Complete Care at Oak Ridge LLC

Inspectors wroteBased on observation, staff interview, and resident interview the facility failed to ensure residents were treated with respect and dignity, by passing medications, and doing blood pressures in the dining room in a group setting and by not ensuring Resident Council Meeting was conducted with no interruptions. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility Census 71.

Inspectors wroteBased on observation, staff interview and resident interview the facility failed to ensure resident grievance forms were easily accessible to residents. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the Long-Term Care Survey Process. Facility Census 71.

Inspectors wroteBased on observation, staff interview, and equipment manual review the facility failed to keep the ice machine in safe operating condition. This has the ability to affect all Residents that get their nutrition from the kitchen, also residents that attend food related activities. Facility Census: 71. Findings Included: a) Ice Machines On 06/05/25 at 9:40 am the tour with the Maintenance Director found the ice machines located in the Kitchen area had a drain pipe running on the floor to a drain and the nutrition room on had no required air gap on the ice machine drains. The drain pipes were touching the drains. On 06/05/25 throughout the tour, the Maintenance Director confirmed the drain pipes / tubing should not be down in the drain or touching the drain. He states that he would get them fixed.

Inspectors wroteBased upon record review and staff interview, the Facility failed to ensure the PASRR Preadmission Screening and Resident Review) was current and coordinated with the MDS. This was true for one (1) resident of five (5) reviewed during the annual survey process. Resident identifier: #2. Facility census: 71.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. The facility failed to collaborate with Hospices services. This was true for one (1) of one (1) resident reviewed for hospice services. Resident identifier #30. Facility Census: 71. Findings Included: a) Resident #30 A medical record review revealed Resident #30 was receiving Hospice Services starting on 03/31/25. A continued record review of physician's orders showed an order: --Order Summary: Resident is on hospice care related to: End of life care due to advanced dementia. Review of Resident # 30's Hospice documentation showed it did not contain an active care plan or collaborating documentation from Hospice Services. [...]

Inspectors wroteBased on record review, staff interview and observation the facility failed to ensure the environment in which it had control of, was free from accidents and hazards. This failed practice was a random opportunity for discovery and had the potential to effect more than a limited number of residents. Resident identifier #40. Facility census 71.

Inspectors wroteBased on Observation, resident interview and staff interviews, the facility failed to honor residents drink preferences. This has the potential to affect a more than a limited number of residents. Resident Identifiers #32 and #40. Facility census: 71.

Inspectors wroteBased on record review and staff interview the facility failed to ensure it had a complete and accurate medical record. This failed practice was found true for (1) one of (5) five residents reviewed for unnecessary medications during the Long-Term Care Survey Process. Resident identifiers #48, and #61. Facility census 71. Findings Include: a) Resident #48 A record review on 06/05/25 at 11:55 AM, of Resident #48's orders, revealed an order for Trazodone oral tablet 50 Milligrams (MG) to give (1) one tablet by mouth one time a day for Depression. Further record review of Resident #48's active diagnosis, revealed that Depression was not listed as a diagnosis. During an interview on 06/05/25 at 1:11 PM, Registered Nurse Unit Manager, (UM) stated, It's on the order, but I could not find it in the diagnosis. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a sanitary environment related to a hole in the dining room counter top that would allow garbage into a storage cabinet. Facility census 71.

Inspectors wroteBased on observation, resident interview, and staff interviews, the facility failed to post menu timely and adequately. This has the potential to affect a limited number of residents. Facility census: 71.

Inspectors wroteBased on record review and staff interview the facility failed ensure each resident maintains acceptable perimeters of nutrition. They specifically failed to timely assess and/or address a significant weight loss and the resident continued to lose weight. This failure resulted in actual harm for Resident #14. This was true for 1 (one) of 2 (two) residents reviewed for the care area of nutrition during the the Long Term Care Survey Process. Resident identifier: Resident #14. Facility census: 63.

Inspectors wroteBased on facility record review and staff interview, the facility failed to ensure the facility assessment was modified to make it facility centered to identify the staff competencies required to provide the level and types of care needed for the resident population. This was a random opportunity for discovery during the long term care survey process and had the ability to affect more than a limited number of residents. Identifier: Facility Assessment Tool. Census: 63.

Inspectors wroteBased on resident interview, record review and staff interview the facility failed to ensure residents were treated with respect and dignity. Resident #24 was provided care by a male Nurse Aide when it was known she preferred a female Nurse Aide to provide her care. In addition a Nurse Aide took photographs of Resident #63, #65, #24, #36, and #28 to prove they were in need of incontinence care before providing the needed care. This failed practice was true for five (5) of five (5) residents reviewed for the care area of dignity during the long term care survey process. Resident Identifiers: #63, #65, #24, #36 and #28. Facility Census: 63. Findings Include: a) Resident #24 During an interview on 07/22/24 at 1:29 PM Resident #24 stated, I don't think they can read to good here. When she was asked to elaborate the resident stated, They know I only want a female nurse aide. [...]

