Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakwood Village East Health And Rehab Center during CMS and state inspections, most recent first.
A resident with a history of pressure ulcers and decreased mobility was inaccurately assessed as not at risk for pressure injuries, resulting in an inadequate care plan and delayed interventions. Staff inconsistently staged and documented wounds, failed to notify the MD promptly of wound deterioration and infection, and did not follow prescribed wound care orders or provide education on treatment refusals. These failures led to the development of multiple stage 3 or unstageable pressure injuries, including an infected wound.
A resident with a physician order specifying that their Foley catheter should not be manipulated or removed except by urology had the catheter removed by an RN after observing improper drainage and a wet bed. The RN, aware of the order, removed the catheter without first consulting a provider or urology, and only attempted contact after removal. Facility policy and physician orders requiring prior notification and authorization were not followed.
The facility failed to maintain an effective infection prevention and control program, as staff returned to work too soon after GI symptoms, illness tracking forms were incomplete, and infection surveillance documentation for two residents was inaccurate. Additionally, a CNA did not perform required hand hygiene during catheter care, despite facility policy. These deficiencies had the potential to impact all residents.
The facility did not report multiple allegations of abuse and neglect to the state agency as required. Incidents included a resident reporting rough handling and a bruise, another resident experiencing unwanted touching by an LPN, a CNA observing an RN yelling and acting aggressively toward a resident, and other cases of staff refusing care or being rough during care. Despite staff and management acknowledging these as reportable allegations, the facility failed to follow its own policy and regulatory requirements for timely reporting.
Multiple residents and their representatives reported concerns of abuse, neglect, and exploitation, including unwanted touching, rough handling, verbal abuse, and refusal to provide care. The facility did not conduct thorough investigations as required, failed to remove accused staff from resident care during investigations, and did not consistently collect statements or report allegations to the state agency. Residents involved had various medical and cognitive conditions, and the facility did not follow its own policies for investigating and responding to these serious concerns.
The facility did not complete required PASARR Level II screenings for four residents with major mental disorders who remained in the facility beyond the 30-day hospital discharge exemption period. Each resident was admitted with diagnoses such as major depressive disorder and prescribed psychotropic medications, but the necessary follow-up screenings were not performed due to lapses in staff responsibility and oversight.
A resident's advance directive indicating a preference for CPR was not accurately reflected in the electronic medical record, which instead listed a DNR order. Nursing staff confirmed that the resident's code status should match across all records, but the update was not made, resulting in conflicting documentation.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have a program in place to monitor antibiotic use, as required. Surveyors found no evidence of a system to track or review antibiotic administration among residents.
A resident's medical record did not contain documentation showing that education about the influenza vaccine was provided or that the resident consented to or declined the vaccine for the most recent season. The required declination form was only completed after surveyors requested it, indicating a lapse in timely documentation as required by facility policy.
The facility failed to maintain a sanitary environment for food service, affecting all residents. Observations showed garbage cans without lids near food prep areas, crumbs in utensil containers, and unclean kitchenettes. Staff did not follow proper food temperature procedures, and a Dietary Aide failed to change gloves or perform hand hygiene while handling food. These deficiencies indicate non-compliance with cleaning and infection control protocols.
The facility failed to manage a COVID-19 outbreak effectively, as it did not recognize a single positive case as an outbreak per CDC guidelines. This led to delayed notification of public health authorities and the Medical Director, and inconsistent documentation of symptoms and testing. The Infection Preventionist acknowledged that outbreak protocols, including masking and testing, should have started earlier, but the absence of the IP and reliance on other staff resulted in inadequate outbreak management.
The facility failed to ensure that residents were appropriately monitored and assessed for the use of psychogenic medications. Four residents were identified as not having adequate monitoring or assessments for their medication use. The facility's staff, including the RN and DON, were interviewed regarding the monitoring of residents. The facility's failure to ensure that residents were appropriately monitored and assessed for the use of psychogenic medications resulted in the residents not receiving the necessary care.
The facility failed to follow its Antibiotic Stewardship Program, resulting in inappropriate antibiotic prescriptions for several residents with UTIs. Documentation of necessary tests and symptoms was often missing, and criteria for antibiotic use were not consistently met, as confirmed by the Infection Preventionist.
A resident was found with an expired medication on their nightstand, which was not listed in their current orders or care plan. The facility lacked a self-administration assessment for the resident and did not have a Self-Administration policy. The LPN and DON confirmed the medication should not have been in the resident's room, highlighting a lapse in medication management.
