Inspection Reports for Complete Care at Oak Ridge LLC

A desk review was conducted for Complete Care At Oak Ridge on July 7, 2025, for the annual recertification/licensure survey concluding on June 2, 2025.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

An unannounced Annual and Complaint survey was conducted at Complete Care at Oakridge from 06/02/25 to 06/05/25 to assess compliance with regulatory requirements and investigate complaints.

The facility was found deficient in multiple areas including failure to coordinate PASRR assessments, inadequate menu posting, unsanitary dining environment, incomplete resident medical records, lack of hospice care collaboration, improper ice machine maintenance, disrespectful treatment of residents during activities, inaccessible grievance forms, failure to honor resident drink preferences, and unsafe storage of cleaning chemicals.

Multiple complaints were investigated during the survey period, all found unsubstantiated.

The inspection was conducted as a routine survey to assess compliance with fire safety, electrical system maintenance, emergency preparedness, and emergency plan testing requirements.

The facility was found deficient in maintaining the fire alarm system per NFPA 72, performing required weekly generator battery testing per NFPA 110, developing and maintaining a comprehensive emergency preparedness plan including community-based risk assessment, and conducting required annual emergency plan exercises. These deficiencies could potentially affect all residents, staff, and visitors.

An unannounced revisit was conducted at Complete Care At Oak Ridge on September 11, 2024 for the annual recertification/licensure survey concluding on July 25, 2024.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

The inspection was conducted to review facility documentation and staff interviews to determine compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

An unannounced Annual and Complaint survey was conducted at Complete Care at Oakridge from 07/22/24 to 07/25/24 to assess compliance with healthcare regulations and investigate complaints.

The facility was found deficient in multiple areas including failure to report abuse allegations timely, failure to ensure residents were treated with dignity, incomplete care plans, inaccurate PASARR assessments, incomplete nurse aide competencies, inaccurate nurse staffing postings, failure to notify physicians of significant weight changes, and infection control lapses.

Complaint #32827 was substantiated related to failure to report abuse allegations and other deficiencies. Other complaints (#33246, #33119, #32447, #30990) were unsubstantiated.

The inspection was conducted to assess compliance with various NFPA (National Fire Protection Association) standards related to fire safety, electrical systems, and corridor door safety in the facility.

The facility was found deficient in maintaining kitchen hood fire suppression system equipment placement, sprinkler head clearance from light fixtures, corridor doors that resist smoke passage, electrical wiring and equipment safety, and emergency generator testing and maintenance. These deficiencies could affect all residents, staff, and visitors.

An unannounced complaint investigation survey was conducted at Complete Care at Oak Ridge on 05/20/24.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaint #31421 was unsubstantiated with no related or unrelated deficiencies cited.

Complaint #31421 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced complaint investigation survey was conducted at Complete Care at Oakridge center on 09/13/23.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and/or 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaints #28952 and #28768 were unsubstantiated with no related or unrelated deficiencies cited.

Complaint #28952 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #28768 was unsubstantiated with no related or unrelated deficiencies cited.

The inspection was conducted to review facility documentation and staff interviews to determine compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with all applicable Federal, State, and local Emergency Preparedness requirements.

An unannounced annual recertification and annual relicensure survey was conducted at Complete Care at Oak Ridge from February 13-15, 2023.

The survey identified multiple deficiencies including failure to notify the State Ombudsman of a resident transfer, incomplete annual in-service training for nurse aides, lack of proper signage for residents on transmission-based precautions, and food safety violations including improper use of beard guards, unclean kitchen equipment, and lack of temperature monitoring for residents' personal refrigerators.

The visit was conducted as an annual recertification and annual relicensure survey for Complete Care at Oak Ridge LLC.

The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit.

The inspection was a routine survey to assess compliance with NFPA 101 fire safety codes and other regulatory requirements at Complete Care at Oak Ridge LLC.

The facility was found deficient in maintaining proper signage for delayed egress doors, ensuring corridor doors with closures were not propped open, and proper use of power strips and extension cords in office areas. These deficiencies could affect all residents, staff, and visitors.

An unannounced complaint investigation survey was conducted at Complete Care at Oak Ridge from September 12-13, 2022.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaint #27280 was unsubstantiated with no related or unrelated deficiencies cited.

Complaint #27280 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced complaint investigation and focused infection control survey was conducted at Community Care at Oak Ridge on 02/09/2022.

