Diversicare of Oak Ridge

Inspectors wroteBased on observations and interview the facility failed to maintain prepared foods in the dietary department within safe serving temperature ranges during the lunch meal service on 5/27/2025.

Inspectors wroteBased on facility policy review, medical record review, facility investigation documentation review, and interview, the facility failed to protect the residents' right to be free from sexual abuse for 1 resident (Resident #1) by Resident #2 of 14 residents reviewed for abuse.

Inspectors wroteBased on facility policy review, observations, and interviews the facility failed to provide a homelike environment for 1 resident room (#512) of 7 resident rooms observed for homelike conditions and failed to prevent foul odors for 1 hallway of 5 hallways observed.

Inspectors wroteBased on facility policy review, medical record review, facility investigation documentation review, observation, and interview, the facility failed to protect the residents' right to be free from physical abuse by a resident for 2 residents (Resident #1 and #7) and verbal abuse by a resident for 2 residents (Resident #7, and #9) of 22 residents reviewed for abuse.

Inspectors wroteBased on facility policy review, medical record review, facility investigation documentation review, and interview, the facility failed to report an allegation of sexual assault to the State Agency within 2 hours as required, for 1 resident (Resident #10) of 22 resident's reviewed for abuse.

Inspectors wroteBased on facility document review, Resident Assessment Instrument (RAI) Manual 3.0 review, medical record review, and interview, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 resident (Resident #8) of 13 residents reviewed.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure professional standards of practice were followed when transportaion was not provided to outpatient scheduled appointments for 2 residents (Resident #25 and Resident #34) of 6 residents reviewed for transportation needs.

Inspectors wroteBased on facility policy review, medical record review, facility investigation review, observation, and interview, the facility failed to implement appropriate fall interventions to prevent falls for 4 residents (#74, #253, #149, and #89) of 6 residents reviewed for falls. [...]

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to develop an individualized care plan to prevent falls for 4 residents (#74, #253, #149, and #89) of 6 residents reviewed for falls. The facility's failure resulted in Resident #74 sustaining a shattered Left Acetabulum (socket of hipbone) and Fracture of the Left Pubic Ramus (Pelvic break). Resident #253 sustaining a Left Femoral Fracture (break in the thigh bone). [...]

Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to revise a comprehensive care plan timely for 3 residents (Resident #202, #61, and #16) of 28 care plans reviewed. The facility failed to revise interventions to the care plan timely for Resident #202 after the resident's family brought cigarettes and lit them, which led to 3 residents smoking unsupervised on 11/28/2023. Resident #61's care plan was not updated timely after the resident was discovered smoking unsupervised on 11/28/2022. Additionally Resident #16's care plan was not revised timely when he obtained cigarettes from a family, smoked cigarette unsupervised on 11/28/2022, attempted to bring cigarettes into the building on 4/19/2023, and tried to burn a staff member on 4/20/2023 with a lit cigarette. The facility's noncompliance placed Resident #202, #61, and #16 in Immediate Jeopardy. [...]

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to ensure a safe discharge for 2 residents (Resident #249 and Resident #250) of 5 residents reviewed for discharge. The facility's failure resulted in Resident #249, who was homeless, being discharged to an unknown friend's house who did not allow the resident to stay, Resident #249 then walked to another friend's house who drove him to a motel where Resident #249 resided for approximately 2 months at which time he was evicted from the motel and hitchhiked to another friend's house. Additionally, the facility's failure resulted in Resident #250 being home alone where she sat in a wheelchair for 4 days in urine and feces before she was provided incontinence care by a home health staff. [...]

Inspectors wroteBased on facility policy review, medical record review, review of facility documentation, observation and interview, the facility's Administration failed to follow facility policy and procedures to ensure safe discharges for Residents #249 and #250; failed to provide adequate supervision for falls prevention, investigating, and implementing resident-centered interventions for 3 Residents (#149, #253, and #74); failed to provide effective leadership to address the elopement of 1 resident (#252); placing the Residents [#249, #250, #149, #253 and #74] in Immediate Jeopardy (IJ) , (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). [...]

Inspectors wroteBased on medical record review, review of facility documents, observation and interviews, the governing body failed to establish and implement policies regarding effective management and training of the facility's new hires in key staff positions and operation of the facility. The Governing Body's failure placed 2 resident (#250 and #249) of 6 discharged residents reviewed for the potential of unsafe and non-orderly discharge; placed 3 residents (#149, #253, and #74) of 5 residents reviewed for falls at high risk for repeat falls; and the Administrator's failure to provide adequate leadership to address the elopement of 1 resident (#252) placed the resident in an unsafe environment. [...]

Inspectors wroteBased on facility policy review, facility document review, medical record review, observation and interview, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to reassess and monitor ongoing concerns with falls (Residents #149, #253, and #74) and elopement (Resident #252). The facility failed develop an effective QAPI program that recognized concerns related to safe smoking by Resident's (#202, #61, #16, and #48) and failed to ensure systems and processes were in place and consistently followed by staff to prevent an elopement, falls and an unsafe smoking environment. The failure of the QAPI Committee to ensure a safe environment for smoking and to develop corrective actions for elopement and falls, placed all residents in Immediate Jeopardy (IJ). [...]