The facility failed to develop comprehensive care plans for two residents using psychotropic medications. One resident, with COPD, diabetes, depression, and anxiety, lacked a care plan addressing antidepressants and antianxiety medication. Another resident, with anxiety disorder and Multiple Sclerosis, also lacked a care plan for antidepressant use. The DON acknowledged the need for care plans and was unsure about non-pharmacological interventions. The facility's care plan policy was not provided.
Failure to Prevent and Treat Pressure Injuries According to Standards of Practice
Penalty
Summary
The facility failed to provide care consistent with professional standards of practice for the prevention and treatment of pressure injuries in a resident with a history of pressure ulcers and significant risk factors. The resident was inaccurately assessed as not at risk for pressure injury development upon admission, despite a documented history of pressure injuries and decreased mobility. This led to an insufficient care plan that did not adequately address the resident's risk factors or include robust interventions to prevent pressure injuries. The care plan was not updated in a timely manner as the resident's condition changed, and interventions to prevent worsening or new injuries were not implemented promptly. Staff inconsistently staged and documented the resident's wounds, failing to provide detailed descriptions of wound characteristics in weekly assessments. There were discrepancies in wound staging, with some wounds being down-staged contrary to standards of practice, and incomplete documentation regarding the extent of granulation and epithelial tissue. Additionally, wound assessments and documentation were sometimes kept outside the resident's official medical record, leading to gaps in continuity of care. The resident's wounds showed signs of deterioration and infection, but the medical doctor was not notified in a timely manner about these changes. The facility also failed to follow physician orders for wound care and did not provide the resident with information about the risks and benefits when he refused to wear offloading boots, which were prescribed for treatment. Staff did not consistently follow standards of practice during wound care procedures, and treatment orders were not always implemented as prescribed. As a result of these failures, the resident developed multiple stage 3 or unstageable pressure injuries, including an infected wound, which constituted a finding of Immediate Jeopardy.
Foley Catheter Removed Against Physician Orders
Penalty
Summary
A deficiency occurred when a resident with a physician order specifying that their Foley catheter should not be manipulated, flushed, or exchanged, and that only urology should address any issues, had their catheter removed by a registered nurse. The nurse observed that the resident's bed was wet, the catheter was not draining properly, and only 3mL of fluid was present in the balloon upon aspiration. Despite being aware of the explicit order not to manipulate or remove the catheter and to contact urology for any issues, the nurse proceeded to remove the catheter without first consulting a provider or urology. The nurse attempted to contact the primary provider and urology only after the removal had already occurred. Interviews confirmed that the nurse was aware of the standing orders and the facility's policies requiring physician notification and authorization for significant changes in treatment, including catheter removal. The urology clinic confirmed that an afterhours contact was available and that the catheter should not have been removed by facility staff. The Director of Nursing acknowledged that the nurse did not consult with a provider prior to removal and that the event took place before the clinic opened. The facility's failure to follow physician orders and internal protocols led to the deficiency.
Deficient Infection Control Program and Incomplete Surveillance Documentation
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple deficiencies in staff illness tracking, resident infection surveillance, and adherence to hand hygiene protocols. One staff member returned to work less than 48 hours after experiencing gastrointestinal symptoms, contrary to CDC guidelines and facility policy, which require exclusion from work for at least 48 hours after symptom resolution. Additionally, the staff illness line list used for infection surveillance was incomplete, with five staff members missing the date of last symptoms, making it difficult to determine appropriate return-to-work timing and to conduct accurate illness tracking. Resident infection surveillance was also found to be deficient. For two residents, the infection line list did not accurately reflect their symptoms or infection details. One resident with a urinary tract infection had missing or incorrect information on the line list, including the onset date, symptoms, and laboratory results, and the infection was not recorded in the appropriate month. Another resident's line list entry did not match the information documented on the McGeer Criteria checklist, with discrepancies in symptoms and infection criteria. These inaccuracies in documentation hindered the facility's ability to conduct effective infection surveillance. Furthermore, staff did not consistently perform appropriate hand hygiene during resident care. During an observation of catheter care, a certified nursing assistant changed gloves four times without performing hand hygiene between glove changes, despite facility policy and standard practice requiring hand hygiene before donning and after removing gloves. The staff member acknowledged the expectation for hand hygiene but did not adhere to it during the observed care. These failures in infection control practices had the potential to affect all residents in the facility.