Oak Park Place of Janesville
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 72 Google reviews
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Quality Concerns Identified
Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.
- Low overall rating (2/5 stars)
- Above-median deficiencies (11 vs median 7)
Below average in WI · Meets national RN staffing standard · Above recommended total nurse staffing · $9,750 in fines
What this means for your family
While the physical facility and therapy department are highly regarded, the recurring reports of medication errors and staffing shortages are critical safety concerns. If you choose this facility, we strongly recommend frequent, unannounced visits and active monitoring of your loved one's care plan and medication administration.
Google Reviews
Google Reviews
72 reviews on Google“Oak Park Place of Janesville presents a polarized experience, with many residents and families praising the modern, clean facility and the high quality of physical therapy services. However, a significant number of reviewers report severe concerns regarding understaffing, medication errors, and inconsistent care, particularly in the nursing and memory care wings. Families should be aware that while the environment is physically appealing, the consistency of care appears to fluctuate significantly based on staffing levels.”
Quality Themes
Tap a score for detailsStrengths
- Modern, clean, and well-maintained facility
- Highly effective physical and occupational therapy
- Spacious and well-designed apartments
- Engaging social atmosphere and community events
Concerns
- Chronic understaffing leading to neglected care (mentioned by 11 reviewers)
- Medication management errors (late, missed, or incorrect doses) (mentioned by 7 reviewers)
- Poor communication and lack of responsiveness from administration (mentioned by 6 reviewers)
- Theft of resident belongings and personal items (mentioned by 4 reviewers)
- Inconsistent hygiene and room cleaning (mentioned by 5 reviewers)
Rating Trends
Tap a year to see what changed
Distribution · 77 analyzed
How They Respond to Reviews
This facility actively engages with reviewer feedback.
Questions for Your Tour
- 1I noticed that therapy services are highly praised here; how do you integrate those physical and occupational therapy programs into the daily routines of residents?
- 2Given the importance of medication safety, could you walk us through the specific protocols and double-check systems you have in place to ensure residents receive the correct doses on time?
- 3I see that you are quite active in responding to feedback online; how do you use that family input to improve communication and responsiveness from your administrative team?
- 4With 35 residents, how do you ensure that staff members are consistently available to provide timely assistance with hygiene and room maintenance throughout the day?
- 5What security measures or inventory tracking systems do you have in place to ensure that residents' personal belongings and private items remain safe and accounted for?
- 6Since the community atmosphere is a highlight, could you tell me about a recent event or activity that really brought the residents together?
Personalized based on this facility's data
Key Review Excerpts
“I've been at 5+ rehab facilities following accidents or surgeries, and Oak Park Place is by far the best! Even on hectic days, at the busiest times, the staff bent over backwards to make me feel as if I were the only patient in their care.”
“My best friends dad had just passed this past weekend, she had a camera in the room because of previous incidents and neglect that have taken place... on the camera he was chocking and he was allowed to drowned in his own vomit and mucus.”
“Meds being given late, meds put on tray and marked as given, the wrong quantity or strength given, dosages doubled up, meds found in patients bed or on the floor, calls for a nurse not answered in 3+ hours.”
Staffing
Staffing Hours
per resident/day · Medicare 2026This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.
Quality Measures
Quality Measures
Resident outcomes compared with national, state, and local averages · 14 measures
8
measures
5
measures
1
measures
Residents on anti-anxiety or sleep medication
Residents with a long-term catheter
Residents whose bladder or bowel control got worse
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents vaccinated for pneumonia
Residents needing more daily help over time
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
This facility has concerning patterns with 64 deficiencies across 9 surveys, including 22 complaint-triggered violations where families reported problems. The most recurring issues involve fire safety systems, resident care quality, and infection control. Recent violations include inadequate wound care, nursing staffing shortages, and failure to respond properly to abuse allegations, with some issues persisting across multiple surveys despite reported corrections.
Jan 21, 2026Complaint1
Resident Rights Deficiencies
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Jun 3, 2025Routine20
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Emergency Preparedness Deficiencies
Include a process for Emergency Preparedness collaboration.
Emergency Preparedness Deficiencies
Conduct testing and exercise requirements.
Smoke Deficiencies
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Resident Rights Deficiencies
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Provide care or services that was trauma informed and/or culturally competent.
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Apr 23, 2025Complaint2
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Jan 11, 2025Complaint7
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
May 21, 2024Complaint10
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Administration Deficiencies
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
May 21, 2024Routine9
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Services Deficiencies
Install properly constructed and protected linen or trash chutes.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Smoke Deficiencies
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Ownership & Operations
Who Operates This Facility
Oak Park Place of Janesville
for profit
Ownership & Management
Owners
James a. Gregory Living Trust
Owner · Organization
Lakeland Janesville LLC
Owner · Organization
Sadler Living Trust
Owner · Organization
Chase, Theodore
Owner
Frank, Hayden
Owner
Frank, Scott
Owner
Halford, Steven
Owner
Helle, Carl
Owner
Osterhaus, Brian
Owner
Richter, Barron
Owner
Sadler, Robert
Owner
Satterlee, Anita
Owner
Satterlee, Brian
Owner
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
72 reviews from families & visitors
Official Website
Visit oakparkplace.com
Medicare data downloads
Original nursing home datasets
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