01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-07-29 | 10 | 2025-07-29 | 8 |
| Cycle 2 | 2024-06-06 | 6 | 2024-06-06 | 11 |
| Cycle 3 | 2023-03-15 | 0 | 2023-03-15 | 4 |
CMS CCN 5256922026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Oakwood Village East Health And Rehab Center
5833 American Parkway · Madison, WI 53718 · Dane County
Certified beds40CMS provider file
Recent citation rows39current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
39 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-10-22 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-11-10 · complaint2025-10-22 · HEALTHF0686Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-11-10 · complaint2025-07-29 · FIREE0006Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2025-08-122025-07-29 · FIREE0013Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop Emergency Preparedness policies and procedures.
Correction field: Deficient, Provider has date of correction · 2025-08-122025-07-29 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-08-182025-07-29 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-08-182025-07-29 · HEALTHF0609Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2025-08-182025-07-29 · HEALTHF0610Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2025-08-182025-07-29 · HEALTHF0645Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Correction field: Deficient, Provider has date of correction · 2025-08-182025-07-29 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-08-182025-07-29 · HEALTHF0881Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
Correction field: Deficient, Provider has date of correction · 2025-08-182025-07-29 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2025-08-182025-07-29 · FIREK0223Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Correction field: Deficient, Provider has date of correction · 2025-08-152025-07-29 · FIREK0346Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Correction field: Deficient, Provider has date of correction · 2025-08-122025-07-29 · FIREK0351Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-29 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-08-292025-07-29 · FIREK0521Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2025-08-152025-07-29 · FIREK0912Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have power receptacles that are properly grounded.
Correction field: Deficient, Provider has date of correction · 2025-08-292024-06-06 · FIREE0004Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2024-06-102024-06-06 · FIREE0006Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2024-06-102024-06-06 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2024-07-062024-06-06 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-07-052024-06-06 · HEALTHF0758Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-07-052024-06-06 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-07-0203 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-10-22 | Fine | $212,069 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- OAKWOOD LUTHERAN SENIOR MINISTRIES, INC.Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 03/10/2008
- CHURCH, MARTHAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/01/2021
- HAYDEN, KEVINIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/01/2023
- KUNZ, TOMIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/01/2024
- NICHOLSON, ROBERTIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/01/2023
- WOLFF, SALLYIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/01/2024
- CHURCH, MARTHAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2021
- HAYDEN, KEVINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2023
- KUNZ, TOMIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2024
- NICHOLSON, ROBERTIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2023
- WOLFF, SALLYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/01/2024
- BARROS, MARYIndividual · CORPORATE OFFICERNOT APPLICABLE · since 07/30/2024
- HAMILTON-CRAWFORD, JANICEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 10/31/2023
- HUSOM, SUSANIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/01/2024
- O'DONNELL, CHRISTINEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 04/09/2023
- RAFFERTY, SUSANIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/13/2023
- OAKWOOD VILLAGE UNIVERSITY WOODS HOMES INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/10/2008
- BARROS, MARYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 07/30/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours5.51per resident day
RN hours1.45per resident day
Weekend nurse hours5.06per resident day
Staff turnover44.1%CMS reported field
06 / LOCAL RECORDS
Open the Madison ledger →Other published facilities nearby
Capitol Lakes Health Center49 beds · CMS overall 4/541 citation rowsComplete Care At Maple Grove Llc184 beds · CMS overall 1/5118 citation rowsHebron Oaks70 beds · CMS overall 4/537 citation rowsMadison Health And Rehabilitation Center83 beds · CMS overall 1/584 citation rowsOak Park Nursing And Rehab Center100 beds · CMS overall 1/576 citation rowsOak Park Place Of Nakoma33 beds · CMS overall 3/557 citation rows