Cycle 1
Health 2025-07-29 · Fire 2025-07-29
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Madison, WI
Oakwood Village East Health And Rehab Center
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
5833 American Parkway, Madison, WI
(608) 230-4000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
33
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2008-05-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.44
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.59
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
5.56
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
5.16
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.18
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.38
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.45
CMS adjusted RN staffing hours
Adjusted total hours
5.57
CMS adjusted total nurse staffing hours
Case-mix index
1.37
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
462
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.39
Composite VBP score used to determine payment impact.
Payment multiplier
1.0221
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.82
Baseline 18.66% · Performance 20.13% · Measure score 2.82 · Achievement 2.82 · Improvement 0
Healthcare-associated infections
9.21
Baseline 3.85% · Performance 5.08% · Measure score 9.21 · Achievement 9.21 · 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
8.80
Baseline 6.49 hours · Performance 5.58 hours · Measure score 8.80 · Achievement 8.80 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.34% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 347 · Observed rate 8.36% · Lower 95% interval 8.16% |
| Discharge to community | 68.41% |
50.57%
17.8 pts better
|
Better than the National Rate · Eligible stays 355 · Observed rate 67.61% · Lower 95% interval 64.51% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 237 · Denominator 237 |
| Falls with major injury | 0.42% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 237 |
| Discharge self-care score | 43.88% |
53.69%
9.8 pts worse
|
Numerator 86 · Denominator 196 |
| Discharge mobility score | 47.45% |
50.94%
3.5 pts worse
|
Numerator 93 · Denominator 196 |
| Pressure ulcers or injuries, new or worsened | 5.06% |
2.29%
2.8 pts worse
|
Numerator 12 · Denominator 237 · Adjusted rate 6.1% |
| Healthcare-associated infections requiring hospitalization | 5.08% |
7.12%
2 pts better
|
No Different than the National Rate · Eligible stays 208 · Observed rate 2.4% · Lower 95% interval 2.71% |
| Staff COVID-19 vaccination coverage | 16.89% |
8.2%
8.7 pts better
|
Numerator 25 · Denominator 148 |
| Staff flu vaccination coverage | 46.99% |
42%
5 pts better
|
Numerator 78 · Denominator 166 |
| Discharge function score | 51.53% |
56.45%
4.9 pts worse
|
Numerator 101 · Denominator 196 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 35 · Denominator 35 |
| Transfer of health information to patient | 98.79% |
96.28%
2.5 pts better
|
Numerator 163 · Denominator 165 |
| Resident COVID-19 vaccinations up to date | 70.83% |
25.2%
45.6 pts better
|
Numerator 85 · Denominator 120 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.1% |
95.7%
3.6 pts worse
|
93.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 92.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
3.2%
2.1 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
5.0%
5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
4.9%
3.4 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.0% |
16.6%
7.4 pts worse
|
19.6%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.0% |
| 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 | 12.0% |
17.3%
5.3 pts better
|
14.9%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.0% |
2.3%
2.7 pts worse
|
1.0%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
3.0%
0.3 pts better
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 40.8% |
25.5%
15.3 pts worse
|
19.8%
21 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 40.8% |
| Percentage of long-stay residents with pressure ulcers | 27.3% |
5.5%
21.8 pts worse
|
5.1%
22.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
86.8%
9.3 pts better
|
81.7%
14.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 97.8% · Q3 93.8% · Q4 96.2% · 4Q avg 96.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
15.0%
0.8 pts better
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 12.2% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.3%
1 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 4.5% · Q3 3.8% · Q4 0.5% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.4% |
82.2%
9.2 pts better
|
79.7%
11.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
22.7%
3.8 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 21.5% · Expected 19.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-06 · Fire 2024-06-06
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2023-03-15 · Fire 2023-03-15
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-29
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2025-08-12
F · Potential for more than minimal harm
2025-07-29
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-08-12
F · Potential for more than minimal harm
2025-07-29
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-08-15
F · Potential for more than minimal harm
2025-07-29
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-08-12
F · Potential for more than minimal harm
2025-07-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-07-29
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-08-15
E · Potential for more than minimal harm
2025-07-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-07-29
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-08-29
F · Potential for more than minimal harm
2024-06-06
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-06-10
F · Potential for more than minimal harm
2024-06-06
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-06-10
F · Potential for more than minimal harm
2024-06-06
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-06-25
F · Potential for more than minimal harm
2024-06-06
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-06-11
F · Potential for more than minimal harm
2024-06-06
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 2024-07-10
E · Potential for more than minimal harm
2024-06-06
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2024-06-10
E · Potential for more than minimal harm
2024-06-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-06-06
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-06-20
D · Potential for more than minimal harm
2024-06-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-06-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-10
D · Potential for more than minimal harm
2024-06-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-22
F · Potential for more than minimal harm
2023-03-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-16
F · Potential for more than minimal harm
2023-03-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-02
F · Potential for more than minimal harm
2023-03-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-02
C · Minimal harm
2023-03-15
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-04-02
Inspection history
Recent health citations
J · Immediate jeopardy
2025-10-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-10-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-10
F · Potential for more than minimal harm
2025-07-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-18
E · Potential for more than minimal harm
2025-07-29
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 2025-08-18
E · Potential for more than minimal harm
2025-07-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-18
E · Potential for more than minimal harm
2025-07-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-29
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-29
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 2025-08-18
D · Potential for more than minimal harm
2025-07-29
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-07-29
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-08-18
F · Potential for more than minimal harm
2024-06-06
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 2024-07-02
F · Potential for more than minimal harm
2024-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-06-06
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 2024-07-05
E · Potential for more than minimal harm
2024-06-06
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-07-06
D · Potential for more than minimal harm
2024-06-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-06
D · Potential for more than minimal harm
2024-06-06
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-05
D · Potential for more than minimal harm
2023-07-27
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-08-27
D · Potential for more than minimal harm
2023-07-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-08-27
Penalties and ownership
What sits behind the stars
Ownership
Oakwood Lutheran Senior Ministries, Inc.
5% Or Greater Direct Ownership Interest · Organization
Barros, Mary
Operational/Managerial Control · Individual
Barros, Mary
Corporate Officer · Individual
Church, Martha
Corporate Director · 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
Kunz, Tom
Corporate Director · Individual
Lefel, Kristin
Operational/Managerial Control · Individual
Nelson, Goldie
Operational/Managerial Control · Individual
Nicholson, Robert
Corporate Director · Individual
O'donnell, Christine
Operational/Managerial Control · Individual
O'donnell, Christine
Corporate Officer · Individual
Oakwood Village University Woods Homes Inc
Operational/Managerial Control · Organization
Raemisch, Sarah
Operational/Managerial Control · Individual
Rafferty, Susan
Operational/Managerial Control · Individual
Rafferty, Susan
Corporate Officer · Individual
Sachtjen, Laura
Operational/Managerial Control · Individual
Schaetzl, Ronnie
Operational/Managerial Control · Individual
Sidhu, Sarfraz
Operational/Managerial Control · Individual
Wolff, Sally
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Avina of Sun Prairie
Sun Prairie, WI
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Sun Prairie Senior Living
Sun Prairie, WI
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Madison Health And Rehabilitation Center
Madison, WI
0-star overall rating with 0-star inspections with Special Focus status with $413,433 in total fines with 10 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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