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
Staffing
Hours and turnover
RN hours / resident day
1.44
Registered nurse staffing
LPN hours / resident day
0.59
Licensed practical nurse staffing
Aide hours / resident day
3.52
Nurse aide staffing
Weekend hours
5.16
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 | 92.1% |
95.7%
3.6 pts worse
|
93.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 12.0% |
17.3%
5.3 pts better
|
14.9%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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