Oak Ridge Rehabilitation & Healthcare Center

Inspectors wroteBased on a review of clinical records, facility documentation, facility policy, and staff interviews, it was determined the facility failed to ensure one of 10 sampled residents (Resident 1) remained free from physical abuse when an employee used force while providing incontinence care.

Inspectors wroteBased on clinical record review, facility policy review, observations, and staff interviews, it was determined the facility failed to ensure residents received necessary treatment and services consistent with professional standards of practice to promote healing of existing pressure injuries for two of 10 residents reviewed (Residents 1 and 2).

Inspectors wroteBased on observation, clinical record review, and staff interviews, it was determined the facility failed to consistently implement person-centered care plan interventions related to fall prevention for three of six residents reviewed for falls (Residents 5, 7, and 9).

Inspectors wroteBased on review of clinical records, select facility policies, and staff interviews, it was determined the facility failed to ensure a resident was afforded the right to participate in the planning of care and treatment, including the facility's failure to conduct a required quarterly care plan conference, for one of 10 residents reviewed (Resident 4).

Inspectors wroteBased on a review of clinical records, the facility's abuse prohibition policy, facility investigative documentation, and staff interviews, it was determined the facility failed to ensure a resident was free from neglect by failing to provide care and services in accordance with the resident's plan of care. Specifically, staff failed to utilize the required sliding board with assistance of one staff member during a transfer from wheelchair to bed, as planned to ensure safety and prevent injury. As a result of this failure, one resident (Resident CR147) sustained an acute distal femur fracture that progressed to an above-the-knee amputation, representing actual harm to one resident out of 3 discharged residents sampled. This deficiency is cited as past noncompliance.

Inspectors wroteBased on observation, review of clinical records, review of hospital records, and resident and staff interview, it was determined that the facility failed to provide care and services consistent with professional standards of practice by failing to follow physician-ordered bowel protocol for one of 26 residents (Resident 75) reviewed, which resulted in hospitalization and actual harm. Additionally, the facility failed to follow professional standards of practice related to medication administration management for one of three closed residents (Resident CR3) sampled.

Inspectors wroteBased on review of clinical records, the Resident Assessment Instrument (RAI), Minimum Data Set (MDS) assessments, and staff interviews, it was determined the facility failed to ensure the MDS accurately reflected the clinical status and services provided for two of 26 sampled residents (Residents 12 and 8).

Inspectors wroteBased on review of facility policies, clinical record review, and staff interview, it was determined the facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and individualized interventions to address a resident's diagnosed medical condition for one of 30 residents reviewed (Resident 13).

Inspectors wroteBased on review of select facility policy and interviews with residents and staff, it was determined the facility failed to review and revise a resident's plan of care in response to a significant weight loss for one resident out 26 residents reviewed (Resident 8).

Inspectors wroteBased on review of clinical records, select facility policies, observations, and staff interviews, it was determined the facility failed to consistently monitor residents' nutritional and hydration status to timely identify declines, failed to implement and document effective non-invasive interventions, and implemented invasive measures (intravenous therapy) without documented evidence that less invasive approaches were attempted or optimized for two of 26 residents reviewed (Resident 58 and Resident 12).

Inspectors wroteBased on clinical record review, review of facility policies and procedures, observation, and staff interview, it was determined the facility failed to ensure intravenous therapy was provided and monitored in accordance with physician orders and professional standards of practice failed to obtain physician orders for monitoring of the PICC line and failed to ensure physician-ordered intravenous antibiotic therapy was administered as prescribed for one of 3 residents reviewed (Resident 5) who required care and monitoring of a Peripherally Inserted Central Catheter (PICC) line (a long, flexible tube inserted into a vein in the arm and advanced to a large vein near the heart to allow administration of intravenous medications and fluids).

Inspectors wroteBased on review of facility policies, clinical records, observations, and staff interviews, it was determined the facility failed to ensure the ready availability of necessary emergency dialysis supplies for two of two residents reviewed who received hemodialysis (Residents 72 and 83), and failed to develop and implement an individualized, person-centered care plan for one of two residents receiving hemodialysis (Resident 83).

Inspectors wroteBased on review of the Centers for Disease Control and Prevention (CDC) guidance, facility policy, clinical records, observations, and staff interviews, it was determined the facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the potential spread of infection for one of five residents reviewed (Resident 83) who had an indwelling medical device.

Inspectors wroteBased on clinical record review, review of facility policy, investigative documentation, and staff interviews, it was determined the facility failed to thoroughly investigate an incident involving a resident being left unattended while at an outside medical appointment to determine whether neglect occurred for one of 22 sampled residents (Resident 1).

Inspectors wroteBased on clinical record review, interview, and policy review, it was determined the facility failed to provide residents and/or their representatives with the required written notice of Medicare coverage termination, including an explanation of the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) and the right to appeal, prior to the end of Medicare Part A services for two of three sampled residents reviewed for Medicare coverage notices (Resident 1 and Resident 2). Findings Include: A review of Resident 1's clinical record revealed admission to the facility on May 14, 2025, with diagnoses to include Parkinsons disease (a progressive, neurological disease), muscle weakness and diabetes. Review of the resident's Medicare coverage documentation revealed the last day of covered Medicare Part A services was June 5, 2025. [...]

