Villages At Oak Ridge, The

Based on observation, interview, and record review, the facility failed to ensure care and services were provided to treat pressure ulcers for 1 of 3 new admisstions reviewed for quality of care. Staff identified a new pressure ulcer but did not assess the wound or obtain new treatment orders for three days. (Resident C)Finding includes:During record review on 4/14/26 at 10:30 A.M., Resident C's diagnoses included, but were not limited to, lumbar fracture, polyneuropathy, muscle weakness, need for personal assistance with care, and cognitive communication deficit. Resident C's most recent admission Minimum Data Set (MDS) assessment, dated 3/2/26, indicated the resident had moderate cognitive impairment, was dependent for mobility, had no unhealed pressure wounds, and was at risk for developing pressure ulcers. Resident C's care plan included but was not limited to:At risk for skin breakdown due to episodes of incontinence and assistance required for mobility/positioning tasks due to decline in functional mobility (started 3/17/26).Resident has a pressure ulcer to left buttock…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to prevent falls for 1 of 3 residents reviewed for accidents. Following multiple falls, a resident care plan interventions were not in place to prevent an additional fall. (Resident C)Findings include: During record review on 2/26/25 at 11:15 A.M., Resident C's diagnoses included, but were not limited to, repeated falls, chronic pain, and depression.Resident C's most recent admission Minimal Data Set (MDS) assessment, dated 5/2/25, indicated the resident had moderate cognitive impairment, used a walker for mobilization, and had one-sided upper extremity impairment. Resident C's physician orders included but were not limited to: call light attendant to bed, check placement and function every shift (started 5/11/25).Resident C's care plan included, but was not limited to, the resident at risk for falls due to falls at home with minor injury, antidepressant medications, altered balance and coordination (started 4/29/25). Fall interventions included but were not limited to; call light attendant to bed, check…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure appropriate care and services were provided to prevent urinary tract infections for residents with urinary catheters or were incontinent of bladder for 4 of 4 residents reviewed for incontinence/catheter care. (Resident B, Resident E, Resident D, Resident C) Findings include: 1. On 3/31/25 at 9:57 A.M., Resident B's clinical record was reviewed. Resident was admitted [DATE]. Diagnosis included, but were not limited to, dementia and kidney failure. The most recent admission Minimum Data Set (MDS) assessment, dated 3/17/25, indicated a severe cognitive impairment and no behaviors. Resident was dependent on staff for eating, toileting, and bathing. Resident frequently incontinent of bladder, and did not have a urinary catheter at admission. Physician orders included, but were not limited to: May dip urine with signs and symptoms of urinary tract infection (UTI), then may send urine for culture and sensitivity (C&S) if positive for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was provided for 7 of 7 days reviewed and 1 of 1 Resident Council meeting. Oxygen orders were not in place, catheter care was not provided, antibiotics given were not indicated for uti, and showers were not given. (Resident 33, Resident E, Resident B, Resident D, Resident C) Finding includes: 1. During the survey dates of 3/25/25 through 4/2/25, the following interviews were completed. a. The confidential interview indicated it was dependent on the hall assigned and if everyone showed up whether there was enough help or not. She frequently stayed after her shift ended to chart. They indicated it would be better and they could get all tasks done if there were two aides on each hall (100/Locked Dementia Unit, 200/TCU, and 300) or at least a float Certified Nurse Aide (CNA) that would be available as needed. b. The confidential interview indicated they were not able to get a break or get a lunch. They indicated there were a lot of call in's. Staff would try to call others to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to ensure infection control practices were implemented for a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for 2 of 2 random observations. (100 Hall, 300 Hall) Findings include: 1. On 4/1/25 at 10:14 A.M., a laundry cart was observed against a wall on the 100 Hall. Clothes were observed on hangers hanging from the top of the cart and folded items observed in the bottom basket. The cart was not covered. Laundry 3 and Laundry 7 were observed wheeling the cart down the hall while the clothes on the hangers were rubbing against the wall, resident doors, and hand sanitizer dispensers. Laundry 3 and Laundry 7 were observed taking the folded items from the basket and hugging them against their uniform tops taking them into the resident rooms. 