Oakwood Village East: Wound Care Failures Reach Immediate Jeopardy - WI
The resident, identified in inspection records only as R2, had wounds that their physician was tracking with urgency. A doctor's note from September 5 instructed staff to keep the bilateral malleolus wounds moist, layer Vaseline over the Santyl ointment already ordered, and apply dressings every day shift. The same note flagged the wounds as fast-developing and ordered a bilateral ankle brachial index test, scheduled for September 19, to rule out vascular insufficiency. The right heel was to be cleaned and covered with Mepilex every day shift. Heel boots were ordered for bedtime. A plantar wound on the left foot required daily cleansing and dressing.
The orders were specific. The layer of Santyl was supposed to be about two millimeters thick, the thickness of a nickel, applied directly to the wound with a spatula or gauze pad, not beyond the wound edges.
A skin assessment conducted during R2's shower on September 7 found redness in the buttock area, four open sores on the right and left outer feet, and one open sore on the right heel, labeled new.
Three days later, on September 10, staff completed a Weekly Wound Observation Tool for two of R2's wounds. For the right malleolus, they recorded a stage 3 pressure ulcer, acquired in-house, with the date of acquisition listed as August 31. For the left gluteal fold, they recorded something different: a Suspected Deep Tissue Injury, or SDTI, with epithelial pink tissue present, no drainage, no odor, and wound measurements of zero across the board.
That last entry is where inspectors focused their immediate jeopardy finding.
A Suspected Deep Tissue Injury is a serious classification. It describes an area of discolored or damaged skin where deeper tissue injury is suspected beneath the surface, and the wound can deteriorate rapidly. According to standards of practice cited in the inspection report, pressure injuries should not be downstaged once classified. What staff recorded on September 10 did the opposite: they described the wound as a SDTI with epithelial pink tissue present and marked it as improving, a characterization inspectors found constituted an improper downstaging.
The assessment also failed to include shearing as a cause, despite the physician's note raising that possibility and the facility's own wound observation tool noting it as a consideration.
The inspection was triggered by a complaint and was conducted on October 22, 2025. Inspectors cited the wound care failures as reaching the level of immediate jeopardy, meaning the deficient practice had placed R2 at risk for serious injury, serious harm, serious impairment, or death.
What the record shows is a resident whose wounds were multiplying across weeks, whose physician was issuing increasingly detailed orders, and whose staff were, at minimum, miscategorizing the severity of what they were seeing. Whether the ordered treatments were being carried out consistently, the inspection report does not fully resolve. What it does establish is that on September 10, with R2 carrying wounds on multiple sites and a physician already on record concerned about vascular insufficiency and wound progression, the staff member completing the wound observation form classified a pressure injury in a way that made it look less serious than it was, and left out a mechanism of injury the physician had raised.
R2's appointment for the ankle brachial index test was set for September 19, two weeks after the physician ordered it. The inspection report does not say whether it was kept.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oakwood Village East Health and Rehab Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 8, 2026 · Our methodology
OAKWOOD VILLAGE EAST HEALTH AND REHAB CENTER in MADISON, WI was cited for immediate jeopardy violations during a health inspection on October 22, 2025.
The resident, identified in inspection records only as R2, had wounds that their physician was tracking with urgency.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.