The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. Complaint 26327 was unsubstantiated with no related or unrelated deficiencies cited.

Complaint 26327 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced annual re-certification, annual re-licensure and complaint investigation survey was conducted at Oak Ridge Center from 2021-11-29 through 2021-12-01.

The facility was found deficient in several areas including failure to honor resident food preferences, incomplete Physician Orders for Scope of Treatment (POST) forms, failure to safeguard resident personal property, and improper food storage practices. The complaint investigation was unsubstantiated with no deficiencies cited.

Complaint #26185 was investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted as an annual recertification survey to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Nursing Home Licensure Rules.

The facility, Complete Care at Oak Ridge LLC, was found to be in substantial compliance with the applicable federal and state regulations. The review included plans of correction and credible evidence accepted in lieu of an onsite revisit.

The inspection was conducted as an annual survey to assess compliance with regulatory requirements including fire safety, emergency preparedness, and resident rights.

The facility was found deficient in maintaining the automatic sprinkler system according to NFPA 25 standards, storing items improperly in mechanical rooms violating NFPA 54 and 70, and failing to conduct required annual emergency plan drills. Plans of correction were submitted addressing these deficiencies.

The inspection was conducted as a complaint investigation survey related to complaint reference #24835, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Oak Ridge Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules. The previously cited deficient practices were corrected.

Complaint reference #24835; the facility was found in substantial compliance with previously cited deficiencies after review of plans of correction and credible evidence.

An unannounced complaint investigation survey was conducted at Oak Ridge from March 29-30, 2021, triggered by complaint #24835 which was substantiated.

The facility failed to ensure that residents receive treatment and care in accordance with professional standards, specifically regarding grooming and Activities of Daily Living for one resident who was sent to a medical appointment poorly dressed and unclean.

Complaint #24835 was substantiated with a deficiency cited at F684 related to Resident #1 being sent to a doctor's appointment poorly dressed and unclean, with family and staff interviews confirming the issue.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency from December 8, 2020 to December 9, 2020.

The facility was found in compliance with 42 CFR infection control regulations and CMS and CDC recommended practices to prepare for COVID-19.

The inspection was conducted as a complaint investigation survey concluding on 10/29/20, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Oak Ridge Center was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule. The facility was in substantial compliance with previously cited deficient practices.

Complaint reference: #24110. The complaint investigation survey concluded on 10/29/20 with substantial compliance found.

The facility was inspected as part of a routine FICS survey to assess compliance with regulatory requirements.

The report includes a deficiency related to the facility's obligation to inform residents of their rights and services in writing and orally. The deficiency is classified as Severity Level C.

An unannounced complaint investigation was conducted at Oak Ridge on 10/29/20. The allegations were unsubstantiated, but unrelated deficient practices were identified during the investigation.

The facility failed to accurately complete Resident #68's minimum data set (MDS) assessment in the area of falls. Specifically, the discharge MDS assessment incorrectly marked 'No' for falls occurring since admission, despite documentation of a fall on 09/12/20.

The complaint investigation was unannounced and conducted on 10/29/20. The original allegations were unsubstantiated, but unrelated deficient practices were identified during the investigation.

Routine facility entrance and exit survey conducted to assess compliance with regulatory requirements.

No deficiencies were identified during the inspection.

A COVID-19 Focused Infection Control Survey and Emergency Preparedness Survey was conducted by the state survey agency on July 6-7, 2020.

The facility was found in compliance with 42 CFR 483.80 infection control regulations, 42 CFR 483.73 related to E-0024 (b)(6), and the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

An unannounced complaint investigation was conducted at Oak Ridge Center on 02/17/20 to 02/18/20.

The allegations were unsubstantiated with no related or unrelated deficient practices identified. The facility was in substantial compliance with applicable regulations.

Complaint #23686 was unsubstantiated with no related or unrelated deficiencies cited.

An unannounced revisit was conducted at Oak Ridge Center on 01/13/20 to 01/14/20 for the annual recertification and relicensure survey concluding on 12/04/19.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

The inspection was conducted to assess the facility's compliance with the NFPA 101 Life Safety Code, 2012, and to verify compliance with Federal, State, and local Emergency Preparedness requirements.

The facility was found to be without waivers and in compliance with the provisions of the NFPA 101 Life Safety Code, 2012, and all applicable Federal, State, and local Emergency Preparedness requirements.