2. On 4/1/25 at 2:14 P.M., Laundry 7 was observed on the 300 Hall holding resident clothing against her uniform top and entering room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents requiring assistance with Activities of Daily Living (ADLs) received adequate assistance with bathing for 2 of 2 residents reviewed for ADL care. (Resident C, Resident J) Findings Include: 1. During an interview on 3/25/25 at 10:41 A.M., Resident J indicated she received showers once a week. On 4/01/25 at 10:57 A.M., Resident J's clinical record was reviewed. Diagnoses included, but was not limited to anemia, coronary artery disease, and depression. The most recent Quarterly Minimum Data Set (MDS) assessment, dated 2/12/25 indicated Resident J had moderate cognitive impairment and required moderate assistance with bathing. A current care plan, initiated on 6/14/2022, was provided and indicated Resident J required staff assistance to complete ADL tasks completely and safely. Resident J's care plan lacked information on functional status related to bathing. On 4/2/25 at 10:00 A.M., Resident J's shower record from 1/1/25 to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory care. A resident's order for oxygen supplementation was not followed. (Resident 7) Finding includes: On 3/25/25 at 11:09 A.M., Resident 7 was laying sideways in bed wearing oxygen per nasal cannula with the oxygen concentration machine indicator between 2.5-3 liters per minute (LPM). On 3/28/25 at 9:53 A.M., Resident 7 was sitting in her room in a Broda chair asleep wearing oxygen per nasal cannula. The oxygen concentrator on the portable tank was set on 3 LPM. On 4/2/25 at 10:35 A.M., Resident 7's Broda chair was in the resident's private bathroom and the nasal cannula tubing was hanging over the Broda chair, uncovered. On 3/31/25 at 11:51 A.M., Resident 7's clinical record was reviewed. Diagnoses included, congestive heart failure and chronic obstructive pulmonary disease (COPD). The most recent Discharge Minimum Data Set (MDS),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure that appropriate treatment and services were provided to prevent UTIs (urinary tract infections) for a resident with a nephrostomy tube (a flexible tube that drains urine from the kidney into a bag outside the body) for 1 of 1 residents reviewed for UTI. A resident's MDS (Minimum Data Set) Assessment was incorrectly coded, the clinical record lacked a resident centered care plan, an antibiotic was ordered for 5 days and given for 6 days, and the resident did not follow up with specialists. (Resident B) Findings include: During an observation on 9/20/24 at 1:50 P.M., Resident B was in bed. At that time, Resident B indicated she had a nephrostomy tube for 2 years and she was in and out of the hospital often due to UTIs. She indicated she occasionally sat in a wet brief until staff came to assist. Resident B indicated the nursing facility would only change the dressing on the nephrostomy tube on shower days or when the dressing fell…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADLs) were provided for dependent residents for 4 of 4 residents reviewed for ADLs. Residents did not receive showers at least twice per week. (Resident 15, Resident 107, Resident 51, Resident 44) Findings include: 1. On 3/19/24 at 11:00 A.M., Resident 15 was observed with greasy, unbrushed hair. On 3/21/24 at 10:17 A.M., Resident 15 was observed sitting in the common area with greasy, unbrushed hair. On 3/25/24 at 9:22 A.M., Resident 15 was observed sitting in the common area with unbrushed hair. On 3/21/24 at 11:24 A.M., Resident 15's clinical record was reviewed. Diagnosis included, but were not limited to, dementia. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 1/12/24, indicated cognitive status unable to be assessed, and no refusals or rejection of care. Resident 15's clinical record lacked care plans and/or current physician orders related to providing assistance for showers or rejection of care. Resident 15's progress notes lacked refusals of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and dignity for 1 of 1 resident reviewed for dignity. Resident was being fed at the nurse's station. (Resident 47) Findings include: On 3/19/24 at 9:30 A.M., upon entrance to the facility, CNA 33 was standing at the 300 hall nurse's station feeding Resident 47, who was sitting in a wheelchair. On 3/25/24 at 11:21 A.M., Resident 47's clinical records were reviewed. She was admitted on [DATE]. Diagnosis included, but were not limited to, cerebral palsy, epilepsy, and