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
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
2.19
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.04
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
6.02
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.98
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
5.55
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.79
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.28
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
2.04
CMS adjusted RN staffing hours
Adjusted total hours
5.60
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
1,316
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.62
Composite VBP score used to determine payment impact.
Payment multiplier
1.0128
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.09
Baseline 19.30% · Performance 20.00% · Measure score 3.09 · Achievement 3.09 · Improvement 0
Healthcare-associated infections
7.25
Baseline 5.11% · Performance 5.67% · Measure score 7.25 · Achievement 7.25 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
6.95
Baseline 5.24 hours · Performance 5.05 hours · Measure score 6.95 · Achievement 6.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.01% |
10.72%
1.7 pts better
|
No Different than the National Rate · Eligible stays 371 · Observed rate 6.47% · Lower 95% interval 6.87% |
| Discharge to community | 70.17% |
50.57%
19.6 pts better
|
Better than the National Rate · Eligible stays 373 · Observed rate 69.17% · Lower 95% interval 67.03% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.23% |
95.27%
4 pts better
|
Numerator 259 · Denominator 261 |
| Falls with major injury | 0.38% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 261 |
| Discharge self-care score | 37.99% |
53.69%
15.7 pts worse
|
Numerator 87 · Denominator 229 |
| Discharge mobility score | 46.72% |
50.94%
4.2 pts worse
|
Numerator 107 · Denominator 229 |
| Pressure ulcers or injuries, new or worsened | 0.77% |
2.29%
1.5 pts better
|
Numerator 2 · Denominator 261 · Adjusted rate 0.96% |
| Healthcare-associated infections requiring hospitalization | 5.67% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 258 · Observed rate 3.49% · Lower 95% interval 3.66% |
| Staff COVID-19 vaccination coverage | 20.41% |
8.2%
12.2 pts better
|
Numerator 40 · Denominator 196 |
| Staff flu vaccination coverage | 46.52% |
42%
4.5 pts better
|
Numerator 107 · Denominator 230 |
| Discharge function score | 52.4% |
56.45%
4.1 pts worse
|
Numerator 120 · Denominator 229 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 50 · Denominator 50 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 172 · Denominator 172 |
| Resident COVID-19 vaccinations up to date | 79.85% |
25.2%
54.6 pts better
|
Numerator 107 · Denominator 134 |
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 · 4Q avg 97.3% |
| 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 · 4Q avg 86.4% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 5.4% |
| 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 · 4Q avg 4.2% |
| 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 · 4Q avg 8.0% |
| 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 · 4Q avg 14.3% · Used in QM five-star |
| 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 · 4Q avg 0.0% |
| 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 · 4Q avg 24.0% · Used in QM five-star |
| 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 · 4Q avg 6.8% · Used in QM five-star |
| 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 · 4Q avg 1.4% · Used in QM five-star |
| 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 · 4Q avg 42.2% |
| 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 · 4Q avg 7.0% · Used in QM five-star |
| 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 · Q1 93.2% · Q2 93.9% · Q3 93.5% · Q4 93.5% · 4Q avg 93.5% |
| 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 · Adjusted 13.0% · Observed 11.6% · Expected 10.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 85.2% |
| 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 · Adjusted 24.2% · Observed 20.5% · Expected 20.1% · Used in QM five-star |
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
Nearby options
Other facilities in reach
#1
Complete Care at Maple Grove LLC
Madison, WI
1-star overall rating with 1-star inspections with $95,303 in total fines with 17 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#2
Oak Park Place of Nakoma
Madison, WI
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Badger Prairie Hcc
Verona, WI
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out