Oakwood Village East Health and Rehab Center
5833 American Parkway · Madison, WI · 53718 · 6082304000
40 certified beds Non profit - Corporation Part of a CCRC
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $326,260 in fines in the last 24 months.
- Inspection results are getting worse cycle over cycle, not better.
- Staffing hours comfortably above national benchmarks.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
$326,260 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 5 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 5.52 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 1.60 | 0.55–0.75 |
| Weekend hours / resident-day | 5.02 | ≈ weekday level |
| Nursing turnover / year | 43% | median 45% |
| Fines (3-yr window) | 1 · $326,260 |
Inspection citations (18 in the current record)
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Immediate jeopardy · J October 22, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected November 10, 2025 · Quality of Life and Care
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Potential for harm · D October 22, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected November 10, 2025 · Quality of Life and Care
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Potential for harm · D July 29, 2025
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 August 18, 2025 · Resident Rights
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Potential for harm · D July 29, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected August 18, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E July 29, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected August 18, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E July 29, 2025
Respond appropriately to all alleged violations.
Corrected August 18, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E July 29, 2025
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected August 18, 2025 · Resident Assessment and Care Planning
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Potential for harm · F July 29, 2025
Provide and implement an infection prevention and control program.
Corrected August 18, 2025 · Infection Control
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Potential for harm · D July 29, 2025
Implement a program that monitors antibiotic use.
Corrected August 18, 2025 · Infection Control
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Potential for harm · D July 29, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected August 18, 2025 · Infection Control
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Potential for harm · D June 6, 2024
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected July 6, 2024 · Resident Rights
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Potential for harm · D June 6, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 5, 2024 · Resident Assessment and Care Planning
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Potential for harm · E June 6, 2024
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 July 5, 2024 · Pharmacy Service
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Potential for harm · F June 6, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected July 2, 2024 · Nutrition and Dietary
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Potential for harm · E June 6, 2024
Implement a program that monitors antibiotic use.
Corrected July 6, 2024 · Infection Control
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Potential for harm · F June 6, 2024 · found via complaint
Provide and implement an infection prevention and control program.
Corrected July 5, 2024 · Infection Control
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Potential for harm · D July 27, 2023 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected August 27, 2023 · Pharmacy Service
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Potential for harm · D July 27, 2023 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected August 27, 2023 · Pharmacy Service
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 22, 2025 | Fine | $326,260 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525692 · certified since May 8, 2008. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.