Oak Park Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Oak Park Nursing and Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jan 10, 2026

  Based on record review, observations, interviews, and facility policy review, the facility failed did not establish and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable disease and infections. This has the potential to affect all 70 residents. The facility failed to ensure adequate infection control processes were followed to ensure containment of Influenza, Respiratory Syncytial Virus (RSV), and COVID during a concurrent facility outbreak of all three infections. […]

• Immediate jeopardy, widespreadF882Jan 10, 2026

  Based on observations, interviews, and document review, the facility failed to designate a qualified infection preventionist (IP) to develop, implement, and monitor the facility's infection prevention program. This has the potential to affect all 70 residents residing at the facility.The facility failed to monitor residents and staff with signs and symptoms of an acute respiratory illness and protect residents and staff from contracting an acute respiratory illness during a concurrent outbreak of influenza, RSV and COVID in January 2026 The facility's failure to have an infection preventionist who developed, implemented and monitored infectious illnesses placed 70 of 70 residents and facility staff at risk for development of an infectious illness which could result in serious harm and/or… […]

• Immediate jeopardy, isolatedF684Sep 9, 2025

  Based on interview and record review, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 out of 19 residents (R74) reviewed for change of condition.R74 had orders to update the physician with pulse greater than 119. R74 had a pulse of 140 and the facility did not complete a nursing assessment, recheck the pulse, consult with the physician, or complete ongoing monitoring of R74. R74 was found pulseless and non-breathing. The facility's failure to recognize a change in condition and perform a thorough nursing assessment along with ongoing assessments and monitoring of a resident created a finding of immediate jeopardy that began on [DATE]. […]

• Actual harm, isolatedF689Sep 9, 2025

  Based on interview, and record review, the facility did not ensure a resident's environment remained free of accidents and hazards for 1 of 3 residents reviewed for falls (R48) and 1 of 3 residents reviewed for supervision (R37). R48 is being cited at severity level 3 (actual harm). R48 sustained three falls. The facility failed to identify a root cause analysis (RCA) or patterns with R48's three falls. Without identifying the RCA, the interdisciplinary team (IDT) did not implement resident specific interventions or identify patterns which could have contributed to her falls and/or prevent future falls, such as a plan to anticipate her toileting needs when she stated she was trying to go to the bathroom. […]

• Actual harm, isolatedF686Apr 17, 2023

  Based on interview and record review, the facility did not provide care consistent with professional standards of practice to prevent pressure injuries (PI) from developing or worsening for 2 of 5 residents reviewed for PIs (R68 and R66.) R68 was admitted to the facility with a stage 2 PI on his spine. The facility did not complete weekly wound assessments and measurements and R68's PI worsened. The facility did not ensure an initial assessment, weekly measurements, and interventions were in place to prevent the PI from developing or worsening for R66's left buttock pressure injury. […]