Oak Ridge Care Center: Hand Hygiene Failures During Wound Care - WI
The inspection, completed October 28, 2025, documented that workers failed to perform hand hygiene at two of the most critical moments in wound treatment: before beginning a dressing change and after coming into contact with soiled materials. Inspectors classified the violation as causing minimal harm or the potential for actual harm, and noted that a few residents were affected.
Hand hygiene during wound care is not a procedural technicality. Open wounds are direct pathways for bacteria to enter the body. Skipping hand hygiene before touching a wound, or continuing to handle a patient after contact with a contaminated dressing, transfers whatever is on a caregiver's hands directly into that pathway. In a care center population, where residents frequently have compromised immune systems, reduced circulation, or conditions like diabetes that slow healing, an introduced infection can turn a manageable wound into something far more serious.
When inspectors raised the issue with Oak Ridge's administrator and director of nursing on October 21, both said education had already been provided to staff about proper hand hygiene during wound dressing changes. They offered nothing beyond that. No timeline for when the education occurred. No description of what the training covered. No explanation of how the facility would verify that the practice had actually changed.
That response, offered four days before the inspection closed, was the entirety of what management put forward.
The inspection report does not describe how many dressing changes were observed, how many staff members were involved, or how long the practice had been occurring before the complaint was filed. It does not name the residents affected or describe the wounds being treated. What it records is a gap between what staff were supposed to do and what they were actually doing, and a management response that amounted to pointing at prior training as both the explanation and the solution.
Oak Ridge Care Center sits at 1400 8th Avenue in Union Grove, a small city in Racine County. The facility carries the CMS provider identification number 525542.
The inspection was triggered by a complaint, meaning someone, whether a resident, a family member, or a staff member, reported the problem before surveyors arrived. Complaint inspections are targeted. Inspectors came to Oak Ridge specifically because of what had been reported, and they found it.
The facility's plan of correction was not included in the inspection materials released. Anyone seeking that information was directed to contact Oak Ridge or the Wisconsin state survey agency directly.
What the record shows is a facility where, on at least one observed occasion, the people responsible for treating wounds were not taking the step that sits at the foundation of infection prevention. And when asked about it, leadership said they had told staff what to do.
Whether staff are now doing it is a different question. The inspection report does not answer it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Ridge Care Center from 2025-10-28 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 6, 2026 · Our methodology
Oak Ridge Care Center in UNION GROVE, WI was cited for violations during a health inspection on October 28, 2025.
Inspectors classified the violation as causing minimal harm or the potential for actual harm, and noted that a few residents were affected.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.