Inspectors wroteBased on resident interview, staff interview, and record review the facility to ensure residents were free from mental abuse and additionally failed to identify what happened to the residents as Mental Abuse when the investigation was complete. Nurse Aide #160 took photos of Resident #63, #65, #24, #36, and #28 which to a reasonable person would cause the resident to suffer humiliation, shame and/or degradation. This was true for Five (5) of eight (8) residents reviewed for the care area of Abuse during the long term care survey process. Resident Identifiers: #63, #65, #24, #36 and #28. Facility Census: 63.

Inspectors wroteBased on record review and staff interview the facility failed to implement their policy titled: Compliance with Reporting Allegations of Abuse/Neglect/Exploitation. The faicliity failed to report all allegations of abuse related to Resident #12. Also for Resident #63, #65, #24, #36 and #28 the facility failed to identify the actions of Nurse Aide #160 as mental abuse when she took pictures of the residents in their briefs. This failed practice was true for six (6) of eight (8) residents reviewed for the care area of abuse during the long term care survey process. Resident Identifiers: #12. #63, #65, #24, #36, and #28. Facility Census: 63. [...]

Inspectors wroteBased on record review and staff interview the facility failed to report all allegations of abuse and/or neglect to the appropriate agencies as required by regulation. Resident Identifiers: #12 and #5. Facility Census:

Inspectors wroteBased on record review and staff interview the facility failed to notify the resident and/or the resident representative of the bedhold policy when Resident #23 was transferred from the facility on three (3) occasions. This was true for one (1) of four (4) residents reviewed for the care area of hospitalizations during the long term care survey process. Resident Identifier: #23. Facility census: 63. Findings Include: a) Resident #23 A review of Resident #23's medical record on 07/23/24 found the resident was transferred to the hospital on [DATE], 05/31/24, and 07/12/24. The facility was asked to provide the bedhold policy notification for the three (3) discharges. They provided a bed hold policy for Resident #23 for each of the dates listed, however the bed hold policies were not signed by the resident and/or their representative. [...]

Inspectors wroteBased on record review and staff interview the facility failed to implement physicians orders, failed to follow their weight policy for reweighs and failed to identify a significant weight gain. This was true for one (1) of two (2) residents reviewed for the care area of nutrition during the long term care survey process. Resident Identifier: #40 Facility Census: 63 Findings Include: a) Physician orders On 07/23/24 at 1:02 PM a review of Resident #40's medical record found a 17.6 pound weight gain from 07/09/24 until 07/16/24. According to the diagnosis sheet for this resident which was provided by the facility, Resident #40 had an active diagnosis of Congestive Heart Failure (CHF). According to further record review of the last six (6) months, the following weeks had no weight documented for this resident. 01/23/24, 04/16/24, 04/30/24 and 06/25/24. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure Nurse Aides (NA's) completed all required competencies. This was true for five (5) of five (5) NA competencies reviewed during the long term care survey process. Identifier: NA #9, NA #20, NA #28, NA #40 and NA #53 Census: 63.

Inspectors wroteBased on observation and staff interview the failed to ensure appropriate environmental controls for safe medication storage by not obtaining the temperature in the Medication Refrigerator and maintaining these temperatures on the temperature log on a daily basis. This discovery was made during the Long Term Care Survey Process. Facility census: 63.

Inspectors wroteBased on observation, staff interview and the facility policy for Safe Handling for Foods from Visitors, the facility failed to ensure the freezers in the resident rooms was being monitored for temperatures daily. This was true for three (3) of three (3) refrigerators/freezers observed during the long term care survey process. Identifiers: Resident room [ROOM NUMBER]B, Resident room [ROOM NUMBER]B and Resident room [ROOM NUMBER]B. Census: 63.

Inspectors wroteBased on record Review and staff interview the facility failed to ensure the residents medical record was complete and accurate. This was true for one (1) of 25 residents reviewed during the long term care survey process. Resident Identifier: #10. Facility Census: 63. Findings Include: a) Resident #10 A review of Resident #10's medical record on 07/23/24, found an order for Hydrocodone five (5) milligram - 325 milligrams as needed every 24 hours. A review of the controlled substance log and medication administration record (MAR) since April 2024 through current found on through current found on the following days the Hydrocodone was signed out on the Controlled Substance log but was not documented as administered on the MAR: 04/24/24 04/30/24 05/09/24 05/13/24 and 05/21/24. An interview with the Director of Nursing on 07/23/24 at 11:55 AM confirmed the above findings.

Inspectors wroteBased on observation and staff interview the facility failed to develop and implements an ongoing infection prevention and control program (PCP) to prevent, recognize, and control the onset and spread of infection. This was a random opportunity for discovery. Resident identifiers: Resident #270 and #5. Facility census: 63.

