Oak Ridge Care Center

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 3 of 3 residents (R1, R2, and R3) reviewed for pressure injuries. R1 admitted to the facility without any pressure injuries and was assessed as being at risk for pressure injuries. R1 developed a blister on the left buttock 10 days after admission that was not assessed by a Registered Nurse and the facility failed to revise R1's skin impairment care plan or pressure injury care plan after the area declined. Aggressive interventions including repositioning were not implemented even after R1 refused an air mattress. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the environment remained free of accident hazards and residents received adequate supervision to prevent accidents for 3 (R34, R29, and R50) of 5 residents reviewed for accidents. *R34 was given a handled cup of hot chocolate with the handle placed towards the right hand. R34 had limited movement of the right hand and, while transferring the cup from the right hand to the left hand, the scalding liquid spilled onto R34's left side/hip/buttock area causing a third degree burn that measured 34 cm x 30 cm. The facility staff did not place the cup in a safe manner for R34 to manage the cup independently and the water was at a temperature hot enough to cause a third degree burn. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 1 of 8 sampled residents. On [DATE], R4 reported being depressed and having thoughts that he would be better off dead or of hurting himself almost daily. The facility did not provide R4 with support or services to address these concerns. Approximately 8 hours later, R4 was found pulseless and non-breathing with a plastic bag over his head and the oxygen tubing wrapped around his neck. The facility's failure to provide support and monitoring to R4 after making statements that he was depressed and had thoughts that he would be better off dead nearly every day created a finding of immediate jeopardy that began on [DATE]. [...]

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to ensure that 1 of 3 sampled residents reviewed for Coumadin usage (R2) received ongoing laboratory testing to monitor the therapeutic dose the resident received. R2 was admitted to the facility with an order for Coumadin (an anticoagulation medication). Use of this medication requires frequent laboratory testing to ensure a person is receiving the correct dose to remain in therapeutic range. The last test that was completed was on [DATE]. R2 began to develop multiple bruises, which can be a sign of over anticoagulation (too much Coumadin). Neither nursing nor pharmacy identified there were no orders for labs and that R2 was not being monitored. On [DATE], R2 developed hematuria (blood in urine) and labs were ordered. [...]

Inspectors wroteBased 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

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility did not ensure 3 (R34, R40 and R46) of 3 sampled residents reviewed for a facility initiated discharge received a written transfer/discharge notice that included the date of transfer, reason for transfer, location of transfer, appeal rights and contact information of the State Long-Term Care Ombudsman. R34 was transferred to the hospital on 9/15/23. R34 and their representative was not given a transfer notice. R40 was transferred to the hospital on [DATE] and 12/25/23. R40 and their representative was not given a transfer notice. R46 was transferred to the hospital on [DATE]. R46 and their representative was not given a transfer notice.

Inspectors wroteBased on interview and record review the facility did not ensure 3 (R34, R40 and R46) of 3 residents received a written notice of the facility's bed hold policy and procedure when they were transferred to the hospital. -R34 was transferred to the hospital on 9/15/23. R34 and their representative was not given a bed hold notice. -R40 was transferred to the hospital on [DATE] and 12/25/23. R40 and their representative was not given a bed hold notice. -R46 was transferred to the hospital on [DATE]. R46 and their representative was not given a bed hold notice.

Inspectors wroteBased 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.

Inspectors wroteBased 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.