Oakwood Village East Health And Rehab Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
removed the catheter, notified NP (Nurse Practitioner) of the removal. Waiting for Urology clinic orders on re-insertion.9/4/25 10:48 AM Note Text: resident was sent out to [Hospital] ER (Emergency Room) to replace foley by urologist. Resident was accompanied by daughter. On 10/6/25 at 11:41 AM, Surveyor interviewed RN D (Registered Nurse) about Resident R1's foley catheter. RN D indicated on 9/4/25 around 6:00 AM,
she was made aware Resident R1's foley catheter was not draining properly. RN D indicated Resident R1's bed was wet with urine. RN D indicated she reviewed Resident R1's medical record and was aware of the physician order to note manipulate, flush, or exchange foley catheter and to not pull foley out. RN D indicated she was aware urology needed to be notified of any issues with the foley catheter. RN D indicated she aspirated the foley catheter balloon and noted there was only 3mL of fluid in the balloon. RN D indicated she believed the catheter was not in the proper place in Resident R1's bladder so she pulled the foley catheter out. RN D indicated
she left a voicemail for Resident R1's primary provider and attempted to call urology after she removed the catheter.
RN D indicated she did not speak to a provider before or after the removal of the foley catheter.On 10/6/25 at 12:11 PM, Surveyor interviewed UCN E (Urology Clinical Nurse) regarding Resident R1's foley catheter. UCN E indicated the clinic does have an afterhours number to contact a physician for urology concerns. UCN E indicated the facility should have left the catheter in place since the nurse would have been unable to determine placement. UCN E indicated the facility should have contacted a provider and should not have removed the catheter.On 10/6/25 at 1:41 PM, Surveyor interviewed DON B (Director of Nursing) regarding Resident R1's foley catheter. Surveyor asked if removing fluid from the balloon would be considered manipulation of
the foley catheter. DON B indicated she did not believe removing the 3mL of fluid from the foley catheter balloon was considered manipulation of the foley catheter. Surveyor asked DON B if RN D should have consulted with a provider prior to removing the foley catheter. DON B indicated RN D removed the foley catheter since RN D did not think the catheter was in the correct place. DON B indicated RN D attempted to contact the provider and urology clinic after the removal as this event took place prior to the clinic opening at 8:00 AM.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/22/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oakwood Village East Health and Rehab Center
5833 American Parkway Madison, WI 53718
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0686
F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
9/10/25, includes Location- left gluteal fold. Type- pressure. Pressure ulcer stage- SDTI (Suspected Deep Tissue Injury). Visible tissue- epithelial pink tissue present. Drainage- none. Odor- no. Wound measurements (in centimeters)- 0.0 x 0.0 x 0.0. Description of peri-wound- intact, pink, blanchable. Current Treatment Plan- barrier cream, offer frequent repositioning. Wound progress- improving, possible sheering injury as opposed to pressure. Special Equipment/ Preventative measures- pressure relieving boots, repositioning schedule.In the assessment of Resident R2's left gluteal fold, dated 9/10/25, staff down staged Resident R2's wound and called the wound a SDTI with epithelial pink tissue. According to standards of practice, pressure injuries should not be down staged. In addition, did not include shearing as a cause of pressure.Resident R2's Weekly Wound Observation Tool, dated 9/10/25, includes Location- right malleolus. In house acquired. Date acquired- 8/31/25. Type- pressure. Pressure Ulcer Stage- stage 3. Visible tissue- granul
Event ID:
Facility ID:
If continuation sheet
OAKWOOD VILLAGE EAST HEALTH AND REHAB CENTER in MADISON, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in MADISON, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from OAKWOOD VILLAGE EAST HEALTH AND REHAB CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.