Oak Ridge Care Center
Union Grove, Wisconsin · CCN 525542
19 surveys since 2012, 8 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 71
- Surveys
- 19
- Harm or worse
- 8
- Immediate jeopardy
- 4
Findings at the most serious level CMS records. 1 of these were recorded as past non-compliance — corrected before the survey.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 74
- Ownership
- For profit - Individual
- Chain
- Independent
- County
- Racine
- Medicare-certified since
- 1994
CMS ratings
- Overall
- 3
- Health inspection
- 2
- Staffing
- 5
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.
Weighted by harm level, against 51 for-profit facilities of 66–99 beds in Wisconsin.
Last survey on record
Oct 28, 2025
377 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 4.75 | 3.71 |
| Registered-nurse hours per resident day | 0.90 | — |
| Annual nurse turnover | 47.1% | 44.4% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $118,771 across 4 penalties
- Payment denials
- 1
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J317.6% | K— | L— |
| Actual harm | G15.9% | H— | I— |
| No harm, potential for more than minimal | D1058.8% | E— | F15.9% |
| No harm, potential for minimal | A— | B— | C211.8% |
Most frequently cited here
In CMS’s current monthly file.
- F8803×
Provide and implement an infection prevention and control program.
- F6862×
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- F6101×
Respond appropriately to all alleged violations.
- F6231×
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- F6251×
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.
In the surveyor’s words
From the most serious findings on record at Oak Ridge Care Center, in the surveyor’s own words.
- Immediate jeopardy, isolatedF686Oct 28, 2025
Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 3 of 3 residents (R1, R2, and R3) reviewed for pressure injuries. R1 admitted to the facility without any pressure injuries and was assessed as being at risk for pressure injuries. R1 developed a blister on the left buttock 10 days after admission that was not assessed by a Registered Nurse and the facility failed to revise R1's skin impairment care plan or pressure injury care plan after the area declined. […]
- Immediate jeopardy, isolatedF745Jun 28, 2024
Based on interviews, record review, and facility policy review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 1 of 8 sampled residents. On [DATE], R4 reported being depressed and having thoughts that he would be better off dead or of hurting himself almost daily. The facility did not provide R4 with support or services to address these concerns. Approximately 8 hours later, R4 was found pulseless and non-breathing with a plastic bag over his head and the oxygen tubing wrapped around his neck. […]
- Immediate jeopardy, isolatedF757Jun 28, 2024
Based on record reviews, interviews, and facility policy review, the facility failed to ensure that 1 of 3 sampled residents reviewed for Coumadin usage (R2) received ongoing laboratory testing to monitor the therapeutic dose the resident received. R2 was admitted to the facility with an order for Coumadin (an anticoagulation medication). Use of this medication requires frequent laboratory testing to ensure a person is receiving the correct dose to remain in therapeutic range. The last test that was completed was on [DATE]. R2 began to develop multiple bruises, which can be a sign of over anticoagulation (too much Coumadin). Neither nursing nor pharmacy identified there were no orders for labs and that R2 was not being monitored. […]
- Actual harm, isolatedF689May 7, 2025
Based on observation, interview, and record review, the facility did not ensure the environment remained free of accident hazards and residents received adequate supervision to prevent accidents for 3 (R34, R29, and R50) of 5 residents reviewed for accidents. *R34 was given a handled cup of hot chocolate with the handle placed towards the right hand. R34 had limited movement of the right hand and, while transferring the cup from the right hand to the left hand, the scalding liquid spilled onto R34's left side/hip/buttock area causing a third degree burn that measured 34 cm x 30 cm. The facility staff did not place the cup in a safe manner for R34 to manage the cup independently and the water was at a temperature hot enough to cause a third degree burn. […]
- Actual harm, isolatedF686Sep 16, 2021
Based on observation, interview, and record review the facility did not ensure 1 (R200) of 3 residents reviewed with or at risk for pressure injuries received the necessary care and services for prevention and healing of pressure injuries/wounds R200 was at risk for developing pressure injuries. There is no indication the facility identified a pressure injury for R200 until it was discovered as stage 3 pressure injury. Upon discovery there was no comprehensive assessment or change in the plan of care. This pressure injury required debridement by the wound physician. During the survey R200 was observed to not have her heels being offloaded despite ongoing risk for pressure injuries. […]
Read 23 findings in full →The most serious and the most recent: 23 of 71 on record.
Every survey on record
FindingsAt actual harm or above
- Oct 28, 2025Complaint3 findings · 1 harm
- May 7, 2025Standard and complaint3 findings · 1 harm
- Jun 28, 2024Complaint4 findings · 2 harm
- Apr 1, 2024Complaint1 finding
- Jan 31, 2024Standard and complaint4 findings
- Apr 14, 2023Complaint1 finding
- Nov 3, 2022Standard2 findings
- Sep 16, 2021Complaint2 findings · 1 harm
Show the 11 earlier surveys
- Jul 27, 2021Standard and complaint3 findings · 1 harm
- Oct 7, 2020Complaint3 findings
- May 8, 2020Infection control1 finding
- Aug 22, 2019Complaint1 finding
- Apr 10, 2019Standard and complaint7 findings
- Feb 19, 2018Standard11 findings · 1 harm
- Oct 17, 2016Standard and complaint8 findings
- Aug 11, 2015Standard10 findings · 1 harm
- May 15, 2014Standard1 finding
- Jun 20, 2013—2 findings
- Apr 4, 2012—4 findings
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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