Oak Ridge Care Center: Immediate Jeopardy Wound Failure - WI
The nurse who assessed her that evening documented the wound in the wrong location.
LPN-R recorded the Stage 4 wound as being on the back of the left thigh. It was on the left buttock. The assessment, created by LPN-R and revised by the Director of Nursing, was still marked "in progress" when federal inspectors reviewed it during an October 28 survey. It contained no wound stage. It contained no description of the wound bed tissue. It contained no documentation of drainage. It was not, inspectors concluded, a comprehensive assessment by any measure.
Federal inspectors cited the deficiency at the level of Immediate Jeopardy, the most serious classification available under Medicare oversight, reserved for situations where a facility's failures have placed residents in immediate risk of serious harm or death.
The resident, identified in inspection records only as R1, had been mostly bedridden at Oak Ridge since a hip fracture and surgery in May 2025. She carried a significant medical history: diabetes, chronic kidney disease, obstructive sleep apnea requiring a CPAP machine, atrial fibrillation, morbid obesity, and osteoporosis. Her Braden score on September 5 was 18, a number that placed her formally at risk for pressure injury development. She was already living with a Stage 4 wound when that score was recorded.
A Stage 4 pressure injury is the most severe classification. It means the wound has broken through skin, through fat, and into muscle or deeper tissue. In R1's case, the wound specialist who evaluated her three days after her return found 40 percent necrotic tissue, meaning nearly half the wound bed was dead. The undermining extended one centimeter beneath the skin at the 2 o'clock position. Exudate was moderate. The wound doctor, identified as Wound MD-K, noted the wound's progress was "exacerbated due to recent return from hospital" and documented that R1 had refused an air bed despite being educated about its benefit.
A physician order dated the same day R1 returned, September 5, instructed staff to document any noncompliance with turning and repositioning and to note whether education had been provided. The skin evaluation noted that R1 had been told to turn every two hours to stay off the wound site, and that wedges were in place. What it did not contain, and what inspectors found conspicuously absent, was the clinical detail that would allow anyone reading the record to understand what they were actually looking at.
The incomplete assessment was not a paperwork problem in isolation. For a resident with MRSA, a wound nearly two inches deep, and a documented history of refusing some interventions, the accuracy and completeness of wound documentation is the mechanism by which nurses across shifts know what they are treating, whether it is getting worse, and when to escalate. A wound logged on the wrong part of the body, with no stage, no tissue description, and no drainage note, is a wound that the medical record does not actually contain.
Wound MD-K's evaluation on September 8 provided the clinical picture that the admitting assessment had not. By then, R1 had been back at the facility for three days.
The inspection was conducted as a complaint survey. Oak Ridge Care Center sits at 1400 8th Avenue in Union Grove, a small city in Racine County in southeastern Wisconsin.
What the record does not resolve is what those three days looked like for R1. A woman bedbound since May, carrying a wound that had already required surgery once, back in the same facility, with an assessment that placed her wound on the wrong part of her body and left the rest of the fields blank.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
Oak Ridge Care Center in UNION GROVE, WI was cited for immediate jeopardy violations during a health inspection on October 28, 2025.
The nurse who assessed her that evening documented the wound in the wrong location.
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.