Oak Ridge Care Center

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

Resident R1's hospitalist Discharge summary dated [DATE REDACTED] under discharge diagnoses documents principal problem: Wound of sacral region, initial encounter. admission condition is documented as poor. Discharge condition is documented as stable. Under hospital course for hospital summary documents past medical history of hip fracture with surgery in May 2025 after fall at [Name], diabetes mellitus, chronic kidney disease, obstructive sleep apnea on CPAP (continuous positive airway pressure), atrial fibrillation, morbid obesity, osteoporosis who was admitted for sacral wound infection and developing abscess. She has been mostly bed bound at the facility since her hip surgery. She was started on PO (by mouth) antibiotics in the outpatient setting; however, wound was worsening therefore she was brought here for evaluation. She was admitted and started on IV (intravenous) antibiotics. General surgery was consulted, and she underwent surgical debridement in the OR (operating room) on 9/2. Cultures are positive for staph aureus, likely MRSA (methicillin-resistant staphylococcus aureus). Infectious disease consulted and have recommended Zyvox (an antibiotic) for 7 additional days at discharge. Wound care consulted and she had a wound VAC (vacuum-assisted closure) placed in house which has since been removed with the recommendations being to continue daily wet to moist dressings. She will need to offload for the wound to heal. discharged to SNF (skilled nursing facility). Resident R1 returned to the facility on 9/5/25 with a Stage 4 left buttock pressure injury. Resident R1's skin only evaluation dated 9/5/25 created by LPN-R and revised by Director of Nursing (DON)-B, dated as still in progress, under skin note documents: back of left thigh wound Measurements: length 7cm Width: 3 1/2 cm no tunneling depth: 5 cm. Bruises noted on left arm: L (left) upper 1 inch long, forearm 1 inch long. Bruise on Right hand 2 inches long. Bruise on Right forearm 1 inch long. Under other education notes documents: Resident is aware of turning every 2 hours to stay of [sic] (off) wound site. Wedges in place.

Surveyor noted LPN-R documented Resident R1's left buttock as left thigh. This skin only evaluation is not a comprehensive assessment as there is no stage, no description of the wound bed with percentages of the wound bed tissue, no documentation regarding drainage, etc. Resident R1's Braden assessment dated [DATE REDACTED] has a score of 18 which indicates Resident R1 is at risk for PI development. Resident R1's physician order dated 9/5/25 documents: document on resident's noncompliance with turning and repositioning and if any education was provided.

Wound MD-K's wound evaluation and management summary dated 9/8/25 under review of system for additional system documents: refused air bed despite education. Offloading with education while husband

in room. Wound MD-K documents Stage 4 pressure wound of the left buttock full thickness. Etiology is pressure and further etiology detail is abrasion. Wound size is 7 x 4 x 5.5 cm, undermining is 1 cm at 2 o'clock, and exudate is moderate serious. Necrotic tissue is 40% and granulation is 60%. Wound progress is exacerbated due to recent return from hospital. Wound MD-K ordered a treatm

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Ridge Care Center

1400 8th Ave Union Grove, WI 53182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Administrator (NHA)-A, Director of Nursing (DON)-B, and Executive Director (ED)-C that proper hand hygiene was not observed during Resident R3's wound treatment. No further information was provided. On 10/21/25, at 9:28 AM, Surveyor interviewed Licensed Practical Nurse Wound Nurse Manager-G who stated when performing wound treatments, staff would be expected to perform hand hygiene before starting treatment, anytime after coming in contact with dirty dressings, and when completing wound care. On 10/21/25, at 9:47 AM, NHA-A and DON-B stated education has been provided regarding proper hand hygiene during wound dressing changes. No additional information was provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Ridge Care Center

1400 8th Ave Union Grove, WI 53182

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility did not have documentation of completion of 12 hours of required in-service training for 5 of 5 Certified Nursing Assistants (CNAs) reviewed potentially affecting all 71 residents in the facility.CNA-W, CNA-X, CNA-Y, CNA-Z, and CNA-AA did not have documentation of completing the 12 hours of required in-service training.Findings include:The Facility assessment dated [DATE REDACTED], last reviewed 8/6/2025, documents: Staff Training/Education and Competencies .-Required in-service training for nurse aides. In-service training must: Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.CNA-W was hired on 7/18/2023 so

the review of training was 7/18/2024-7/18/2025.CNA-X was hired on 12/26/2022 so the review of training was 12/26/23-12/26/2024.CNA-Y was hired on 5/22/2024 so the review of training was 5/22/2024-5/22/2025.CNA-Z was hired on 7/26/2023 so the review of training was 7/26/2024-7/26/2025.CNA-ZZ was hired on 2/6/2024 so the review of training was 2/6/2024-2/6/2025.On 10/28/2025 at 10:37 AM, Surveyor requested from Executive Director (ED)-C and Director of Nursing (DON)-B employee files for review of training and education for CNA-W, CNA-X, CNA-Y, CNA-Z, and CNA-AA. ED-C shared the request with Assistant Administrator (AA)-O. AA-O asked for clarification of what was requested. Surveyor shared with AA-O, ED-C, and DON-B that CNAs need to have documentation of receiving 12 hours of education annually per their hire date. DON-B stated DON-B would look for that information and provide what DON-B could locate.ED-C provided to Surveyor an undated document with employee names and number of hours of training. The document did not denote what type of education or when the education was provided. Surveyor shared with ED-C the need to see when the education was provided, what education was provided, and the length of the education to show CNA-W, CNA-X, CNA-Y, CNA-Z, and CNA-AA had the required 12 hours yearly of education based on their date of hire. Surveyor shared with ED-C the education was based on the month of hire and was a rolling year depending on that date; an example was given if an employee was hired on 2/1/2023 then the training hours and topics that would be reviewed would be from 2/1/2024 to 2/1/2025 since that would be the most recent year based on

the hire date. ED-C acknowledged understanding of what was requested.DON-B provided to Surveyor multiple sign-in sheets attached to in-service trainings. DON-B provided written quizzes completed by CNA-W, CNA-X, CNA-Y, CNA-Z, and CNA-AA. Some of the quizzes were not dated and the CNA that completed a quiz did not consistently sign the in-service sign-in sheet. Surveyor asked DON-B if CNA-W, CNA-X, CNA-Y, CNA-Z, and CNA-AA had documentation of what trainings had been received and when.

DON-B stated no, they did not keep individual records. Surveyor asked DON-B how DON-B knew if each employee had the training that was required annually. DON-B stated DON-B would have to look at each in-service sign-in sheet to see if the employee had attended.On 10/28/2025 at 3:30 PM, Surveyor shared with ED-C, DON-B and AA-O the concern CNA-W, CNA-X, CNA-Y, CNA-Z, and CNA-AA did not have the documentation of completing required training in the timeframe based on the hire date of the employee.

DON-B agreed there was not a system in place to monitor the training completed or required for employees.On 10/29/2025 at 12:04 PM via email, ED-C provided a spreadsheet with staff education topics, dates provided, and hours per topic. The spreadsheet had an initial date of 10/9/2024 and a final date of 10/10/2025. The spreadsheet did not incorporate the rolling 12 months from the CNA dates of hire to show training was completed during the individual timeframes.

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