Hebron Oaks
510 Genomic Drive, Madison, WI 53719 · Dane County · 70 certified beds · avg 41 residents/day · certified since Nov 1, 1984
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Feb 18, 2025 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Apr 1, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (10)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 8, 2026 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jan 8, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jan 8, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jul 17, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 17, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Feb 18, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Feb 18, 2025 | F · Potential for harm, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. · from a complaint |
| Mar 9, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 9, 2023 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 9, 2023 | D · Potential for harm, one-off | The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them. |
Inspection trend by year
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 3 | 0 | F |
| 2025 | 4 | 1 | J ▲ |
| 2026 | 3 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $14,901, plus 1 Medicare payment denial period.
| Date | Type | Amount / length |
|---|---|---|
| Feb 18, 2025 | Fine | $14,901 |
| Feb 18, 2025 | Payment Denial | 17 days from Mar 15, 2025 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Wisconsin avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.56 | 4.29 | 3.95 | top 11% in Wisconsin; top 7% in the U.S. |
| Registered Nurse hours | 2.16 | 1.01 | 0.69 | top 2% in Wisconsin; top 1% in the U.S. |
| Weekend total nurse staffing | 5.12 | 3.84 | 3.50 | top 9% in Wisconsin; top 5% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.94 | 0.68 | 0.48 | top 1% in Wisconsin; top 1% in the U.S. |
| Total nursing staff turnover (%) | 46.2 | 46.9 | 45.8 | top 50% in Wisconsin; bottom 47% in the U.S. |
| RN turnover (%) | 44.4 | 39.7 | 42.9 | bottom 41% in Wisconsin; bottom 45% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 5.91, RN 2.30, weekend 5.44. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Oakwood Lutheran Senior Ministries, INC. | Organization | 5% or Greater Direct Ownership Interest | 100% | 01/01/1966 |
| Barros, Mary | Individual | Corporate Officer | NOT APPLICABLE | 07/30/2024 |
| Barros, Mary | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/30/2024 |
| Cliftonlarsonallen LLP | Organization | ADP of the SNF | NOT APPLICABLE | 12/31/2020 |
| Donovan, Amber | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/17/2024 |
| Donovan, Amber | Individual | ADP of the SNF | NOT APPLICABLE | 12/17/2024 |
| Hamilton-Crawford, Janice | Individual | Corporate Officer | NOT APPLICABLE | 10/31/2023 |
| Hamilton-Crawford, Janice | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/31/2023 |
| Hayden, Kevin | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2023 |
| Hayden, Kevin | Individual | Corporate Director | NOT APPLICABLE | 06/01/2023 |
| Hayden, Kevin | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2023 |
| Husom, Susan | Individual | Corporate Officer | NOT APPLICABLE | 12/01/2024 |
| Husom, Susan | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Husom, Susan | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
| Jacobson, Eric | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/31/2025 |
| Jacobson, Eric | Individual | ADP of the SNF | NOT APPLICABLE | 03/31/2025 |
| Lefel, Kristin | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/31/2013 |
| Metz, Mary | Individual | Corporate Director | NOT APPLICABLE | 06/01/2023 |
| Metz, Mary | Individual | ADP of the SNF | NOT APPLICABLE | 06/01/2023 |
| O'Donnell, Christine | Individual | Corporate Officer | NOT APPLICABLE | 04/09/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "How often do you evaluate your nurse aides and what ongoing training do they receive?"
- "Who on your staff manages IV therapy, and what training and monitoring is in place?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Complete Care at Maple Grove LLC | 1.5 mi | Madison, WI | ★☆☆☆☆ | 1/5 | |
| Oak Park Place of Nakoma | 2.5 mi | Madison, WI | ★★★☆☆ | 3/5 | |
| Badger Prairie HCC | 3.0 mi | Verona, WI | ★★★★★ | 5/5 | |
| Four Winds Manor | 3.5 mi | Verona, WI | ★★☆☆☆ | 2/5 | |
| Middleton Village Nursing and Rehab | 3.9 mi | Middleton, WI | ★☆☆☆☆ | 1/5 | |
| Capitol Lakes Health Center | 6.2 mi | Madison, WI | ★★★★☆ | 3/5 | |
| Madison Health and Rehabilitation Center | 10.3 mi | Madison, WI | ★☆☆☆☆ | 1/5 | |
| Waunakee Valley Senior Living | 10.7 mi | Waunakee, WI | ★★★☆☆ | 2/5 | |
| Oak Park Nursing and Rehab Center | 11.5 mi | Madison, WI | ★☆☆☆☆ | 1/5 | |
| Ingleside Manor | 11.7 mi | Mount Horeb, WI | —/5 | SFF |
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Facility data as of CMS processing date 2026-08-01. CCN 525375.