Inspectors wroteBased on review of clinical records and select facility investigative reports and staff interview it was determined the facility failed to fully develop and implement person-centered comprehensive care plans to meet the individualized toileting and safety needs of two residents (Residents 18 and 11) out of 27 sampled.

Inspectors wroteBased on a review of the facility's abuse prohibition policy, employee personnel files and staff interviews, it was determined the facility failed to fully develop and implement its established abuse prohibition procedures by not adequately screening two of five employees for employment (Employee 2 and 3).

Inspectors wroteBased on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interviews, it was determined the facility failed to conduct a significant change Minimum Data Set Assessments (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for one of 27 residents reviewed (Resident 76).

Inspectors wroteBased on observation, a review of select facility policy, review of clinical records and staff and resident interviews it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses follow physician's orders and ensure accurate medication administration as prescribed for one resident (Resident 31) out of one sampled.

Inspectors wroteBased on clinical record and select facility policy review and staff interview, it was determined the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed (PRN) basis for one resident out of twenty-seven sampled (Resident 52).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of 27 residents (Resident 115).

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure that non-pharmacological interventions were attempted by staff prior to administering a PRN antianxiety medication, for Resident 129.

Inspectors wroteBased on observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper labeling and storage of medications and failed to prevent significant medication errors for one resident (Resident 31) out of 27 residents sampled. Specifically, a registered nurse administered a medication that was both expired and not prescribed, resulting in a significant medication error.

Inspectors wroteBased on a review of select facility policy, observation, and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness, in the dietary department and the second floor and Memory Care Unit resident food storage areas.

Inspectors wroteBased on review of facility documents and staff interviews, it was determined that the facility failed to ensure that the Medical Director or designee was in attendance at monthly Quality Assurance Process Improvement (QAPI) Committee meetings for four of four months (January 2024 through April 2024)

Inspectors wroteBased on observation, facility pest service records and resident and staff interview, it was determined that the facility failed to maintain an effective pest control program.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to provide housekeeping services to maintain a clean environment on one of three resident units (third floor dementia unit).

Inspectors wroteBased on a review of clinical records and grievances filed with the facility and resident and staff interviews, it was determined that the facility failed to demonstrate timely and adequate efforts to resolve resident grievances including those voiced by two out of 23 residents sampled (Residents 76 and 90).

Inspectors wroteBased on a review of clinical records, select facility policy and investigative reports and staff interviews it was determined that the facility failed to assess and implement individualized measures planned to meet the toileting needs of one resident out of three residents sampled with a decline in continence (Resident 27).

Inspectors wroteBased on review of clinical records and resident and staff interview it was determined that the facility failed to ensure each resident was provided with the necessary behavioral health care and services to meet the needs of two residents out of 23 sampled (Residents 90 and 28) to maintain the residents' highest practicable physical, mental, and psychosocial well-being).

Inspectors wroteBased on a review of clinical records and select incident reports, observations, and staff interviews, it was determined that the facility failed to ensure that staff possessed the necessary skills and competencies to implement person-centered dementia care approaches planned to decrease the potential for further escalation of dementia-related behaviors for one resident out of six residents sampled with dementia (Resident A1).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to attempt a gradual dose reduction of psychoactive medications for two residents out of 23 sampled (Resident 52 and 77).

Inspectors wroteBased on a review of select facility policy and manufacturer's directions for use, observations, and staff interview, it was determined that the facility failed to ensure adherence to pharmacy supplies expiration/use by dates on two of three resident units (First and Second Floor).

Inspectors wroteBased on observation, review of facility scheduled meal times and select facility policy, and resident and staff interviews the facility failed to ensure the provision of a nourishing (satisfying to the resident) evening snack when greater than 14 hours elapsed from the supper meal to breakfast the next day for residents including four residents of 23 sampled (Residents 72, 5, 64, and 41).

Inspectors wroteBased on staff interviews and a review of documentation provided by the facility, it was determined that the facility failed to timely review and update its facility wide assessment in order to identify the specific personnel and resources presently available and/or required, which are necessary to care for its current resident population.

Inspectors wroteBased on a review of clinical records and select facility policy, observation and staff and resident interviews it was determined that the facility failed to provide care in a manner that maintains the personal dignity, privacy and quality of life of two residents out of 23 sampled (Resident 49 and 90).

Inspectors wroteBased on review of clinical records, select facility policy and investigative reports resident and staff interview, it was determined that the facility failed to ensure that one resident was free from physical abuse out of 23 sampled residents (Resident 85). Findings including A review of the current facility policy titled Abuse Policy, last reviewed by the facility November 27, 2023, revealed that residents have the right to be free from abuse. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The facility's goal is to achieve and maintain an abuse-free environment. [...]

Inspectors wroteBased on a review of the facility's abuse prevention policy and clinical records and staff interview, it was determined that the facility failed to implement their established abuse prohibition policy and procedures for responding to incidents of resident abuse for one resident out of 23 sampled (Resident 85).

