Oakwood Village East Health And Rehab Center
OAKWOOD VILLAGE EAST HEALTH AND REHAB CENTER in MADISON, WI — inspection on October 22, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
AM, she was made aware R1's foley catheter was not draining properly. RN D indicated R1's bed was
she was aware urology needed to be notified of any issues with the foley catheter. RN D indicated she
indicated she believed the catheter was not in the proper place in R1's bladder so she pulled the foley catheter out. RN D indicated she left a voicemail for 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 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 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.
525692 10/22/2025
Oakwood Village East Health and Rehab Center 5833 American Parkway Madison, WI 53718
Malleolus where eschar is present, clean with normal saline or wound cleanser.
Apply: Use a spatula
jeopardy to resident health or millimeters thick or the thickness of a nickel. Do not apply beyond the wound edges.
Cover the treated safety area with a clean nonadherent dressing.R2's Physician Orders state in part; start date 9/4/25 Bilateral heel boots place on both feet at bedtime.Start date: 9/5/25 Left lateral plantar wound-
dated 9/5/25, includes Please ensure that wounds in bilateral malleolus stay moist.
Add Vaseline over top of the Santyl and then apply wound dressing per Dermatology recommendations. I ordered bilateral ankle brachial index test for both legs to rule out vascular insufficiency given fast developing wounds.
Patient has an appointment for this test on Friday 9/19/25 at 10:30 AM.R2's Physician Orders state in part; start date: 9/5/25 Right heel wound, clean with normal saline or wound cleanser, cover with Mepilex every day shift.R2's Physician orders state in part; start date: 9/6/25 Please ensure that wounds in bilateral malleolus (ankle) stay moist.
Add Vaseline over the top of the Santyl and then apply dressing every day shift.R2's Nurse Shower Review Skin Assessment, dated 9/7/25, includes redness noted in buttock area, 4 open sores noted on right and left outer foot, one open sore noted on right heel and labeled new .R2's Weekly Wound Observation Tool, dated 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 R2's left gluteal fold, dated 9/10/25, staff down staged 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.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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.