Inspectors wroteBased on facility policy review, review of facility documentation, and interview, the facility failed to maintain competent staff in the kitchen to deliver the evening meal service on 9/3/2023, for 22 residents of 28 residents reviewed.

Inspectors wroteBased on record review and interview, the facility failed to manage the Resident Trust Accounts for 6 residents (Resident #19, Resident #20, Resident #27, Resident #33, Resident #37, and Resident #50) to ensure they did not exceed the allowable Medicaid limit of $2,000.00 and failed to refund personal trust fund monies within 30 days of death for Resident #151, of 36 resident Trust Accounts reviewed.

Inspectors wroteBased on medical record review, observation and interview, the facility failed to assist 1 resident (#14) with obtaining glasses of 28 residents reviewed.

Inspectors wroteBased on medical record review, observation and interview, the facility failed to provide 1 resident (#33) with podiatry care of 28 residents reviewed for ADL (activities of daily living) care.

Inspectors wroteBased on patient education material review, observation, and interview, the facility failed to ensure 1 resident (Resident #58's) of 3 residents reviewed had their dialysis access assessed and the findings documented every shift.

Inspectors wroteBased on facility policy review, medical record review, and interview, the facility failed to act timely on a consultant pharmacy recommendation for 1 resident (#74) of 5 residents reviewed.

Inspectors wroteBased on medical record review, observation and interview, the facility failed to secure dental services for 2 residents (#14 and #23) of 28 residents reviewed for dental services.

Inspectors wroteBased on facility policy review, medical record review, and interview the facility failed to maintain a complete medical record to ensure the resident information was readily available to all disciplines to reflect the resident's condition and services provided for 3 residents (Residents #252, #199, and #78) of 28 resident records reviewed.

Inspectors wroteBased on observation, and interview, the facility failed to ensure Residents were offered or provided hand hygiene prior to meals for 1 of 4 halls for 20 residents observed.

Inspectors wroteBased on review of facility policy, observation, and interview, the facility failed to maintain a sanitary environment in the kitchen; failed to maintain an accurate temperature log for the walk-in cooler and walk-in freezer; and failed to maintain a cleaning log for food service equipment in 1 of 1 kitchen observed with the potential to affect 97 of 101 residents in the facility.

Inspectors wroteBased on facility policy review, review of Centers for Disease Control and Prevention (CDC) guidance, medical record review, observation, and interview, the facility failed to ensure infection control practices were followed for 1 resident (#38) of 2 residents reviewed for transmission based precautions; failed to follow isolation guidance to prevent COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) spread for 1 resident (#251) of 3 residents reviewed for COVID-19 transmission based precautions; failed to provide employee screening at the beginning of the shift for 119 of 313 shifts between 1/17/2022 - 1/24/2022; failed to implement universal use of eye protection as part of Personal Protective Equipment (PPE) during all patient care encounters in a community with high COVID-19 transmission; [...]

Inspectors wroteBased on facility policy review, medical record review, observations, and interviews, the facility failed to ensure personal and medical information was not visible for 12 residents (#2, #10, #14, #16, #21, #22, #25, #33, #36, #42, #62, and #75) of 101 residents observed.

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to dispose of discontinued medications for 2 residents (#34 and #55) and failed to dispose of deceased residents' narcotics for 2 residents (#449 and #450) of 10 residents reviewed for medication storage.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to ensure personal medical information was not visible for 1 resident (#11) of 37 residents reviewed for patient rights.

Inspectors wroteBased on medical record review and interview, the facility failed to refer 2 residents (#34 and #70) to the state-designated authority for a Level II Pre-admission Screening and Resident Review (PASARR) after the residents were identified with possible serious mental disorders, of 10 residents reviewed for PASARR.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to maintain an accurate medical record for 2 residents (#81 and #93) of 10 residents reviewed for medical records.

Inspectors wroteBased on Centers for Disease Control and Prevention (CDC) guidance, facility policy review, observation, and interview, the facility failed to ensure a staff member performed self-testing for COVID-19 according to current guidance to prevent spread of COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) for 1 of 1 self-testing observations, which had the potential to result in transmission of COVID-19.

Inspectors wroteBased on facility policy review, observation, and interview, the facility failed to post daily staffing for 3 days of 6 days reviewed.

Inspectors wroteBased on facility policy review, observation, and interview the facility failed to ensure expired food items and expired nutritional supplements were not available for resident use in 2 of 2 nourishment refrigerators observed.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to implement dietary recommendations to monitor weight loss for 1 resident (#59) of 2 residents reviewed for weight loss of 24 sampled residents.

Inspectors wroteBased on facility policy review, medical record review, observation, and interview, the facility failed to perform hand hygiene to prevent the potential spread of infection during wound care for 1 resident (#15) of 3 residents reviewed for hand hygiene/infection control practices of 18 sampled residents.