An unannounced annual re-certification and annual re-licensure survey was conducted at Oak Ridge Center from 12/02/19 through 12/04/19. The survey included complaint investigations #23436 (unsubstantiated) and #23347 (substantiated with related deficiency cited).

The facility was found deficient in multiple areas including resident self-determination, advance directives, privacy and confidentiality, comprehensive care planning, activities of daily living, quality of care including medication administration and aspiration risk, accident hazards and supervision, drug labeling and storage, dental services, infection prevention and control, and resident call system functionality.

Complaint #23436 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #23347 was substantiated with related deficiency cited.

The inspection was conducted as a complaint investigation survey concluding on 10/02/19, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The facility, Oak Ridge Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia nursing home licensure rules, with previously cited deficient practices corrected.

Complaint reference number #23116. The complaint investigation survey concluded with the facility in substantial compliance and no new deficiencies cited.

An unannounced complaint survey was conducted at Oak Ridge Center from 09/30/19 to 10/02/19 to investigate complaints #23230 and #23116.

Complaint #23230 was unsubstantiated with no deficiencies cited. Complaint #23116 was substantiated with one related deficiency regarding failure to ensure a safe, clean, comfortable, and homelike environment in three resident rooms due to debris and dried spills on floors.

Complaint #23230 was unsubstantiated with no related or unrelated deficiencies cited. Complaint #23116 was substantiated with one related deficiency cited.

The visit was conducted as an annual recertification and relicensure survey to assess compliance with long term care facility regulations.

The facility, Oak Ridge Center, was found to be in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

The document is a statement of deficiencies and plan of correction related to a facility survey, including compliance with emergency preparedness requirements.

The facility was found to be in compliance with all applicable Federal, State, and local Emergency Preparedness requirements. One deficiency related to notice of rights was cited.

The inspection was conducted as an annual survey to assess compliance with federal and state regulations related to fire safety, resident rights, and facility maintenance.

The facility was found to have deficiencies related to obstructed sprinkler heads and corridor doors that did not close and latch properly, potentially affecting all residents, staff, and visitors. The facility was compliant with emergency preparedness requirements.

An unannounced annual re-certification and annual re-licensure survey was conducted at Oak Ridge Center from 11/05/18 through 11/08/18.

The survey identified deficiencies related to reasonable accommodations for residents' needs, safe and homelike environment maintenance, nursing staff competency and performance evaluations, resident record completeness and confidentiality, and infection control including air flow issues in the laundry department.

An unannounced complaint investigation was conducted at Oak Ridge Center from April 17, 2018 to April 19, 2018 for Complaint Reference #19738.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified.

The document is a statement of deficiencies and plan of correction for Complete Care at Oak Ridge LLC, reviewing compliance with long term care facility regulations and licensure rules.

Oak Ridge Center is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. A review of plans of correction and credible evidence was accepted in lieu of an onsite revisit for the Quality Indicator and Licensure Surveys concluding on 11/03/2017.

Re-visit survey was conducted on 11/20/17 to recite tags #0353 and 0914 as they were not corrected in accordance with the Plan of Correction.

The facility failed to maintain the automatic sprinkler system in accordance with NFPA 25 due to communication wires and tie wires attached to sprinkler piping. Additionally, the facility failed to test electrical receptacles at patient bed locations in accordance with NFPA 99 standards. Corrective actions and re-education were implemented.

Re-visit survey was conducted on 11/20/17 to verify correction of previously cited deficiencies tagged #0353 and 0914 which were not corrected in accordance with the Plan of Correction.

The survey focused on reciting tags #0353 and 0914 as the facility had not corrected these deficiencies according to the Plan of Correction.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Oak Ridge Center from October 30, 2017 through November 2, 2017 to assess compliance with federal and state regulations.

The survey identified multiple deficiencies including failure to ensure dignified dining experiences, maintain a homelike and sanitary environment, complete accurate comprehensive assessments, implement care plans, maintain hearing devices, ensure sanitary food service, maintain infection control, and maintain complete and accurate medical records.

The inspection was conducted to assess compliance with various NFPA 101 fire safety standards including emergency lighting, sprinkler system maintenance, HVAC fire dampers, fire drills, and electrical systems maintenance.

The facility was found deficient in maintaining emergency lighting testing, sprinkler system piping clearance, fire damper inspections, fire drill scheduling, and electrical receptacle testing at patient bed locations. Plans of correction were submitted with re-education and ongoing monitoring procedures.

