Oak Ridge Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from abuse, when Resident 2 grabbed and scratched Resident 1's left hand. This failure had the potential to negatively impact Resident 1's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to deliver care within professional standards of practice when spironolactone (a medication used to manage high blood pressure and heart failure) was administered to Resident 45 despite low blood pressure readings, and the order was not clarified. This failure increased the risk for disease complications and adverse effects associated with hypotension (low blood pressure).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical procedures were in place to meet the needs of a resident and to ensure accurate accounting of controlled substance medications (medications under tight government control due to high addiction and abuse potential) when:The facility did not have a procedure to ensure Resident 26's weekly clonidine patch (a medication patch used to help manage high blood pressure) was in place for continued delivery of the medication. Controlled Drug Record (CDR) sheets (an inventory log used to track the receipt, administration, and remaining inventory of controlled substances) did not reconcile for 2 out of 4 sampled records (Resident 45 and Resident 57). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 45) was free from unnecessary medication. The resident received insulin lispro without monitoring for potential side effects and doses were held without clinical indication. These failures had the potential to result in uncontrolled blood sugars and complications related to hypoglycemia and hyperglycemia.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its medication error rate was below 5 %. The facility had a medication error rate of 13.89% when 5 medication errors occurred out of 36 opportunities observed during the medication administration for 2 out of 5 sampled residents (Residents 81 and 62). Resident 81 received a lower-than-prescribed dose of cholecalciferol (Vitamin D3 supplement), placing the resident at risk for vitamin deficiency and weakened bones. Resident 81 also received a higher than prescribed dose of magnesium (electrolyte supplement), creating the potential for diarrhea, nausea, or stomach cramps. Nursing staff crushed Resident 62's delayed release aspirin, a medication designed to bypass the stomach, creating the potential for stomach upset, nausea, and vomiting. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 10 sampled residents (Resident 45) was free from a significant medication error when Resident 45's insulin lispro (a short acting insulin used to treat diabetes) was not administered according to physician orders, manufacturer guidelines, and the facility's policies. The facility's failure to administer Resident 45's insulin at the correct time increased the potential for severe low blood sugar (hypoglycemia) and other medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and maintained according to manufacturer guidelines and facility policies and procedures when:Medications requiring temperature control were not stored at the proper temperature. The medication refrigerator was observed to be out of range for over five hours without follow up. The refrigerator stored medications for a census of 62 residents. An expired bottle of latanoprost (a medication used to reduce and control eye pressure in glaucoma) labeled for Resident 66, and an opened, undated multidose container of glucose test strips, were observed in the Station 3 medication cart (one out of two medication carts sampled). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper infection control practices were implemented when:1. Clean gauze was not used to dry the wound after cleansing for Resident 76.2. Glucometer not sanitized properly between residents, and;3. Insulin pen hub not sanitized before the needle was attached. These failures had the potential to compromise resident's health and safety and potentially lead to infection and the spread of communicable diseases.

Inspectors wroteBased on observation, interview and record review, the facility failed to respect one out of eighteen sampled residents (Resident 26) right to privacy, and respect for personal property when staff searched and took Resident 26's belongings without consent. This deficient practice resulted in psychosocial distress for Resident 26 who was observed visibly upset, expressing anger, pacing in his room and verbalizing that the staff opened and took something from his belongings while he was not in his room and without his permission.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure smoking safety interventions per care plan were implemented and adequate supervision was provided to prevent smoking related accidents for one out of 18 sampled residents (Resident 26). This failure to implement smoking safety intervention per care plan despite the facility's non-smoking status, had the potential to place Resident 26 at risk for foreseeable smoking-related accidents and injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of two residents observed for wound treatment (Resident 53) received necessary treatment and services to promote healing and prevent infection when the wound dressing was not changed as needed. This failure had the potential to delay wound healing and increase the risk of wound infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a substitute meal was offered when food intake was 50% or less for one of eighteen sampled Residents (Resident 53). This failure had the potential to cause weight loss, malnutrition, poor wound healing and a decline in overall health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the needs of one of four sampled residents (Resident 1) were accommodated when the call light was not within reach. This failure had the potential for Resident 1 to experience delayed assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices for one of four sampled residents (Resident 1) when Enhanced Barrier Precautions (EBP, involves use of gown and gloves during high contact resident care designed to reduce transmission of Multi Drug Resistant Organisms [MDRO, bacteria resistant antibiotics]) were not in place or used during care. This failure increased the risk of higher infection rates, outbreaks, and potential resident harm in the 67-certified bed facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the full-time Director of Food and Nutrition Services (Dietary Manager-DM) met the state's education qualification requirements, as required per federal regulation, to be in the DM to carry out the functions of the food and nutrition while the Registered Dietitian (RD) was on site as part-time consulting basis. As a result, there were lapses in the delivery of food and nutrition services associated with meal distribution accuracy (cross refer to F803), and safe food handling and sanitation (cross refer to F812), which lacked the benefit of a qualified Food and Nutrition Services Director (DM) responsible for the day-to-day food service operation for the skilled nursing facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility to prepare, store, serve, and distribute food in accordance with professional standards of food service safety when: 1. The ice machine was not clean; 2. Several various kitchenware in the clean and ready-to-use storage areas: a. Were stacked and stored wet b. Had brown sticky liquid; 3. Found two boxes of slice turkey deli meat required frozen upon receiving from delivery that stored in the walk-in refrigerator; 4. The clean dishes splashed with water during handwashing procedure caused cross contamination since the handwashing sink was adjacent to the clean side of the dishwashing machine; 5. [NAME] (CK) 1 was not practiced sanitary manner during puree making when: a. She washed her hands at the prep sink (sink food preparation, such as washing vegetable) b. She did not perform proper handwashing in between tasks, and 6. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to adequately maintain pharmacy services for a census of 60 residents when emergency medications (E-kit-a box with the supply of medications that may be used for residents when the pharmacy is not available) were removed and not replaced in timely manner. This failure had the potential to make emergency medications unavailable to residents when needed, for not meeting resident's therapeutic or cause a worsening medical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during the lunch meals on 2/25/25 and 2/26/25 when: A. During a dining observation on 2/25/25: 1. Two residents (Resident 46 and 56) with CCHO (Consistent Carbohydrate) diet (a therapeutic diet to manage diabetic disease and/or to stabilize blood sugar level) received one slice of garlic bread instead of half (1/2) slice. B. During a meal service distribution on 2/26/25: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when: 1. Four meal trays with dessert not covered were transported from the dining room. 2. A shared glucometer was not cleaned and sanitized in between resident use. 3. Resident 170's foley catheter (thin, flexible tube inserted into the bladder to drain urine) collection bag was observed on the floor. These failures had the potential to compromise resident's health and safety, and potentially lead to the spread of communicable illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 1) was treated with dignity and respect when Licensed Nurse 3 (LN 3) was disrespectful to Resident 1 during blood draw. This failure reduced the facility's potential to treat Resident 1 with respect.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the policy and procedure of medication self-administration for two (Resident 29 and Resident 43) of 18 sampled residents when: - There were no assessments for safe medication self-administration and storage of medication at the bedside for Resident 29 and Resident 43. - The facility did not obtain physician's orders for medication self-administration and storage of medications at the bedside for Resident 29 and Resident 43. - The facility did not ensure safe labeling of medication stored at the bedside for Resident 29. - The facility did not ensure safe storage of beside medication for Resident 29. - The facility did not ensure that self-administration of medication at the bedside is documented accurately. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one of 18 sampled residents (Resident 35), when nursing staff did not accurately document medications administered to Resident 35 on the medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). This failure had the potential for Resident 35 to receive more medications than ordered and experience side effects including kidney injury and respiratory depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 18 sampled residents (Resident 39 and Resident 33) were offered activities that meet their interests and preferences when Resident 39 and Resident 33 were not offered activities according to care plan and assessment. This failure had the potential to affect the residents' physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, record reviews, interviews, and facility document review, the facility failed to ensure that pureed meat was prepared in a manner that preserved nutritional value. This had the potential to affect 5 (Residents #20, #30, #32, #35, and #45) of 5 residents who had physician's orders for pureed diets.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) reflected accurate mental health diagnoses for 1 (Resident #35) of 1 sampled resident reviewed for PASRR requirements.

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review, the facility failed to ensure that a single bottle of ophthalmic solution (eye drops) was not labeled for use by two separate residents. This deficient practice was observed during 1 of 25 medication pass opportunities and had the potential to affect 2 (Resident #8 and Resident #15) of 2 residents reviewed with orders for ophthalmic solutions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three sampled residents (Resident 3), who required assistance with activities of daily living (ADL), was provided the scheduled twice weekly showers/baths. This failure had the potential for Resident 3 to experience a feeling of neglect and negatively impact his psychosocial well-being.