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to the administrator and to the State Survey Agency as required by state and federal regulations. In five separate cases, allegations of abuse or neglect were either not reported at all or not reported in a timely manner. These included incidents involving unwanted touching by a staff member, verbal and mental abuse, rough handling during care, and refusal to provide care. In each case, the facility's own policy required immediate reporting to the state agency, but this was not followed. One resident with mild cognitive impairment, anxiety, and depression reported that a nurse threw a pill in her mouth and made a derogatory comment, and later reported that a CNA caused a bruise by being rough during care. Both incidents were documented as concerns but were not reported to the state agency as allegations of abuse. Another resident and her representative reported unwanted touching in the vaginal area by an LPN during a skin assessment, which made the resident uncomfortable and fearful. Despite the resident's request for a female caregiver and the clear policy on reporting such allegations, the incident was not reported to the state agency or law enforcement. Additional incidents included a CNA reporting that an RN yelled at a resident, pulled a blanket off without warning, and slammed doors, which was not reported as verbal or mental abuse. Another resident's representative reported that a staff member refused to assist with care, and a resident reported being handled roughly during evening care. In all these cases, staff and management acknowledged during interviews that these were allegations of abuse or neglect that should have been reported, but there was no evidence that the required reports were made to the state agency.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure thorough investigations of multiple allegations of abuse, neglect, and exploitation involving several residents. In several instances, residents or their representatives reported concerns through the facility's grievance process, including unwanted touching by staff, rough handling during care, verbal abuse, and refusal to provide care. Despite these reports, the facility did not conduct comprehensive investigations as required by its own policies. For example, when a resident and her representative reported that an LPN touched her in a private area after she requested a female caregiver, the facility did not remove the staff member from duty pending investigation, nor did it interview other staff or residents who may have had relevant information. Similarly, when a CNA reported that an RN yelled at a resident, pulled off her blanket, and slammed doors, the RN was not suspended, and no further staff or resident interviews were conducted. The facility's policy mandates immediate action to ensure resident safety, including suspension of accused staff and thorough investigation of all allegations, regardless of perceived severity. However, in the reviewed cases, staff members accused of abuse or neglect continued to work with residents during and after the incidents. In several cases, the facility did not collect written statements from witnesses or involved parties, nor did it report the allegations to the state agency as required. Staff interviews revealed uncertainty about what constitutes a thorough investigation, and there was a lack of documentation showing that the facility followed its own procedures for investigating and reporting abuse allegations. Residents involved in these incidents had varying degrees of cognitive impairment and medical complexity, including diagnoses such as mild cognitive impairment, anxiety, depression, chronic obstructive pulmonary disease, and need for assistance with personal care. The failure to investigate allegations thoroughly was consistent across multiple cases, including those involving physical, verbal, and potential sexual abuse, as well as neglect. The facility did not provide evidence of comprehensive investigations, did not consistently remove accused staff from resident care, and did not always report allegations to the appropriate authorities, as required by policy.
Failure to Complete PASARR Level II Screenings for Residents with Major Mental Disorders
Penalty
Summary
The facility failed to complete the required PASARR Level II (Preadmission Screening and Resident Review) screenings for four residents who were admitted with diagnoses of major mental disorders and prescribed psychotropic medications. Each of these residents was initially admitted under a hospital discharge exemption, which allows for a 30-day maximum stay without a Level II screening. However, all four residents remained in the facility beyond the 30-day exemption period, and there was no evidence that the necessary Level II screenings were completed as required by federal regulations and facility policy. For each resident, documentation showed that the Level I PASRR screens identified the presence of a major mental disorder and the use of psychotropic medications. Despite this, and the fact that their stays exceeded the 30-day exemption, the facility did not initiate or complete the Level II screening process. Interviews with social workers and the Assistant Nursing Home Administrator confirmed that the oversight occurred due to a change in staff responsibilities and a lack of follow-up to ensure the PASRR program was maintained during staff transitions. The deficiency was further substantiated by the facility's own policy, which mandates that all new admissions and readmissions be screened for mental disorders or intellectual disabilities per the PASRR process. The failure to complete the Level II screenings was acknowledged by staff during interviews, who indicated that the screenings should have been completed once it was clear the residents would remain in the facility beyond the permitted exemption period.
