Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Oak Ridge Care Center
UNION GROVE, WI · 74 certified beds · Last Life Safety survey May 7, 2025
CMS Certification Number 525542 · first certified September 1994
Ownership
Independently operated (no chain recorded by CMS) · For profit - Individual
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within WI
21 citations — more than 62% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (June 2026 to August 2026), and past the point by which nine in ten WI facilities have been surveyed. This facility’s last Life Safety survey was May 2025. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 21 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 21 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 21 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 3, 2022 | 5 |
| January 31, 2024 | 8 |
| May 7, 2025 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-01-31 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 2 | 2025-05-07 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2025-05-07 |
| E-0020 | Establish policies and procedures including evacuation. | 1 | 2025-05-07 |
| K-0925 | Ensure that sources of ignition are removed from patients receiving respiratory therapy. | 1 | 2025-05-07 |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | 1 | 2024-01-31 |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | 1 | 2022-11-03 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2022-11-03 |
What the citations cover
- Smoke Deficiencies 7
- Miscellaneous Deficiencies 5
- Egress Deficiencies 2
- Services Deficiencies 2
- Other 5
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Miscellaneous Deficiencies | 5 |
| Egress Deficiencies | 2 |
| Services Deficiencies | 2 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Emergency Preparedness Deficiencies | 2 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 7, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (June 4, 2025) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (June 4, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (June 4, 2025) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (May 29, 2025) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (June 4, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 4, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 2, 2025) |
| K-0925 | Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Deficient, Provider has date of correction (June 4, 2025) |
January 31, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0132 | Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0354 | Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (March 6, 2024) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (March 6, 2024) |
November 3, 2022 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (December 3, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 16, 2022) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (November 16, 2022) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (December 3, 2022) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Waiver has been granted (May 1, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.