Oak Ridge Care Center: Stage 4 Wound Neglect - WI
The resident, identified in inspection records only as R1, had been mostly bedridden at Oak Ridge Care Center since hip surgery in May 2025. She had diabetes, chronic kidney disease, morbid obesity, and osteoporosis. When oral antibiotics failed to stop the wound from worsening, she was hospitalized, underwent surgical debridement in the operating room on September 2, and was sent back to the facility on September 5 with a wound VAC removed, daily wet-to-moist dressings ordered, and a clear instruction: she needed to stay off the wound for it to heal.
The skin assessment created that same day by LPN-R, and revised by the Director of Nursing, described the wound as being on the "back of left thigh." It wasn't. Inspectors noted the wound was on the left buttock. The assessment recorded measurements — 7 centimeters long, 3.5 centimeters wide, 5 centimeters deep — but included no wound stage, no description of the wound bed tissue, and no documentation of drainage.
The wound doctor who examined her three days later found a Stage 4 full-thickness pressure wound, 7 by 4 by 5.5 centimeters, with 40 percent necrotic tissue and moderate drainage. His notes recorded that she had refused an air bed despite education, and that offloading instruction was only accomplished with her husband present in the room.
The facility's own physician order from September 5 directed staff to document any noncompliance with turning and repositioning. Her Braden score that day was 18, placing her at risk for further pressure injury development.
Inspectors classified the failures as Immediate Jeopardy. The wound the facility struggled to accurately describe on paper had already cost R1 a hospitalization, an operating room procedure, and a MRSA infection. She still needed to stay off it to have any chance of healing.
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.
Download the official CMS inspection PDF from Medicare.gov
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 5, 2026 · Our methodology
Oak Ridge Care Center in UNION GROVE, WI was cited for neglect violations during a health inspection on October 28, 2025.
The resident, identified in inspection records only as R1, had been mostly bedridden at Oak Ridge Care Center since hip surgery in May 2025.
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.