Oregon Health Care and Rehab Center closing after violations

Oregon Health Care and Rehab Center, a 45-bed nursing home in the village of Oregon, is closing after four serious regulatory violations in recent months led to a $260,000 fine and a ban on government payments for new patients.

The nursing home, formerly known as Oregon Manor and located at 345 N. Main St., will close Aug. 1, as will an adjoining 20-bed assisted living facility called Main Street Quarters, Anna Johnson, executive director, said in a statement. The complex, which opened in 1975, was purchased in 2020 by Oregon Healthcare, a for-profit company.







Oregon Nursing Home 1

Oregon Healthcare and Rehabilitation Center and its assisted living facility, Main Street Quarters, will close Aug. 1.




The Wisconsin Department of Health Services issued at least 10 citations to the nursing home from November to February, including four immediate jeopardy citations, the most serious type of violation. The serious citations involved inadequate control of a COVID-19 outbreak, delayed treatment of a resident with COVID-19 who died and improper treatment of a resident who required a blood transfusion after unnecessarily being on a drug that can increase bleeding.

DHS inspectors found the facility “was not in substantial compliance” with federal requirements and the most serious deficiencies put “the health and safety of your residents in immediate jeopardy,” said an April 4 letter from the federal Centers for Medicare and Medicaid Services, or CMS.

CMS fined the nursing home $260,165 and stopped payments for new patients from Dec. 26 to March 14, when the facility was found to be compliant. The agency also banned the center from training nurse aides for two years.


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It’s not clear if Oregon Healthcare appealed the penalties, as is often done.

Johnson’s statement attributed the closure to “our industry’s workforce shortages, federal staffing mandates, our community’s census, and increased regulatory challenges.”

As of this week, the nursing home has 13 residents and the assisted living facility has 14. Staff are helping them find other places to live, Johnson said.

The closure will leave Dane County with 17 nursing homes, down from 21 in 2012. Statewide, there were 340 nursing homes last year, with 25,314 beds, compared with 377 nursing homes, with 29,579 beds, in 2019, according to DHS.


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Nursing home groups have cited low Medicaid payments, along with staffing shortages and aging facilities, for closures in recent years. Nurse and nurse aide staffing requirements announced by the Biden administration last month will make operations more challenging, the groups say.

There has also been a shift in demand to home care and assisted living, which are less regulated and generally used by people with fewer medical needs. A report last year by the consultant Baker Tilly said Wisconsin had an excess of 6,180 nursing home beds.

Facility’s problems

Oregon Health Care and Rehab, referred to in inspection reports as Grace Healthcare of Oregon, had a COVID-19 outbreak that started in late October and by late November involved 18 of 19 residents and nine staff, inspectors said.

The facility failed to follow numerous infection control procedures, from screening residents and isolating patients to wearing protective equipment and keeping infected staff away from work long enough, according to a Nov. 28 inspection report detailing one of the immediate jeopardy citations.


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One resident, who tested positive for COVID-19 on Nov. 10, three days after being admitted to the facility, died in the hospital Nov. 30 after not being treated promptly and developing pneumonia and other complications, a Dec. 18 inspection report said, summarizing another immediate jeopardy citation.

A resident on the blood thinner warfarin started taking an antibiotic, which increases the risk of bleeding, for a suspected urinary tract infection, a Jan. 25 inspection report said. But the sample for the infection test was contaminated, so the antibiotic should have been stopped and the warfarin wasn’t properly monitored, leading to severe bleeding and a transfusion, which resulted in another immediate jeopardy citation, the report said.

A report detailing the fourth immediate jeopardy citation, issued Feb. 27 and involving maintenance of nutrition and hydration, was not available Wednesday.

The Oregon assisted living facility, referred to by regulators as Oregon Healthcare and Rehabilitation Center, also had recent violations. It was fined $400 in April 2023, after an inspection that resulted in five citations, and fined $450 in September 2023, after an inspection with two citations.







Oregon Nursing Home 2

Four serious regulatory violations in recent months led to a $260,000 fine levied against Oregon Healthcare and Rehabilitation Center.




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