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
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 R1's foley catheter. RN D indicated on 9/4/25 around 6:00 AM, she was made aware R1's foley catheter was not draining properly. RN D indicated R1's bed was wet with urine. RN D indicated she reviewed 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 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/22/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Oakwood Village East Health and Rehab Center
5833 American Parkway Madison, WI 53718
SUMMARY STATEMENT OF DEFICIENCIES
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
Facility ID: