medication administration observation, an LPN administered insulin pens to two residents without open dates, which is against the facility's policy that requires multi-dose vials to be dated upon opening. The LPN confirmed that the insulin pens should have been dated and are only good for 28 days after opening. Additionally, a surveyor observed a medication cart containing open and undated medications for four residents. These included an insulin glargine pen, latanoprost eye drops, a Stiolto inhaler, and a bottle of calcitonin nasal spray, all of which lacked open dates. Manufacturer recommendations for these medications specify storage conditions and timeframes for use after opening, which were not adhered to. The Director of Nursing confirmed that staff should have dated the medications when they were opened.
Failure to Provide Transfer Notice
Penalty
Summary
The facility failed to provide a required transfer notice to a resident, identified as R14, who was transferred to the hospital. R14 was admitted to the facility with diagnoses including acute kidney injury, adjustment disorder with depressed mood, unspecified fall, and pulmonary embolism. On the date of transfer, R14's Minimum Data Set (MDS) assessment did not indicate an assessment for cognition, and there was no activated Power of Attorney (POA) for R14. Despite these circumstances, neither R14 nor R14's emergency contact received a written transfer notice that included essential information such as the date, reason, location of the transfer, appeal rights, and contact information for the State Long-Term Care Ombudsman. This deficiency was confirmed during an interview with the Corporate Registered Nurse (CRN)-C, who acknowledged the absence of a transfer notice for R14's hospital transfer.
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a bed hold notice to a resident, identified as R14, or their emergency contact when the resident was transferred to the hospital. According to the facility's Bed-Holds and Returns policy, residents and/or their representatives should be informed in writing about the bed hold policies at least twice: well in advance of any transfer and at the time of transfer, or within 24 hours if the transfer was an emergency. R14 was transferred to the hospital on 8/10/24, but the medical record did not indicate that a bed hold notice was provided. During an interview on 9/18/24, a Corporate Registered Nurse confirmed that the facility did not issue a bed hold notice for R14's hospital transfer. R14's medical record included diagnoses such as acute kidney injury, adjustment disorder with depressed mood, unspecified fall, and pulmonary embolism, but did not show an assessment for cognition or an activated Power of Attorney.
Failure to Clean CPAP Machine as per Policy
Penalty
Summary
The facility failed to ensure that a CPAP machine was cleaned according to its policy for a resident with obstructive sleep apnea. The facility's policy required daily cleaning of CPAP masks, nasal pillows, and tubing by soaking them in warm, soapy water for five minutes, rinsing with warm water, and allowing them to air dry. However, observations and interviews revealed that the CPAP machine used by the resident was not cleaned as per the policy. The resident, who had severely impaired cognition and an activated Power of Attorney for Healthcare, was unable to recall seeing staff clean the CPAP mask since admission. Interviews with staff members, including CNAs and LPNs, indicated a lack of clarity and responsibility regarding the cleaning of CPAP equipment. One CNA mentioned that the AM shift CNAs were responsible for cleaning the CPAP mask and equipment, while another CNA stated that they did not clean the mask, assuming a nurse would do so. An LPN also indicated that they did not handle CPAP machines or equipment. The Director of Nursing was unable to provide information on the cleaning process but expected staff to follow the facility's policy.
Failure to Monitor High-Risk Medication Side Effects
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not monitoring for adverse reactions or side effects of high-risk medications. The resident, identified as R2, was prescribed lamotrigine, an anticonvulsant, and oxycodone, an opioid, without a plan of care that included monitoring for potential side effects. The facility's Medication Therapy policy requires that each resident's medication regimen be reviewed to identify potential or suspected side effects, but this was not done for R2. R2 was admitted with diagnoses including spondylosis and bipolar disorder and had a BIMS score indicating intact cognition. Despite these conditions, the medical record lacked documentation of monitoring for adverse reactions to lamotrigine and oxycodone. During an interview, the Corporate Registered Nurse confirmed that there was no side effect monitoring in place for R2's medications, which should have been documented in the Medication Administration Record or care plan.
Infection Control Deficiencies in Equipment Sanitization and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving staff members. In the first incident, a Licensed Practical Nurse (LPN) did not sanitize a blood pressure cuff before or after using it on a resident, despite the facility's policy requiring the sanitization of multi-use equipment between residents. This was confirmed by the LPN during an interview with the surveyor, who acknowledged the oversight. In the second incident, another LPN entered the room of a resident on contact isolation precautions for Clostridium difficile without donning the required personal protective equipment (PPE), such as a gown and gloves. The LPN admitted to missing the contact isolation precautions sign posted outside the resident's room and confirmed that PPE should have been worn. The Director of Nursing verified that staff are expected to follow PPE protocols as indicated by signage for residents on contact isolation precautions.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that pneumococcal vaccinations were reviewed, offered, or administered for two residents, R12 and R10, out of a sample of five. For R12, the facility did not review the resident's vaccination history or offer the PCV20 vaccine. R12's medical record lacked documentation of receiving either the PPSV23 or PCV13 vaccines, and there was no indication that the PCV20 vaccine was offered or administered. For R10, the resident had previously received a PPSV23 vaccine in 2009 and a PCV13 vaccine in 2015. However, the facility did not offer or administer the PCV20 vaccine, as recommended by the CDC guidelines. The Corporate Registered Nurse acknowledged that the facility was not up to date with pneumococcal vaccinations and was in the process of implementing their policies.
Failure to Document and Administer Updated COVID-19 Vaccines
Penalty
Summary
The facility failed to ensure that COVID-19 immunizations were offered, declined, or administered to two residents, R12 and R10, as per the guidelines. R12 was admitted to the facility and had previously received a COVID-19 vaccine on August 5, 2021. However, there was no documentation in R12's medical record indicating that an updated COVID-19 vaccine was offered, declined, or administered. Similarly, R10, who was admitted to the facility and had received a COVID-19 vaccine on June 28, 2022, also lacked documentation in their medical record regarding the offer, declination, or administration of an updated COVID-19 vaccine. The surveyor's review of the medical records on September 18, 2024, revealed these deficiencies. During an interview on the same day, the Corporate Registered Nurse (CRN)-C acknowledged that the facility was not up to date with COVID-19 vaccinations and was in the process of implementing their policies. This lack of documentation and failure to offer or administer updated COVID-19 vaccines to the residents constitutes a deficiency in the facility's adherence to CDC guidelines and the Advisory Committee on Immunization Practices (ACIP) recommendations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hebron Oaks | 2.5 mi | ★★★★★ | 3 | 0 |
| Complete Care At Maple Grove Llc | 3.2 mi | ★★★★★ | 0 | 0 |
| Capitol Lakes Health Center | 3.8 mi | ★★★★★ | 11 | 1 |
| Middleton Village Nursing And Rehab | 4 mi | ★★★★★ | 21 | 0 |
| Badger Prairie Hcc | 5 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.