Oak Ridge Manor

Inspectors wroteBased on interviews and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 6 of 6 kitchen staff (DC -E, DC-F, DS-G, DS-H, DS-I, and DC-J) reviewed for qualified dietary staff. The facility failed to ensure that DC-E, DC-F, DS-G, DS-H, DS-I, and DC-J met the requirements for food handling by obtaining a current and valid Food Handler's Certificate. This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 (CNA-A, CNA-B and CNA-C) staff observed during incontinent care for 2 (Res #4 and Res. #5) of 2 residents. The facility failed to ensure CNA-A, CNA-B, and CNA C performed proper peri-care (incontinent care) and proper hand hygiene during peri-care for Resident #4 and Resident # 5. These failures placed residents of the facility at risk of infections from improper incontinent care and hand hygiene while performing incontinent care.

Inspectors wroteBased on observation, interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 16 residents (Residents #5) reviewed for care plans. The facility failed to ensure Resident #5 had a care plan in place for an indwelling urinary catheter and a fractured left radius (the bone on the thumb side of the forearm) in a cast and sling. This failure could place residents at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #34, Resident #50) of 5 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop care plans based on assessed needs for diagnosis of Type II Diabetes Mellitus, and Interventions for Suprapubic catheter not followed. 2. The facility failed to develop care plan based on assessed needs for weight loss and Knee immobilizer. These failures could affect the residents by placing them at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 of 3 residents (Residents #50, #258, and #8) reviewed for indwelling urinary catheter. 1. The facility failed to ensure Resident #50's and Resident #258's catheter bag was off the floor and protect from potential contaminants on the floor. 2. The facility failed to ensure Resident #50, Resident #258, and Resident #8 had a related diagnoses for urinary catheter in the physician orders This deficient practice could place residents with indwelling urinary catheters at-risk for urinary tract infections and/or pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 3 (Resident #259, Resident #8, and Resident #32) of 3 residents reviewed for respiratory care. 1. The facility failed to obtain a Physician's order for Resident #259's continuous supplemental oxygen. 2. The facility failed to ensure Residents #8's nasal cannula and Resident #259's nebulizer was kept in a bag while not in use. 3. The facility failed to ensure Resident #8's and Resident #32's humidifier bottles (bottled water) were changed out weekly per physician orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods. These failures could place residents at risk for food borne illness and cross-contamination.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement written policies and procedures that protected residents from abuse, neglect, exploitation of residents, and misappropriation of resident property for 3 of 15 employees (ADM, LVN A, and LVN B) reviewed for EMR/NAR's. The facility failed to conduct an EMR/NAR check ADM for 18 months from hire date of 02/14/22 to 08/12/23. The facility failed to conduct an EMR/NAR check on LVN B annually since her hire date of 07/26/22. The facility failed to conduct an EMR/NAR check on LVN C annually since her hire date of 01/09/18. These failures placed residents at risk of abuse, neglect, exploitation and misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents for 6 (08/09/23, 08/10/23, 08/11/23, 08/12/23, 08/13/23, and 08/15/23) of 16 days reviewed for DON coverage. The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 08/09/23, 08/10/23, 08/11/23, 08/12/23, 08/13/23, and 08/15/23. This failure leaves residents without the nursing administrative oversight that only the DON can provide.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents are free of any significant medication errors, for 4 of 8 Residents (Resident #31, Resident #18, Resident #276, and Resident #29) reviewed for medication administration. 1. The facility failed to administer 7 doses of Creon (medication used to help digest food for people with pancreas issues and gastric issues) to Resident #31 due to medication not being available, but MAR indicated 3 of those doses were administered when they were not. 2. The facility failed to administer 4 doses of Empagliflozin (medication used to lower blood glucose) to Resident #18 due to medication not being available and did not monitor blood glucose per physicians' orders. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and discarded when expired in accordance with currently accepted professional principles and the open date and expiration date when applicable for 1 of 3 medication carts (medication cart on 100 hall) reviewed for labeling and storage. The facility also failed to store all drugs and biologicals in locked compartments for 2 (medication cart 100 hall and medication cart 200 hall) of 3 medication carts reviewed for medication storage. The facility failed to discard expired insulin for Resident # 10 from 100 hall medication cart. The facility failed to properly label insulin with open date for Resident # 6 from 100 hall medication cart. The facility failed to properly label insulin with open date for Resident # 40 from 100 hall medication cart. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 (RN-A, LVN-B, and NA-G) staff observed during medication administration and incontinent care. 1. The facility failed to ensure RN-A sanitized the glucometer before or after use on a resident. 2. The facility failed to ensure RN-A did not sanitize the blood pressure cuff before or after use on a Resident #29. 3. The facility failed to ensure LVN-B did not sanitize blood pressure cuff or use hand hygiene during medication pass. 4. The facility failed to ensure NA-G did not perform proper peri-care (incontinent care) or proper hand hygiene for Resident #13. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents have the right to formulate an advance directive for 2 of 24 residents (Resident #07, Resident #276) reviewed for advanced directives. The facility failed to have an Advanced Directive, Out of Hospital Do Not Resuscitate (OOHDNR) consent form which includes a Representative and physician signature and License # in the electronic charting or admission paperwork for Resident #07 and Resident #276. This failure could affect residents by not having their preferences honored concerning advanced directives.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents the right to be free from misappropriation of property for 1 of 24 (Resident #15) reviewed for personal property. The facility failed to maintain a system to prevent Resident #15's personal money from being taken by a staff member. This failure placed residents at risk of loss of personal property and financial hardship.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 17 (Resident #14) reviewed for MDS information. The facility failed to encode, complete and submit a discharge MDS for Resident #14. This failure could place residents at risk of facilities have provided resident specific information for payment and quality measure purposes.