Oakwood Village East Health and Rehab Center
5833 American Parkway, Madison, WI 53718 · Dane County · 40 certified beds · avg 33 residents/day · certified since May 8, 2008
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
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 · Oct 22, 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: Nov 10, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (16)
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 |
|---|---|---|
| Oct 22, 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 |
| Oct 22, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jul 29, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 29, 2025 | E · Potential for harm, repeated | 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. |
| Jul 29, 2025 | E · Potential for harm, repeated | 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. |
| Jul 29, 2025 | E · Potential for harm, repeated | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Jul 29, 2025 | 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. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Jul 29, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Jun 6, 2024 | 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. |
| Jun 6, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (6 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 6 | 0 | F |
| 2025 | 10 | 1 | J ▲ |
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 $212,069.
| Date | Type | Amount / length |
|---|---|---|
| Oct 22, 2025 | Fine | $212,069 |
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) | 5.06 | 4.29 | 3.95 | top 20% in Wisconsin; top 12% in the U.S. |
| Registered Nurse hours | 1.34 | 1.01 | 0.69 | top 17% in Wisconsin; top 7% in the U.S. |
| Weekend total nurse staffing | 4.65 | 3.84 | 3.50 | top 18% in Wisconsin; top 10% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.15 | 0.68 | 0.48 | top 7% in Wisconsin; top 4% in the U.S. |
| Total nursing staff turnover (%) | 44.1 | 46.9 | 45.8 | top 43% in Wisconsin; top 48% in the U.S. |
| RN turnover (%) | 40.0 | 39.7 | 42.9 | bottom 48% in Wisconsin; top 46% 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 5.51, RN 1.45, weekend 5.06. 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: 1/5
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% | 03/10/2008 |
| Barros, Mary | Individual | Corporate Officer | NOT APPLICABLE | 07/30/2024 |
| Barros, Mary | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/30/2024 |
| Barros, Mary | Individual | ADP of the SNF | NOT APPLICABLE | 07/30/2024 |
| Church, Martha | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/01/2021 |
| Church, Martha | Individual | Corporate Director | NOT APPLICABLE | 01/01/2021 |
| Cliftonlarsonallen LLP | Organization | ADP of the SNF | NOT APPLICABLE | 12/31/2020 |
| 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 |
| 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 |
| Kunz, Tom | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2024 |
| Kunz, Tom | Individual | Corporate Director | NOT APPLICABLE | 06/01/2024 |
| Lefel, Kristin | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/31/2023 |
| Nelson, Goldie | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/12/2021 |
| Nicholson, Robert | Individual | Managing Control - Governing Body | NOT APPLICABLE | 06/01/2023 |
| Nicholson, Robert | Individual | Corporate Director | NOT APPLICABLE | 06/01/2023 |
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?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "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?"
- "How do you screen new residents for mental health and disability-related needs, and how do you provide the specialized services they require?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "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 |
|---|---|---|---|---|---|
| Avina of Sun Prairie | 2.7 mi | Sun Prairie, WI | ★★★★★ | 4/5 | |
| Sun Prairie Senior Living | 3.9 mi | Sun Prairie, WI | ★★★☆☆ | 3/5 | |
| Madison Health and Rehabilitation Center | 4.5 mi | Madison, WI | ★☆☆☆☆ | 1/5 | |
| Oak Park Nursing and Rehab Center | 4.9 mi | Madison, WI | ★☆☆☆☆ | 1/5 | |
| Capitol Lakes Health Center | 7.9 mi | Madison, WI | ★★★★☆ | 3/5 | |
| Waunakee Valley Senior Living | 9.2 mi | Waunakee, WI | ★★★☆☆ | 2/5 | |
| Middleton Village Nursing and Rehab | 11.4 mi | Middleton, WI | ★☆☆☆☆ | 1/5 | |
| Oak Park Place of Nakoma | 11.6 mi | Madison, WI | ★★★☆☆ | 3/5 | |
| Hebron Oaks | 13.8 mi | Madison, WI | ★★★★☆ | 3/5 | |
| Complete Care at Maple Grove LLC | 14.8 mi | Madison, WI | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 525692.