Oakwood Village East Health And Rehab Center

Penalties

• Oct 22, 2025 — Fine ($212,069)

Inspection findings

1. Oct 22, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Nov 10, 2025 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Nov 10, 2025 · CMS health inspection

2. Jul 29, 2025 Fire Safety · 16 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Aug 12, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0013 Emergency Preparedness Deficiencies

     Develop Emergency Preparedness policies and procedures.

     Corrected Aug 12, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0578 Resident Rights Deficiencies

     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 Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Aug 18, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0223 Egress Deficiencies

     Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

     Corrected Aug 15, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0346 Smoke Deficiencies

     Follow proper procedures when the fire alarm was out of service for more than 4 hours.

     Corrected Aug 12, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Aug 29, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 29, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Aug 15, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0912 Gas, Vacuum, and Electrical Systems Deficiencies

     Have power receptacles that are properly grounded.

     Corrected Aug 29, 2025 · CMS fire safety

3. Jun 6, 2024 Fire Safety · 17 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Jun 10, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Jun 10, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

     Allow residents to self-administer drugs if determined clinically appropriate.

     Corrected Jul 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jul 5, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0758 Pharmacy Service Deficiencies

     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 Jul 5, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jul 2, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 5, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Jul 6, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0132 Construction Deficiencies

     Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.

     Corrected Jun 10, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0331 Smoke Deficiencies

     Construct fire resistant interior walls.

     Corrected Jun 20, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 26, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected Jun 10, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0531 Services Deficiencies

     Have elevators that firefighters can control in the event of a fire.

     Corrected Jun 25, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0541 Services Deficiencies

     Install properly constructed and protected linen or trash chutes.

     Corrected Jun 11, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0914 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

     Corrected Jul 10, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jun 18, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Jun 22, 2024 · CMS fire safety

4. Mar 15, 2023 Fire Safety · 4 findings
   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Mar 16, 2023 · CMS fire safety

   • Not serious Scope/severity C

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Apr 2, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Apr 2, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0923 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper medical gas storage and administration areas.

     Corrected Apr 2, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• BARROS, MARY — operational/managerial control, NOT APPLICABLE, since 07/30/2024
• BARROS, MARY — adp of the snf, NOT APPLICABLE, since 07/30/2024
• BARROS, MARY — corporate officer, NOT APPLICABLE, since 07/30/2024
• CHURCH, MARTHA — managing control - governing body, NOT APPLICABLE, since 01/01/2021
• CHURCH, MARTHA — corporate director, NOT APPLICABLE, since 01/01/2021
• HAMILTON-CRAWFORD, JANICE — corporate officer, NOT APPLICABLE, since 10/31/2023
• HAMILTON-CRAWFORD, JANICE — operational/managerial control, NOT APPLICABLE, since 10/31/2023
• HAYDEN, KEVIN — corporate director, NOT APPLICABLE, since 06/01/2023
• HAYDEN, KEVIN — managing control - governing body, NOT APPLICABLE, since 06/01/2023
• HUSOM, SUSAN — adp of the snf, NOT APPLICABLE, since 12/01/2024
• HUSOM, SUSAN — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• HUSOM, SUSAN — corporate officer, NOT APPLICABLE, since 12/01/2024
• KUNZ, TOM — managing control - governing body, NOT APPLICABLE, since 06/01/2024
• KUNZ, TOM — corporate director, NOT APPLICABLE, since 06/01/2024
• LEFEL, KRISTIN — operational/managerial control, NOT APPLICABLE, since 12/31/2023
• NELSON, GOLDIE — operational/managerial control, NOT APPLICABLE, since 09/12/2021
• NICHOLSON, ROBERT — managing control - governing body, NOT APPLICABLE, since 06/01/2023
• NICHOLSON, ROBERT — corporate director, NOT APPLICABLE, since 06/01/2023
• O'DONNELL, CHRISTINE — operational/managerial control, NOT APPLICABLE, since 04/09/2023
• O'DONNELL, CHRISTINE — adp of the snf, NOT APPLICABLE, since 04/09/2023
• O'DONNELL, CHRISTINE — corporate officer, NOT APPLICABLE, since 04/09/2023
• RAEMISCH, SARAH — operational/managerial control, NOT APPLICABLE, since 07/18/2021
• RAFFERTY, SUSAN — operational/managerial control, NOT APPLICABLE, since 06/13/2013
• RAFFERTY, SUSAN — corporate officer, NOT APPLICABLE, since 06/13/2023
• SACHTJEN, LAURA — operational/managerial control, NOT APPLICABLE, since 10/29/2024
• SCHAETZL, RONNIE — operational/managerial control, NOT APPLICABLE, since 05/28/2024
• SCHAETZL, RONNIE — adp of the snf, NOT APPLICABLE, since 05/28/2024
• SIDHU, SARFRAZ — operational/managerial control, NOT APPLICABLE, since 11/01/2022
• SIDHU, SARFRAZ — adp of the snf, NOT APPLICABLE, since 11/01/2022
• WOLFF, SALLY — corporate director, NOT APPLICABLE, since 06/01/2024
• WOLFF, SALLY — managing control - governing body, NOT APPLICABLE, since 06/01/2024
• CLIFTONLARSONALLEN LLP — adp of the snf, NOT APPLICABLE, since 12/31/2020
• OAKWOOD LUTHERAN SENIOR MINISTRIES, INC. — 5% or greater direct ownership interest, 100%, since 03/10/2008
• OAKWOOD VILLAGE UNIVERSITY WOODS HOMES INC — operational/managerial control, NOT APPLICABLE, since 03/10/2008
• OAKWOOD VILLAGE UNIVERSITY WOODS HOMES INC — adp of the snf, NOT APPLICABLE, since 03/04/2025