Inspectors wroteBased on a review of clinical records, select facility incident reports, and the facility's abuse prohibition policy and staff interview it was determined that the facility failed to thoroughly investigate potential neglect of five residents out of 23 sampled (Residents 99, 43, 17, 46, and 97).

Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility failed to identify a resident's need for monitoring of the resident's respiratory status and oxygen use on the resident's comprehensive care plan for one resident out of 23 sampled (Resident 102).

Inspectors wroteBased on observation, clinical record review and staff interview it was determined that the facility failed to consistently administer oxygen (O2) as ordered for one out of 23 sampled residents (Resident 7).

Inspectors wroteBased on review of clinical records and select facility policy, observations, and staff interviews it was determined that the facility failed to provide person-centered care and coordination of individualized resident services for one of one residents sampled receiving hemodialysis (Resident 51).

Inspectors wroteBased on review of clinical records, observation and staff interviews it was determined that the facility failed to maintain and accurate and complete clinical records for two out of 23 residents reviewed.

Inspectors wroteBased on observation and staff interviews it was determined that the facility failed to ensure call bells were accessible to one of 23 residents sampled (Resident 52).

Inspectors wroteBased on observation, review of select facility policy and clinical records, and staff interview, it was determined that the facility failed to implement established procedures to assure safe smoking ability for one resident out of one resident identified as a current smoker (Resident 34).

Inspectors wroteBased on a review of clinical records, guidance issued by the Centers for Medicare and Medicaid Services and facility documentation, and staff interview, it was determined that the facility failed to develop and implement policies and procedures designed to protect residents from unacceptable practices of disenrolling residents from their Medicare health plans by ensuring all risks of disenrolling are explained, both verbally and in writing, and the residents are found to be competent to make informed decisions for four of four reviewed disenrolled from Medicare health plans (Resident 11, 16.17, 21).

Inspectors wroteBased on a review of clinical records and select reports, observations, and staff interview, it was determined that the facility failed to develop and implement individualized plans to manage residents' dementia related behavioral symptoms to promote resident safety and the residents' highest practicable physical and mental well-being for two residents (Resident 14 and 19) out of 21 sampled.

Inspectors wroteBased on review of the facility's plan of correction from the survey of January 25, 2024, and the findings of the survey ending February 27, 2024, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies related to abuse and dementia care and to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies.

Inspectors wroteBased on a review of facility's abuse policy, clinical records, and select reports and staff interviews it was determined that the facility failed to assure that one resident (Resident 18) out of four sampled was free from sexual abuse perpetrated by another resident (Resident 19).

Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to ensure that one resident out of 21 sampled was free of chemical restraints used to most readily control the resident's behavior and not required to treat the resident's medical symptoms (Resident 19).

Inspectors wroteBased on a review of clinical records, information submitted by the facility, and select incident reports and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms displayed by one resident (Resident CR1) which, resulted in one resident (Resident 4) out of 6 residents sampled sustaining a serious injury, a fractured hip, caused by Resident CR1's dementia-related behavioral symptoms.

Inspectors wroteBased on observations, a review of clinical records, facility investigations, and staff interview, it was determined that the facility failed to provide sufficient staff, providing direct services to residents, who possess the necessary competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by five residents out of six sampled (Residents 1, 2, 3, 4 and CR1).

Inspectors wroteBased on observations, resident and staff interview, a review of grievances lodged with the facility, and test tray results, it was determined that the facility failed to provide meals that are served at safe and palatable temperatures for a test tray completed during the lunch meal for in-room tray service.

Inspectors wroteBased on observation, a review of facility pest service records and staff interview, it was determined that the facility failed to maintain an effective pest control program.

Inspectors wroteBased on review of select facility policy, clinical records, and investigative reports, and staff interview, it was determined that the facility failed to ensure that two residents (Resident 1 and 2) out of six sampled were free from physical abuse perpetrated by other residents, Residents 2 and 3).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness on one of three resident pantries areas (3rd Resident Pantry/ Kitchenette).

Inspectors wroteBased on a review of clinical records, select investigative reports and information submitted by the facility and staff interview, it was determined that the facility failed to timely implement effective safety interventions including necessary staff supervision of resident with known unsafe behaviors that increased the resident's risk for falls to prevent a fall with serious injuries, a fractured hip and tail bone, for one resident out of six sampled (Resident 365).

Inspectors wroteBased on a review of grievances lodged with the facility and the minutes from Residents' Council meetings and resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance as reported by seven alert and oriented residents out of 15 interviewed (Residents 7, 27, 38, 47, 72, 98, and 14).

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the food and nutrition services department and two of three resident pantries.

Inspectors wroteBased on review of clinical records, select facility policy and incident reports and staff interview it was determined that the facility failed to provide necessary supervision and assistance with activities of daily living for a resident with known unsafe behaviors and poor safety awareness to prevent repeated falls and serious injury, a fractured hip, for one resident out of eight sampled residents (Resident 4).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility failed to provide and/or obtain radiology/diagnostic services to meet the needs of one of eight residents' clinical record reviewed (Resident 2).