Inspectors wroteBased on facility record review and staff interview, the facility failed to ensure all Nursing Assistants (NA's)received the required minimum of 12 hours of nurse aide training per year. This was true for one (1) of five (5) NA's reviewed during the long term care survey process. Identifier: NA #28. Census: 63.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident and or representative was informed in advance by the physician, other practitioner or health professional of the risks and benefits of proposed care, of treatment alternatives or treatment options and to choose the alternative option preferred prior to the administration of an psychotropic medication. This was true for 1 (one) of 5 (five) residents reviewed for unnecessary medications in the Long Term Care Survey Process. Resident identifier: #5. Facility census: 63.

Inspectors wroteBased on record review and staff interview the facility failed to notify the physician of a significant weight loss for Resident #14. This was true for 1 (one) of 2 (two) residents reviewed for the care area of nutrition during the Long Term Care Survey Process. Resident identifier: Resident #14.n Facility census: 63.

Inspectors wroteBased on record review and staff interview the facility failed to notify the ombudsman when Resident #23 was transferred to the hospital. This was true for one (1) of four (4) residents reviewed for the care area of hospitalization during the Long term care survey process. Resident Identifier: #23. Facility Census: 63. a) Resident #23 A review of Resident #23's medical record on 07/23/24 found the residents was transferred to the hospital on [DATE]. An interview with Social Worker #75 on 07/25/24 at 9:45 AM found the resident did not print on the discharge list because he was on behold during this hospital stay. She confirmed the ombudsman was not notified of this transfer because he did not print on the discharge list for March 2024 and that is the list she faxes to the ombudsman monthly.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete an accurate [NAME] Virginia Pre-admission Screening (PASR) to include all diagnosis with a new condition. This was true for two (2) of two (2) residents whose PASR's were reviewed during the long term care survey process. Resident identifier #1 and #20. Facility Census:

Inspectors wroteBased on record review, observation, and staff interview the facility failed to ensure an accurate comprehensive care plan was developed for Resident #37 in the area of dental and for Resident #64 in the area of pressure ulcers. This was true for two (2) of 25 sampled residents reviewed during the long term care survey process. Resident Identifiers: #37 and #64. Facility Census: 63. Findings Include: a) Resident #37 An observation of Resident #37 on 07/22/24 at 1:28 PM found the resident had metal pieces visible in lower gum line. On 07/24/24 at 2:45 PM the Director of Nursing was asked to look into the residents mouth to determine what the metal which was visible was. Upon the completion of the observation it was discovered the resident had a partial plate on the bottom and the metal was visible because she had no natural teeth left to hook it to. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to update a care plan in regards to a diagnosis of psychosis r/t (related to) dementia. This was true for one (1) of five (5) residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review during the long term care survey process. Resident Identifier: #1. Facility Census: 63.

Inspectors wroteBased on record review and staff interview the facility failed to take appropriate measures when they had knowledge a resident's court appointed guardian was no longer able to serve as the guardian because they had lost decision making capacity for themselves while a resident at the same facility as Resident #68. Resident Identifiers: #68 and #372. Facility Census: 63.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident had monthly drug regimen reviews. This was true for one (1) of five (5) residents reviewed for unnecessary medications, psychotropic medications, and Medication Regimen Review (MRR) during the long term care survey process. Resident Identifier: #1. Facility Census: 63.

Inspectors wroteBased on facility record review and staff interview, the facility failed to ensure nurse staff posting was accurate in the area of the number of staff with two (2) of eight (8) nursing staff postings reviewed and there were no total hours worked for the staff on eight (8) of eight (8) nurse staff postings reviewed. Census:

Inspectors wroteBased on observations and staff interviews the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. During the kitchen tour it was discovered a dietary aide was not wearing a beard guard, a dirty drip pan and dirty dish racks. Also, no temperatures were taken for resident's personal refrigerators. This had the potential to affect any resident receiving nourishment from the kitchen or from personal refrigerators. Facility census: 67.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the ombudsman of a facility-initiated transfer for Resident #71. This failed practice was true for one (1) on one (1) Residents reviewed for hospitalizations. Resident identifier: #71. Facility census: 67.

Inspectors wroteThe facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Residents on transmission-based precautions did not have signage at their doors to indicate the type of transmission based precautions to be observed and the personal protective equipment required. These were random opportunities for discovery that had the potential to affect a limited number of residents. Resident identifiers: #21, #59. Facility census: 67.

Inspectors wroteBased on employee record reviews and staff interview the facility failed to provide the 12 hour training in-services required annually for nurse aides (NA). This was true for two (2) of five (5) employee training records reviewed for staffing during the Long Term Care Survey Process. Employee Identifiers: NA #4 and #40. Facility census: 67.