Hebron Oaks

• Fine

  CMS changed the fine from February 18, 2025 from $22,925 to $14,901.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS staffing star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on February 2, 2026.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on February 2, 2026.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on February 2, 2026.

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• Ownership

  CMS ownership records list new owners for this home.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on July 30, 2025.

  CMS has cited this home for F0812 2 times since 2023.

• Citation F0607. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  CMS lists it as corrected on August 6, 2025.

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CMS lists this as a standard inspection.

• Citation K0293. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have properly located and lighted "Exit" signs.

  CMS lists it as corrected on July 28, 2025.

  CMS has cited this home for K0293 2 times since 2024.

• Citation K0324. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on August 17, 2025.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on August 17, 2025.

  CMS has cited this home for K0345 2 times since 2024.

• Citation K0346. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  CMS lists it as corrected on August 8, 2025.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  The home is disputing this citation through CMS's informal review.

  CMS lists it as corrected on August 17, 2025.

  CMS has cited this home for K0353 3 times since 2023.

• Citation K0355. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  The home is disputing this citation through CMS's informal review.

  CMS lists it as corrected on August 17, 2025.

  CMS has cited this home for K0355 2 times since 2024.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on July 29, 2025.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on August 17, 2025.

  CMS has cited this home for K0918 2 times since 2024.

• Citation K0531. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have elevators that firefighters can control in the event of a fire.

  CMS lists it as corrected on August 7, 2025.

  CMS has cited this home for K0531 2 times since 2024.

• Citation K0912. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have power receptacles that are properly grounded.

  CMS lists it as corrected on August 17, 2025.

• Citation K0541. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install properly constructed and protected linen or trash chutes.

  CMS lists it as corrected on August 17, 2025.

  CMS has cited this home for K0541 2 times since 2024.

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• Star rating

  The CMS overall star rating changed from 4 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 2 of 5.

CMS stopped payment for new admissions from March 15, 2025, for 17 days.

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• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

71 of 323 Wisconsin homes (22%) got a citation at the immediate jeopardy level in 2025.

• Citation F0686. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on April 1, 2025.

  CMS has cited this home for F0686 2 times since 2023.

• Citation F0730. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Observe each nurse aide's job performance and give regular training.

  CMS lists it as corrected on March 11, 2025.

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CMS fine of $14,901 on February 18, 2025.

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• Star rating

  The CMS overall star rating changed from 5 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 5 of 5 to 1 of 5.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 5 of 5.

• Star rating

  The CMS health inspection star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 6.9 to 5.4 hours per resident per day.

CMS lists this as a standard inspection.

• Citation E0029. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop a communication plan.

  CMS lists it as corrected on June 20, 2024.

• Citation K0293. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have properly located and lighted "Exit" signs.

  CMS lists it as corrected on June 18, 2024.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on June 13, 2024.

• Citation K0372. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on July 21, 2024.

• Citation K0321. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on July 21, 2024.

• Citation K0353. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on August 9, 2024.

• Citation K0531. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have elevators that firefighters can control in the event of a fire.

  CMS lists it as corrected on June 14, 2024.

• Citation K0918. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on June 18, 2024.

• Citation K0355. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on August 9, 2024.

• Citation K0374. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install smoke barrier doors that can resist smoke for at least 20 minutes.

  CMS lists it as corrected on July 21, 2024.

• Citation K0541. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install properly constructed and protected linen or trash chutes.

  CMS lists it as corrected on July 21, 2024.

• Citation K0923. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on June 17, 2024.

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CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on April 4, 2023.

• Citation F0686. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on April 4, 2023.

• Citation F0694. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide for the safe, appropriate administration of IV fluids for a resident when needed.

  CMS lists it as corrected on April 4, 2023.

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CMS lists this as a standard inspection.

• Citation K0919. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Meet requirements for the use of electrical equipment.

  CMS lists it as corrected on March 27, 2023.

• Citation K0281. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install proper backup exit lighting.

  CMS lists it as corrected on March 27, 2023.

• Citation K0353. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on March 27, 2023.

• Citation E0033. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Establish methods for sharing information.

  CMS lists it as corrected on March 8, 2023.

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