Oak Ridge Care Center

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], 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…

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 and interview, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 (R3) of 3 residents.*During wound care, hand hygiene was not performed prior to placing a clean dressing on R3's stage 4 sacral pressure wound.Findings include:The facility policy titled Wound Management with effective date 10/2020 and reviewed date 9/2025 documents: . committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure injuries, unless the individual's clinical condition demonstrates they are unavoidable. Any resident with a wound receives treatment and services consistent with the resident's goals and treatment. A commitment to the Wound Management Program is demonstrated by implementation of processes founded on accepted standards of practice, research-driven clinical guidelines, and…

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 interview and record review the facility did not ensure 3 (R51, R8, R63) of 15 residents care plans were revised. * R51's behaviors care plan was not patient centered or specific to R51's behavior concerns/needs. * R8's care plan was not revised to monitor for emotional well-being after R8 was involved in a resident to resident altercation on 4/2/2025. * R63's care plan documented R63 was in contact isolation related to an UTI (urinary tract infection). R63 was to be on contact isolation for Clostridium difficile (C-Diff, bacteria in the colon) not an UTI. Findings include: The facility policy titled Care Plan Changes and Updates reviewed 9/2024 documents: It is the policy of [Facility name] to make necessary changes and updates to resident plans of care when needed as soon as possible. The facility also strives to effectively and efficiently communicate care plan changes and updates between staff. Procedure: 1. Anytime a care plan change is need [sic], the nurse will make the appropriate change in 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.

Based on observation, interview, and record review the facility did not ensure staff performed proper hand hygiene and infection control for 2 (R9, R63) of 4 residents observed during the medication pass observation. * R63 was in contact isolation and Licensed Practical Nurse (LPN)-D took R63's blood pressure and then used the same blood pressure cuff on R9 without sanitizing it. Findings include: On 5/6/25, at 7:57 AM, LPN-D was observed administering medication to R63. R63 was observed to have a sign on her door indicating she was on contact isolation. LPN-D put on a gown and gloves and took R63's blood pressure with the blood pressure machine from the medication cart. After taking R63's blood pressure LPN-D took off her gown and gloves sanitized her hands and placed the blood pressure machine on the medication cart in the hall. LPN-D did not sanitize the blood pressure machine. LPN-D then took the same blood pressure machine and took R9's blood pressure. R9 had a sign on his door indicating he was on enhanced barrier precautions. After LPN-D took R9's blood pressure she placed it…

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 interview, record review, and review of facility policy, the facility failed to thoroughly investigate the death that occurred for 1 of 3 sampled residents R4 reviewed for abuse and/or neglect of eight sample residents. R4 died of a presumed suicide. The facility did not thoroughly investigate the death Findings include: Review of the facility's policy titled, Investigation and Reporting of Alleged Incidents of Abuse, Neglect, and Misappropriation, dated 08/17, stated All abuse, neglect, and exploitation of residents and misappropriation of resident property are prohibited at [Name of facility]. All alleged violations will be taken seriously and investigated and reported as necessary .1. All alleged violations involving mistreatment, neglect, abuse, injuries of unknown source and misappropriation of resident property shall immediately be reported to the Administrator (or designee), the employee's supervisor, or nurse who will immediately report to the Administrator (or designee) .e. Examples of neglect…

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 interview and record review, the facility failed to ensure that 1 of 3 residents (R1) received accurate medication administration resulting in a significant medication error of eight sample residents. R1 received another resident's anti-seizure and laxative medications in error placing R1 at risk for discomfort and a potential risk to his health and safety. Findings include: Review of R1's undated Face Sheet provided by the facility, revealed an admission date of 02/16/22 with an admission diagnosis of unspecified dementia. Review of R1's significant change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/18/24, revealed R1 did not have a Brief Interview for Mental Status (BIMS) conducted and was assessed as having cognitive skills for daily decision making that was severely impaired. Review of a Medication/Treatment Error Report, dated 03/19/24 and provided by the facility, indicated that R1 received Depakote (an anti-seizure medication) 875 mg po (by mouth), Keppra (an anti-seizure medication) 500 mg po (by mouth), and lactulose 45 ml (milliliters)/30…

