Safety Report: Oak Ridge Care Center

Union Grove, Wisconsin · Based on official CMS inspection records as of October 1, 2026.

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How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.

Official ratings

Overall★★★★★
Health inspections★★★★★
Staffing★★★★★
Quality measures★★★★★
Long-stay quality★★★★★
Short-stay quality★★★★★

Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.

Stars are calculated by CMS, not by us. We do not create our own safety score.

Serious documented violations

3Immediate jeopardy citations (severity J–L)
1Actual harm citations (severity G–I)
2Requirements cited on more than one inspection
J
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of October 28, 2025, during a complaint investigation. Facility reported correction by November 24, 2025.
Quality of Life and Care Deficiencies · Tag F686
G
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors rated this “actual harm to a resident (not immediate jeopardy).” The problem affected one or a very small number of residents or staff. Inspection of May 7, 2025. Facility reported correction by June 4, 2025.
Quality of Life and Care Deficiencies · Tag F689
J
Government finding: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of June 28, 2024, during a complaint investigation. Facility reported correction by April 18, 2024.
Pharmacy Service Deficiencies · Tag F757
J
Government finding: Provide medically-related social services to help each resident achieve the highest possible quality of life.
Inspectors rated this “immediate jeopardy to resident health or safety.” The problem affected one or a very small number of residents or staff. Inspection of June 28, 2024, during a complaint investigation. Facility reported correction by July 16, 2024.
Quality of Life and Care Deficiencies · Tag F745

Citations by topic

1Abuse, neglect & exploitation
3Infection control
2Medications & pharmacy
1Accidents & supervision

Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.

Is it getting better or worse?

More citations in the most recent cycle (6) than in the cycle before (4).

Two cycles ago
2 serious
Prior cycle
none serious
Most recent cycle
2 serious

An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.

Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.

Repeat findings

These requirements were cited on more than one inspection date in the last three cycles.

RequirementTimes citedInspection dates
Provide and implement an infection prevention and control program. (F880)3October 28, 2025; May 7, 2025; January 31, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686)2October 28, 2025; April 1, 2024

Fines and enforcement

DateTypeAmount / length
October 28, 2025Fine$62,305
May 7, 2025Fine$27,600
June 28, 2024Payment DenialPayment denial for 3 days, starting July 13, 2024
June 28, 2024Fine$14,433
June 28, 2024Fine$14,433

Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.

Complete inspection history

17 citations across 6 inspection dates.

October 28, 2025 — 3 citations (includes serious) · complaint investigation
J
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F686 · complaint · corrected November 24, 2025
F
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F947 · complaint · corrected November 24, 2025
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected November 24, 2025
May 7, 2025 — 3 citations (includes serious)
G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F689 · corrected June 4, 2025
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected June 1, 2025
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · complaint · corrected June 4, 2025
June 28, 2024 — 4 citations (includes serious) · complaint investigation
J
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Immediate jeopardy to resident health or safety · Isolated · Pharmacy Service Deficiencies · F757 · complaint · corrected April 18, 2024
J
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F745 · complaint · corrected July 16, 2024
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · complaint · corrected July 16, 2024
D
Respond appropriately to all alleged violations.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F610 · complaint · corrected July 16, 2024
April 1, 2024 — 1 citation · complaint investigation
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · complaint · corrected April 29, 2024
January 31, 2024 — 4 citations
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected February 19, 2024
D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F693 · complaint · corrected February 19, 2024
C
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.
No actual harm, potential for minimal harm · Widespread · Resident Rights Deficiencies · F625 · corrected February 19, 2024
C
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
No actual harm, potential for minimal harm · Widespread · Resident Rights Deficiencies · F623 · corrected February 19, 2024
November 3, 2022 — 2 citations
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected November 30, 2022
D
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F692 · corrected November 30, 2022

Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare

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