Cycle 1
Health 2025-07-17 · Fire 2025-07-17
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Madison, WI
Hebron Oaks
3-star overall rating with 3-star inspections with $22,925 in total fines with 5 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
510 Genomic Drive, Madison, WI
(608) 230-4000
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
42
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
2.19
Registered nurse staffing
LPN hours / resident day
0.78
Licensed practical nurse staffing
Aide hours / resident day
3.04
Nurse aide staffing
Weekend hours
5.55
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
95.7%
1.6 pts better
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.4% |
95.0%
8.6 pts worse
|
95.5%
9.1 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.2%
3.2 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 5.4% |
5.0%
0.4 pts worse
|
11.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.2% |
4.9%
0.7 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.0% |
16.6%
8.6 pts better
|
19.6%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
16.7%
2.4 pts better
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 24.0% |
17.3%
6.7 pts worse
|
14.9%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 6.8% |
2.3%
4.5 pts worse
|
1.0%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
3.0%
1.6 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 42.2% |
25.5%
16.7 pts worse
|
19.8%
22.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
5.5%
1.5 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
86.8%
6.7 pts better
|
81.7%
11.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
15.0%
2 pts better
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.2% |
82.2%
3 pts better
|
79.7%
5.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
22.7%
1.5 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-23 · Fire 2024-05-23
2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
12 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-03-09 · Fire 2023-03-09
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-28
F · Potential for more than minimal harm
2025-07-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-17
F · Potential for more than minimal harm
2025-07-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-17
F · Potential for more than minimal harm
2025-07-17
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-07-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-17
F · Potential for more than minimal harm
2025-07-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-08-17
F · Potential for more than minimal harm
2025-07-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-29
F · Potential for more than minimal harm
2025-07-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-17
E · Potential for more than minimal harm
2025-07-17
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-08-07
E · Potential for more than minimal harm
2025-07-17
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-08-17
D · Potential for more than minimal harm
2025-07-17
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-08-17
F · Potential for more than minimal harm
2024-05-23
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-06-20
F · Potential for more than minimal harm
2024-05-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-18
F · Potential for more than minimal harm
2024-05-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-13
F · Potential for more than minimal harm
2024-05-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-21
E · Potential for more than minimal harm
2024-05-23
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-21
E · Potential for more than minimal harm
2024-05-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-05-23
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-06-14
E · Potential for more than minimal harm
2024-05-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-05-23
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-05-23
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-05-23
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-07-21
D · Potential for more than minimal harm
2024-05-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-17
F · Potential for more than minimal harm
2023-03-09
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-03-27
E · Potential for more than minimal harm
2023-03-09
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-03-27
E · Potential for more than minimal harm
2023-03-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-27
C · Minimal harm
2023-03-09
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2023-03-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-02-02
D · Potential for more than minimal harm
2026-01-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-02
F · Potential for more than minimal harm
2025-07-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-30
D · Potential for more than minimal harm
2025-07-17
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-08-06
J · Immediate jeopardy
2025-02-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-01
F · Potential for more than minimal harm
2025-02-18
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-03-11
F · Potential for more than minimal harm
2023-03-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-04
E · Potential for more than minimal harm
2023-03-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-04
D · Potential for more than minimal harm
2023-03-09
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-04-04
Penalties and ownership
What sits behind the stars
$22,925
2025-02-18
Fine
Fine · fine $22,925
Fine
$0
2025-02-18
Payment Denial
Payment Denial · denial start 2025-03-15 · 17 days
17 day denial
Ownership
Oakwood Lutheran Senior Ministries, Inc.
5% Or Greater Direct Ownership Interest · Organization
Barros, Mary
Operational/Managerial Control · Individual
Barros, Mary
Corporate Officer · Individual
Donovan, Amber
Operational/Managerial Control · Individual
Hamilton-Crawford, Janice
Operational/Managerial Control · Individual
Hamilton-Crawford, Janice
Corporate Officer · Individual
Hayden, Kevin
Corporate Director · Individual
Husom, Susan
Operational/Managerial Control · Individual
Husom, Susan
Corporate Officer · Individual
Jacobson, Eric
Operational/Managerial Control · Individual
Lefel, Kristin
Operational/Managerial Control · Individual
Metz, Mary
Corporate Director · Individual
O'donnell, Christine
Operational/Managerial Control · Individual
O'donnell, Christine
Corporate Officer · Individual
Rafferty, Susan
Operational/Managerial Control · Individual
Rafferty, Susan
Corporate Officer · Individual
Rossmiller, Richard
Corporate Director · Individual
Sachtjen, Laura
Operational/Managerial Control · Individual
Sidhu, Sarfraz
Operational/Managerial Control · Individual
Turner, Marcia
Operational/Managerial Control · Individual
Vercauteren, Thomas
Corporate Director · Individual
Williams-Racette, Sarah
Operational/Managerial Control · Individual
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#3
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