Cycle 1
Health 2024-09-18 · Fire 2024-09-18
14 health deficiencies
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Madison, WI
Oak Park Place of Nakoma
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
4327 Nakoma Rd., Madison, WI
(608) 640-4100
Overall
2 / 5
CMS overall stars
Health inspections
2 / 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
33
Certified beds
Average residents
20
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2019-06-05
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
1.82
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.29
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.52
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
5.63
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.11
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.85
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.24
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.47
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
2.03
CMS adjusted RN staffing hours
Adjusted total hours
6.29
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
81%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
73%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,235
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.60% · Performance 22.58% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.04
Baseline 5.61% · Performance 5.73% · Measure score 7.04 · Achievement 7.04 · Improvement 0
Total nurse turnover
1.19
Performance 58.82% · Measure score 1.19 · Achievement 1.19 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.21% |
10.72%
3.5 pts worse
|
Worse than the National Rate · Eligible stays 245 · Observed rate 15.92% · Lower 95% interval 11.17% |
| Discharge to community | 57.41% |
50.57%
6.8 pts better
|
Better than the National Rate · Eligible stays 228 · Observed rate 53.51% · Lower 95% interval 50.94% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 147 · Denominator 147 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 147 |
| Discharge self-care score | 60.53% |
53.69%
6.8 pts better
|
Numerator 69 · Denominator 114 |
| Discharge mobility score | 42.98% |
50.94%
8 pts worse
|
Numerator 49 · Denominator 114 |
| Pressure ulcers or injuries, new or worsened | 1.36% |
2.29%
0.9 pts better
|
Numerator 2 · Denominator 147 · Adjusted rate 1.69% |
| Healthcare-associated infections requiring hospitalization | 5.73% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 139 · Observed rate 3.6% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 6.76% |
8.2%
1.4 pts worse
|
Numerator 5 · Denominator 74 |
| Staff flu vaccination coverage | 22.39% |
42%
19.6 pts worse
|
Numerator 15 · Denominator 67 |
| Discharge function score | 59.65% |
56.45%
3.2 pts better
|
Numerator 68 · Denominator 114 |
| Transfer of health information to provider | 98.44% |
95.95%
2.5 pts better
|
Numerator 63 · Denominator 64 |
| Transfer of health information to patient | 98.53% |
96.28%
2.2 pts better
|
Numerator 67 · Denominator 68 |
| Resident COVID-19 vaccinations up to date | 50% |
25.2%
24.8 pts better
|
Numerator 32 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.0% |
95.7%
20.7 pts worse
|
93.4%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 75.0% |
| 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 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 with a catheter inserted and left in their bladder | 7.5% |
2.3%
5.2 pts worse
|
1.0%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
3.0%
1.2 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with pressure ulcers | 13.8% |
5.5%
8.3 pts worse
|
5.1%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.6% |
86.8%
11.2 pts worse
|
81.7%
6.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 86.8% · Q2 73.7% · Q3 72.5% · Q4 68.7% · 4Q avg 75.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
15.0%
3.2 pts better
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 10.9% · Expected 10.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.2% |
82.2%
5 pts better
|
79.7%
7.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.9% |
22.7%
2.2 pts worse
|
23.9%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 24.8% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-20 · Fire 2023-07-20
10 health deficiencies
Top issue: Administration (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2022-05-11 · Fire 2022-05-11
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-30
E · Potential for more than minimal harm
2024-09-18
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-18
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-18
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-10-30
F · Potential for more than minimal harm
2023-07-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-08-20
F · Potential for more than minimal harm
2023-07-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-20
F · Potential for more than minimal harm
2023-07-20
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2023-08-20
F · Potential for more than minimal harm
2023-07-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-08-20
E · Potential for more than minimal harm
2023-07-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-20
E · Potential for more than minimal harm
2023-07-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-20
E · Potential for more than minimal harm
2023-07-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-20
E · Potential for more than minimal harm
2023-07-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-20
E · Potential for more than minimal harm
2023-07-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
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 2023-08-20
D · Potential for more than minimal harm
2023-07-20
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-08-20
F · Potential for more than minimal harm
2022-05-11
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 2022-09-08
F · Potential for more than minimal harm
2022-05-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-05-25
F · Potential for more than minimal harm
2022-05-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-21
E · Potential for more than minimal harm
2022-05-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-06-06
E · Potential for more than minimal harm
2022-05-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-06-01
D · Potential for more than minimal harm
2022-05-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-05-26
D · Potential for more than minimal harm
2022-05-11
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-06-03
D · Potential for more than minimal harm
2022-05-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-05-24
D · Potential for more than minimal harm
2022-05-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-06-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2026-01-21
D · Potential for more than minimal harm
2025-12-23
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-12-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-19
E · Potential for more than minimal harm
2025-01-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-15
D · Potential for more than minimal harm
2025-01-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-15
D · Potential for more than minimal harm
2025-01-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-15
F · Potential for more than minimal harm
2024-09-18
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 2024-10-30
E · Potential for more than minimal harm
2024-09-18
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-18
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-18
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-18
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-10-30
F · Potential for more than minimal harm
2023-07-20
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 2023-08-20
F · Potential for more than minimal harm
2023-07-20
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-08-20
F · Potential for more than minimal harm
2023-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-07-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-08-20
C · Minimal harm
2023-07-20
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-08-20
D · Potential for more than minimal harm
2022-05-11
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-06-02
Penalties and ownership
What sits behind the stars
Ownership
Frank, Scott
5% Or Greater Direct Ownership Interest · Individual
Chase, Byron
5% Or Greater Direct Ownership Interest · Individual
Helle Revocable Trust
5% Or Greater Direct Ownership Interest · Organization
Lakleland Nakoma LLC
5% Or Greater Direct Ownership Interest · Organization
Frank, Scott
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Hebron Oaks
Madison, WI
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
#2
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
#3
Capitol Lakes Health Center
Madison, WI
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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