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 did not provide the necessary care and services to prevent development of pressure injuries and promote healing of pressure injuries for 1 (R1) of 3 Residents reviewed with pressure injuries. R1 had a Stage 4 pressure injury and was observed to be in bed with her air mattress unplugged for 2 hours and 10 minutes. Findings include: R1 was admitted to the facility on [DATE] with diagnoses that Dementia. R1 receives hospice services that started on 12/21/22. On 3/28/24 at 10:00 AM R1 was observed in bed and her air mattress was observed to be unplugged from the wall and no power to the air mattress. On 3/28/24 at 12:10 PM Director of Nurses (DON)-B came into R1's room with the Surveyor and verified R1's mattress did not have power. DON-B plugged R1's air mattress in and it inflated. On 3/28/24 R1's pressure injury measurements to her coccyx were reviewed and indicated it was facility acquired and was declining rapidly as R1 only was eating 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview, the facility did not ensure a resident received the appropriate treatment during medication administration through a g (gastrostomy)-tube to prevent possible complications. This was observed with 1 (R3) of 1 residents with a G-tube. R3 received medications without ensuring the g-tube was appropriately placed in the stomach prior to the water flush and medication administration. On 1/30/24, LPN (Licensed Practical Nurse)-F did not auscultate or aspirate the g-tube prior to administering the medication. Findings include: The facility policy and procedure entitled, Feeding Tube Management dated January 28, 2019, states: Management . Feeding tube placement verification prior to each instillation into the tube is based on current standards of practice which include: a. Auscultate an air bolus in the stomach. Verify a whoosh, [NAME], bubbling sound or b. Aspirate gastric content (none may exist if stomach is empty). c. Other alternatives include: measure gastric pH…

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 staff did not utilize the appropriate (personal protective equipment) PPE for residents on droplet isolation. This was observed with 2 (R162 and R160) of 2 residents in droplet isolation. -R162 and R160 have a respiratory illness requiring droplet isolation. The required PPE was noted on their doorway, along with PPE supplies outside of the room. Staff was observed to not don the required PPE when entering the room. Findings include: Surveyor reviewed the facility's policy and procedure PPE (personal protective equipment) Precautions Policy dated 12/2022. Under section C. Enhanced Droplet Precautions: Enhanced Droplet Precautions are used for patients known or suspected with covid-19. The following is indicated: - perform hand hygiene when entering and exiting room; -Don a N95, gown, gloves, and eye protection upon entry into a patient room/space. 1.) On 01/29/24, at 9:52 AM, Surveyor observed Certified Nursing Assistant (CNA)-D answer R162's call light. R162 has a sign on their door indicating a need for droplet…

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 staff interview, the facility did not ensure residents were assessed promptly with a weight loss and quarterly nutritional assessments. This was observed with 3 (R16, R45 and R50) of 4 residents with nutritional concerns. * R16 had a weight loss and the RD (Registered Dietitian) and Physician were not notified. * R45 did not have a nutritional assessment completed with a Significant Change in Status and Quarterly MDS (minimum data set) assessments. * R50 had a weight loss and the RD and Physician were not notified. Findings include: The facility's policy and procedure Nutrition and Weight Management, dated 11/2017, was reviewed by Surveyor. The procedures include the following: The RD will perform a comprehensive nutritional risk assessment with any significant change in condition. If a significant or severe weight loss occurs despite interventions, the Nurse Practitioner/Physician and the RD shall be notified. 1.) On 11/01/22 at 9:22 AM Surveyor observed R16 laying in bed…

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, record review and staff interview, the facility did not ensure a residents oxygen orders were implemented. This was observed with 1 (R42) of 1 residents with oxygen use in the facility. R42 was observed without a humidifier with oxygen use and their oxygen tubing was not dated per physicians orders. Findings include: The facility's policy and procedures for Changing Oxygen Cannula, Tubing and Bubbler, dated 5/2017, was reviewed by Surveyor. Procedures #2 indicates that the facility prefers to change cannula, oxygen tubing and bubbler weekly and with application of date. On 11/01/22 at 09:35 AM Surveyor observed R42 in their bed. R42 had oxygen at 2 LPM (liters per minute) via a nasal cannula. Surveyor observed the oxygen cannula tubing has no apparent date and no humidifier attached to the oxygen. R42's medical record was reviewed by Surveyor. R42's signed physician orders, dated 11/2/22 indicate to administer oxygen at 2-5 LPM per nasal cannula to keep saturations above 89%. Change humidifier and tubing every week and as needed. On 11/02/22 at 08:55 AM…

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.