Oak Park Place of Janesville

In the surveyor’s words

From the most serious findings on record at Oak Park Place of Janesville, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 29, 2026

  Based on interview and record review the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (R33) reviewed for accidents out of a sample of 17 Residents. R33 received a laceration (that required 10 stitches) during a transfer that was done with 1 assist and R33 required 2 assist. This is evidenced by: The Facility's Policy and Procedure entitled Safe Lifting and Movement of Residents dated July 2017 documents in part: .3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. […]

• Actual harm, isolatedF684Jan 11, 2025

  Based on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three of three residents (R3 and R1) of 8 sampled residents. The facility failed to assess and monitor R3's diuretic medication and provide supplemental medication to prevent critical laboratory values which caused R3 to be hospitalized due to the critically low blood levels. In addition, the facility failed to monitor and document R1 and R3's physician ordered weights. These failures placed the residents at increased risk of health complications and hospitalization . R3 is being cited at severity level 3 (actual harm). R1 is being cited at severity level 2 (potential for more than minimal harm). […]

• Actual harm, isolatedF689Apr 11, 2024

  Based on interview and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 3 residents (R1) reviewed for falls. R1 has a history of multiple falls. Facility staff did not implement appropriate fall interventions and provide adequate supervision. R1 had a fall that resulted in a displaced right inferior pubic ramus fracture (a break in part of the pelvis). Evidenced by: The facility's policy titled, Falls Policy and Prevention Program dated 6/29/21, states in part; .all residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls . […]

• Actual harm, isolatedF689Mar 25, 2024

  Based on interview and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 1 of 4 residents (R2) reviewed for falls. R2 has a history of multiple falls. Facility staff did not implement appropriate fall interventions and provide adequate supervision. R2 had a fall that resulted in a head laceration requiring seven (7) sutures. This is evidenced by: The facility's policy titled Falls Policy and Prevention Program dated 6/29/21 states in part, .All residents will receive adequate supervision, assistance, and assistive devices to aid in the prevention of falls . According to Superior Health Quality Alliance, Root Cause Analysis (RCA) is a problem-solving method to investigate an actual or potential problem, incident or concern. […]

• No harm, potential for more than minimal, widespreadF812Jun 3, 2025

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect 24 of 25 residents. Surveyor observed staff going into the main kitchen and kitchenette without hairnets on. Surveyor observed food that had been removed from original containers and not labeled with a use by date. Surveyor observed a dented can to be in circulation. Surveyor observed food that was uncovered and/or not labeled in a kitchenette freezer and refrigerator. The freezer temperature in one of the kitchenettes is not being consistently monitored or recorded. […]