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Nursing HomeMedicaid Investigative

Oak Park Place of Nakoma

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

4327 Nakoma Rd., Crawford-Marlborough-Nakoma · Madison, WI 5371133 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.2/5

based on 33 Google reviews

5
4
3
2
1
Oak Park Place of Nakoma Nursing Home in Madison, WI — Street View
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5/ 10
high Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • Above-median deficiencies (14 vs median 7)
  • High staff turnover (73%)
  • High RN turnover (81%)

Below average in WI · Meets national RN staffing standard · Above recommended total nurse staffing · Very high staff turnover · No penalties on record

Source: Medicare data

What this means for your family

This facility offers excellent physical therapy and a modern environment, making it a strong candidate for short-term rehab. However, families should be extremely cautious regarding long-term or memory care placement; please conduct unannounced visits to verify staffing ratios and hygiene standards, as multiple reviewers have reported inconsistent care.

Google Reviews

Google Reviews

33 reviews on Google
Oak Park Place of Nakoma presents a polarized experience for families, with high praise for its physical facility, therapy services, and some individual staff members. However, multiple families have reported serious concerns regarding consistent understaffing, neglect in hygiene care, and administrative turnover that impacts the quality of daily resident life.

Quality Themes

Tap a score for details
Food9.0Staff5.0Clean6.0Activities7.0Meds3.0Memory2.0Comms4.0ValueN/A

Strengths

  • High-quality physical therapy and rehabilitation services
  • Modern, clean, and well-maintained facility
  • Friendly and compassionate front-line nursing and CNA staff
  • Appetizing and well-regarded food service

Concerns

  • Chronic understaffing leading to delayed response times and neglect (mentioned by 5 reviewers)
  • Inconsistent hygiene care (e.g., residents left in soiled clothing) (mentioned by 3 reviewers)
  • High administrative and staff turnover (mentioned by 3 reviewers)
  • Medication administration errors or delays (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2344.7'19(3)2.03.9'21(7)4.52.3'23(3)5.05.0'25(3)4.4'26(7)

Distribution · 35 analyzed

5
25
4
2
3
1
2
1
1
6

How They Respond to Reviews

83%response rate

This facility actively engages with reviewer feedback.

Questions for Your Tour

  • 1I noticed that the facility has a strong reputation for physical therapy and dining; how do you ensure that same level of quality and attention carries over into daily hygiene assistance for residents?
  • 2Given the feedback regarding response times, what is your current process for ensuring that call lights are answered promptly, especially during shift changes?
  • 3I see that the facility is very active in responding to family feedback online; how do you incorporate that family input into your day-to-day operations and staff training?
  • 4With your focus on modern facilities, what specific activities or engagement programs are currently in place to support residents, particularly those in memory care?
  • 5How does your nursing team manage medication administration to ensure accuracy and consistency for residents who require complex daily routines?
  • 6What steps are you taking to maintain staff stability and consistency so that residents can build long-term, trusting relationships with their primary caregivers?

Personalized based on this facility's data


Key Review Excerpts

The staff are the stars of our healing journey. PT/OT Jessica/Ashley worked tirelessly to bring about strength and mobility.

Rehab patient's family · 2025★★★★★

They have a high level of turn over with staff, which led to us explaining mom's condition every day to new staff.

Long-term resident's family · 2026☆☆☆☆

He would be sitting in urine soaked clothing on several occasions on a daily basis. Not only through his clothing but through furniture cushions and bedding.

Memory care family member · 2021☆☆☆☆
Source: 33 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
1.40hrs
OK
Registered nurses for medical care
Total Nursing
5.25hrs
OK
All nurses + aides combined
Staff Turnover
74%
Lower is better (< 30% = good)
RN Turnover
83%
Lower is better (< 30% = good)

This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 13 measures

Medicare Rating
4/ 5
Better Than Avg

3

measures

Worse Than Avg

8

measures

Mixed Results

2

measures

Long-Stay Residents
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility80.0%
Worse than Avg
Here
80.0%
US
93.4%
WI
95.6%
Dane
96.5%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility4.0%
Better than Avg
Here
4.0%
US
19.5%
WI
16.8%
Dane
12.6%
🩹

Residents with pressure sores (bedsores)

↓ Lower is better
This Facility11.2%
Worse than Avg
Here
11.2%
US
4.9%
WI
5.3%
Dane
6.2%
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility23.5%
Mixed vs Avgs
Here
23.5%
US
19.4%
WI
25.0%
Dane
29.0%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility17.4%
Worse than Avg
Here
17.4%
US
14.4%
WI
16.7%
Dane
13.2%
🩺

Residents with a long-term catheter

↓ Lower is better
This Facility4.3%
Worse than Avg
Here
4.3%
US
0.9%
WI
2.2%
Dane
3.8%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility74.5%
Worse than Avg
Here
74.5%
US
81.8%
WI
86.6%
Dane
89.0%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility87.2%
Mixed vs Avgs
Here
87.2%
US
79.8%
WI
82.2%
Dane
87.9%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
1.6%
WI
1.3%
Dane
1.7%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

11deficiencies
Above state avg (9.8)
10 complaint-triggered

This facility shows recurring problems across multiple areas, with families filing 10 complaint-triggered reports over recent years. The most persistent issues involve fire safety systems, medication management, and resident rights violations. While the facility corrects deficiencies when cited, problems resurface across surveys, including recent complaints about medication errors and response to alleged violations, suggesting ongoing operational challenges that warrant careful consideration during visits.

Jan 22, 2026Routine
14
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0814Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

0868Potential for harm · WidespreadCorrected

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

0006Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

0025Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Create arrangements with other facilities to receive patients.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0712Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0912Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0223Potential for harm · IsolatedCorrected

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.

0321Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0582Minimal · WidespreadCorrected

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Jan 8, 2026Complaint
1
0627Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Dec 23, 2025Complaint
2
0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Dec 3, 2025Complaint
2
0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0692Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Jan 15, 2025Complaint
3
0658Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Sep 18, 2024Routine
17
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0345Potential for harm · WidespreadCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

0291Potential for harm · PatternCorrected

Egress Deficiencies

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

0912Potential for harm · PatternCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

0623Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

0625Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0757Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0883Potential for harm · IsolatedCorrected

Infection Control Deficiencies

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

0887Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

0132Potential for harm · IsolatedCorrected

Construction Deficiencies

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

0222Potential for harm · IsolatedCorrected

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0372Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

0911Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Oak Park Place of Nakoma

Organization Type

for profit

Ownership & Management

Owners

Helle Revocable Trust

Owner · Organization

6%

Lakleland Nakoma LLC

Owner · Organization

6%

Chase, Byron

Owner

6%

Frank, Scott

Owner

63%

Key personnel

Frank, ScottManagerFrank, ScottAdp of the Snf
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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