dysphagia. The most current Significant Change in Condition MDS (Minimum Data Set) Assessment, dated 2/5/24 indicated Resident 47's cognitive status was unable to be assessed, extensive assistance of two was needed for bed mobility, transfers and toilet use, and extensive assistance of one was needed for eating. Physician's orders included, but were not limited to the following: Diet: Fortified Foods (therapeutic), Pureed (Texture),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure assessments were completed for a resident that self administered medications for 2 of 2 random observations. A resident was observed in a room alone with a medication cup containing pills. (Resident 34) Findings include: On 3/19/24 at 10:25 A.M., Resident 34 was observed sitting in her room. Two medication cups were observed stacked together with applesauce in the top one, and a blue capsule in the bottom one. On 3/19/24 at 11:51 A.M., Resident 34's room was observed with Licensed Practical Nurse (LPN) 21. At that time, Resident 34 was in the dining room. To medication cups were observed still stacked together with applesauce in the top one, and the following medications in the bottom one: 1 round white tablet 1 blue capsule 1 round rust colored tablet 1 oval peach tablet with a 5 on one side At that time, LPN 21 indicated the medications were not supposed to be in the room, and were probably Resident 34's morning medications. On 3/19/24 at 12:00 P.M., Resident 34's clinical record was reviewed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to implement the care plan for 2 of 2 residents reviewed for implementation of a care plan. The facility failed to fill the oxygen humidification bottle for one resident and failed to give a medication to one resident. (Resident 30, Resident 29) Findings include: 1. On 3/19/24 at 10:59 A.M., Resident 30 was observed lying in bed with her eyes closed. Oxygen (O2) tubing was lying on the floor, the humidification bottle was empty and the oxygen machine was on at 4 l/min (liters per minute). On 3/20/24 at 10:04 A.M., Resident 30's humidification bottle on the oxygen machine was empty. At that time, RN 27 indicated the humidification bottles were changed as needed, usually on the night shift. After she replaced the empty bottle, she indicated she checked the bottles routinely but missed this one. On 3/21/24 at 9:50 A.M., Resident 30's clinical records were reviewed. Diagnosis included, but were not limited to chronic obstructive pulmonary disease, pulmonary fibrosis, and other pulmonary collapse. The most current…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain safe and secure storage of medications for 1 of 2 medication carts observed. Loose pills were observed in the medication cart. (300 Hall) Findings include: On 3/26/24 at 10:31 A.M., the 300 Hall medication cart was observed with the following loose pills in the drawers: 1 round yellow pill 1 round white pill marked with HH210 on the pill 2 oblong white tablets marked with L484 on the pill 1 round pink pill marked with L21 on the pill 1 round light yellow pill During an interview on 3/26/24 at 10:37 A.M., QMA (Qualified Medication Aide) 23 indicated all nursing staff was responsible to clean out medication carts every other day and loose pills should be disposed of. During an interview on 3/27/24 at 10:26 A.M., the IP (Infection Preventionist) indicated there should not be loose pills in the med cart. On 3/27/24 at 12:20 P.M., the Administrator provided a Medication Storage in the Facility policy, revised 11/18 that indicated, .contaminated, or deteriorated medications and those in containers that are…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure infection control practices were in place for 1 of 1 residents observed for insulin administration, and 1 of 1 random observation. Staff handled medications with bare hands prior to administering them to a resident, and staff placed an insulin syringe on the sink and an insulin supply case on a resident's catheter bag prior to administration of insulin. (Resident 107, Resident 43) Findings include: 1. On 3/19/24 at 11:14 A.M., Registered Nurse (RN) 3 was observed to prepare medications for administration. RN 3 removed medication cards from the medication cart, popped the pills into her bare other hand, then placed them into a medication cup. RN 3 was then observed to administer the medications to Resident 107. 2. On 3/25/24 at 10:22 A.M., Qualified Medication Aide (QMA) 5 was observed to administer insulin to Resident 43. QMA 5 entered the room, and placed the insulin supply box on top of the resident's catheter bag which was lying on top of his leg at the foot of the bed. QMA 5 then went into the bathroom, placed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.