Failure to Update and Reconcile Advance Directives in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurate and up to date in the electronic medical record. Specifically, one resident's CPR preference form indicated a desire for full code status (to receive CPR), while the electronic medical record and physician orders reflected a DNR (Do Not Resuscitate) status. This discrepancy was identified during a review of the resident's records and confirmed through interviews with nursing staff, who acknowledged that the resident's code status should be consistent across all documentation. The facility's policy requires that information about advance directives be prominently displayed and updated in the medical record, and that changes be communicated to the interdisciplinary team and reflected in the care plan. Despite this, the resident's updated CPR preference was not entered into the electronic medical record, resulting in conflicting documentation. Staff interviews confirmed awareness of the need for consistency between the resident's expressed wishes and the medical record, but the necessary updates were not made at the time the new preference was obtained.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement a program that monitors antibiotic use. There is no evidence provided that the facility had a system in place to track, review, or evaluate the use of antibiotics among residents. The absence of such a program was identified during the survey, indicating a lack of oversight regarding antibiotic administration and stewardship within the facility. No specific residents or staff were mentioned in relation to this deficiency, and no details about individual medical histories or conditions were provided.
Failure to Document Influenza Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure that a resident's medical record included required documentation regarding influenza vaccination. Specifically, the record did not indicate that the resident or their representative was provided education about the benefits and potential side effects of the influenza immunization, nor did it document whether the resident received the vaccine, declined it, or had a medical contraindication. The facility's policy requires that all residents be offered the influenza vaccine annually and that any refusal be documented and placed in the resident's medical record. In this instance, a resident was admitted to the facility and had documentation of receiving the influenza vaccine in a previous season, but there was no record of vaccination or declination for the most recent influenza season. When surveyors requested documentation, the facility was unable to provide a signed and dated declination form until after the request was made, at which point the resident and staff completed the form. This indicates that the required documentation was not present in the medical record at the time of the surveyor's initial review.
Sanitation and Hygiene Deficiencies in Food Service
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food preparation, storage, and distribution, potentially affecting all 36 residents. Observations revealed that garbage cans in the kitchenettes and main kitchen lacked lids and were placed near food preparation areas. Additionally, containers holding spatulas and spoons contained crumbs and dried substances. The kitchenettes on the first and second floors had crumbs and dust inside cupboards, and the microwave on the first floor had dried food inside. These conditions indicate a lack of adherence to cleaning protocols, despite management providing cleaning checklists and staff meeting notes outlining cleaning expectations. The facility's staff did not follow proper procedures for taking food temperatures. An Executive Chef was observed using a thermometer incorrectly by placing it in a liquid sanitizer without properly drying it before using it on another food item. The chef also failed to use alcohol wipes as recommended by the facility's policy. This improper practice was acknowledged by the Director of Culinary Services, who indicated that education would be provided to staff regarding the correct procedures. Hand hygiene and glove use were also inadequate. A Dietary Aide was observed handling food and touching various surfaces in the kitchenette without changing gloves or performing hand hygiene. This included touching meal tickets, microwave, plates, and other items before returning to serve food. The Dietary Aide admitted to not changing gloves as required, despite having been educated on proper glove use during orientation. This failure to adhere to infection control policies poses a risk of cross-contamination and highlights a need for improved compliance with hand hygiene standards.
Inadequate COVID-19 Outbreak Management
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, which led to a deficiency in managing a COVID-19 outbreak. The outbreak began when an occupational therapist tested positive for COVID-19, but the facility did not recognize this as an outbreak according to CDC guidelines, which define an outbreak as a single new case of COVID-19 among residents or staff. Consequently, the facility did not notify public health authorities, the Medical Director, or the community in a timely manner, nor did it implement outbreak protocols such as masking and testing immediately. The facility's documentation was inconsistent and incomplete, as evidenced by multiple line lists with differing symptomology for staff members. This inconsistency made it difficult to determine the correct symptomology used for outbreak surveillance and tracking. Additionally, the facility failed to document COVID-19 testing in the resident medical records or staff files, further complicating the tracking and management of the outbreak. The Infection Preventionist (IP) admitted that the outbreak should have been declared earlier and that testing and masking should have started with the first positive case. However, due to the IP's absence on vacation, the outbreak management was left to a medical assistant and supervisors, leading to a lack of proper notification and documentation. The facility's failure to follow CDC recommendations and maintain accurate records contributed to the ineffective management of the COVID-19 outbreak.
Failure to Monitor Residents on Psychogenic Medications
Penalty
Summary
The facility failed to ensure that residents were appropriately monitored and assessed for the use of psychotropic medications. Four residents were identified as not having adequate monitoring or assessments for their medication use. Specifically, one resident was receiving psychogenic medication without adequate monitoring, and another was not receiving proper assessment for their medication. Additionally, the facility did not have a policy in place for sleep assessments, and one resident was not receiving the necessary assessment for their medication. The facility's staff, including the RN and DON, were interviewed regarding the monitoring of residents. The RN reported that they were monitoring for specific conditions, but the facility did not have a policy in place for sleep assessments. The DON reported that they were not sure if the residents were being monitored for side effects, and the facility did not have a policy in place for sleep assessments. The facility's staff were not adequately monitoring the residents, and the facility did not have a policy in place for sleep assessments. The facility's failure to ensure that residents were appropriately monitored and assessed for the use of psychogenic medications resulted in the residents not receiving the necessary care. The facility's staff were not adequately monitoring the residents, and the facility did not have a policy in place for sleep assessments. The facility's failure to ensure that residents were appropriately monitored and assessed for the use of psychogenic medications resulted in the residents not receiving the necessary care.
Inappropriate Antibiotic Use Due to Non-Adherence to Stewardship Program
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Program (ASP) by not ensuring appropriate antibiotic use protocols and monitoring systems were followed for several residents. Specifically, five residents were prescribed antibiotics for urinary tract infections (UTIs) without appropriate indications. The facility's policy requires the use of McGeers and/or Loeb Minimum Criteria to determine the necessity of antibiotic treatment, but this was not consistently applied. For Resident 9, the facility's infection control log indicated a UTI with symptoms of mood swings and irritability, but there was no documentation of a urinalysis (UA) or culture and susceptibility (C&S) to support the antibiotic prescription. Similarly, Resident 23 was prescribed antibiotics despite the absence of documented symptoms and criteria not being met, as confirmed by the Infection Preventionist (IP). Resident 4 was also on antibiotics without documented symptoms or justification, and the prescribed antibiotic was not on the susceptibility list for the identified pathogen. Resident 5 was treated with antibiotics for a UTI, but the facility could not provide the necessary UA and C&S documentation. Lastly, Resident 291 was prescribed antibiotics without documented symptoms or pathogen information, and the IP confirmed that the resident should not have been on antibiotics. These deficiencies highlight a lack of adherence to the facility's ASP and infection control policies, resulting in inappropriate antibiotic use.
Failure to Ensure Appropriate Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the self-administration of medications was clinically appropriate for a resident, identified as R10, who was part of a sample of 12 residents. The surveyor observed a medication bottle on R10's nightstand, which R10 identified as an as-needed medication. However, there was no self-administration assessment on file for R10, and the medication was not listed in R10's current orders or care plan. The medication was also expired, and the resident was unable to recall if an assessment had been completed. Further investigation revealed that the facility did not have a Self-Administration policy in place. Interviews with the LPN and the DON confirmed that R10 did not have a self-administration assessment and that the medication should not have been in R10's room. The LPN was unaware of the medication and confirmed it was not ordered for R10, indicating a lapse in medication management and oversight by the facility.
Deficiency in Care Planning for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for two residents regarding their use of psychotropic medications. Resident 11, who was admitted with diagnoses including COPD, Type 2 Diabetes Mellitus, depression, and anxiety, was taking antidepressants buspirone and sertraline daily, as well as the antianxiety medication lorazepam on an as-needed basis. However, the care plan for Resident 11 did not address the use of these medications, the side effects to monitor for, or any non-pharmacological interventions to assist with managing depression or anxiety. Similarly, Resident 32, admitted with generalized anxiety disorder, Multiple Sclerosis, and status-post abdominal surgery, was taking the antidepressant sertraline daily. The care plan for Resident 32 also lacked details on the use of the medication, side effects to monitor, and non-pharmacological interventions for anxiety. During an interview, the Director of Nursing acknowledged that psychotropic medications should be addressed in care plans and expressed uncertainty about the non-pharmacological interventions in place for residents with depression and anxiety. The facility's care plan policy was requested but not provided.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avina Of Sun Prairie | 2.7 mi | ★★★★★ | 10 | 0 |
| Sun Prairie Senior Living | 3.9 mi | ★★★★★ | 23 | 0 |
| Madison Health And Rehabilitation Center | 4.5 mi | — | 39 | 0 |
| Oak Park Nursing And Rehab Center | 4.9 mi | ★★★★★ | 41 | 3 |
| Capitol Lakes Health Center | 7.9 mi | ★★★★★ | 11 | 1 |
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