An unannounced complaint survey was conducted at Oak Ridge Center from 05/22/17 to 05/30/17 to investigate Complaint #17485, which was unsubstantiated but resulted in unrelated deficiencies being cited.

The facility was found to have deficiencies including failure to ensure residents could make choices about significant aspects of their life, incomplete neurological assessments after unwitnessed falls or head injuries for some residents, failure to schedule a nephrology consult for one resident, and incomplete medical records related to incontinence diaries.

Complaint #17485 was investigated and found unsubstantiated, but unrelated deficiencies were cited based on observations, record reviews, and interviews.

The document is a plan of correction submitted in response to a Quality Indicator and Licensure Survey for Complete Care at Oak Ridge LLC, addressing previously cited deficient practices.

The facility is in substantial compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules. The plan of correction and credible evidence were accepted in lieu of an onsite revisit, confirming substantial compliance with previously cited deficiencies.

An unannounced complaint survey was conducted at Oak Ridge Center from 03/06/17 to 03/09/17 based on complaints #17351 and #17383.

Complaint #17351 was substantiated with a related deficiency cited regarding failure to provide written notification of bed-hold policy at the time of hospital transfer for two residents. Complaint #17383 was unsubstantiated with no related deficiencies.

Complaint #17351 was substantiated with a related deficiency cited. Complaint #17383 was unsubstantiated without any related or unrelated deficiencies cited.

The inspection was conducted as a Quality Indicator and Licensure Survey to assess compliance with 42 CFR Part 483 and West Virginia nursing home licensure rules.

The facility, Oak Ridge Center, was found to be in substantial compliance with the applicable federal and state regulations based on review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Unannounced annual Quality Indicator Survey conducted at Oak Ridge Center from October 3, 2016 through October 6, 2016.

The facility had multiple deficiencies including failure to timely convey personal funds upon resident death, failure to encourage residents to create a homelike environment, failure to locate missing personal property, failure to protect residents from repeated inappropriate sexual behavior by a cognitively impaired resident, failure to report incidents of inappropriate sexual behavior to the State agency, failure to offer residents choices regarding shower times and bed/wake times, failure to provide nourishing bedtime snacks, failure to properly label opened multi-use vials of Purified Protein Derivative, and failure to maintain adequate ventilation in the common shower room.

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically regarding fire drills and the maintenance of automatic sprinkler systems.

The facility failed to ensure fire drills were held at unexpected times under varying conditions on each shift as required by NFPA 101, and failed to maintain automatic sprinkler systems in reliable operating condition due to wiring and ductwork laying across sprinkler piping.

An unannounced revisit was conducted at Oak Ridge Center from September 14 to September 15, 2016 for the Quality Indicator Survey concluding on May 18, 2016.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

An unannounced revisit was conducted at Oak Ridge Center from 08/01/16 to 08/04/16 for the Complaint Investigation Survey concluding on 05/08/16. The revisit was to verify correction of previous deficiencies and investigate complaints.

The facility was found to remain out of compliance with multiple deficiencies including failure to report and investigate allegations of abuse and neglect, inaccurate resident assessments, failure to provide care according to care plans, failure to provide timely pain management, failure to obtain ordered lab tests, and failure to coordinate care with dialysis center. The Quality Assurance Committee failed to ensure effective corrective actions. These deficiencies affected multiple residents and posed actual harm.

The facility received three complaints since 07/06/16. One complaint involved Resident #65 regarding missing arm sling, being left in urine, inattentive RN supervisor, and being left in same clothes for three days. These allegations were not reported to State agencies within 24 hours. The facility addressed the concerns but failed to investigate or report possible verbal and emotional abuse allegations documented by RN #84. Administrator and social workers confirmed the failure to report and investigate.

An unannounced complaint survey was conducted at Oak Ridge Center from July 06, 2016 to July 07, 2016 in response to Complaint #16045.

The complaint was unsubstantiated with no deficiencies cited during the investigation. The complaint sample consisted of 6 residents.

Complaint #16045 was unsubstantiated with no deficiencies cited.

An unannounced complaint survey was conducted based on complaint #15246, substantiated with related and unrelated deficiencies cited. The survey included observations, record reviews, and interviews.

The facility failed to provide appropriate diabetic management, including failure to notify physicians when insulin was held or blood sugars were out of range, resulting in immediate jeopardy. Additional deficiencies included failure to follow care plans for pain management, bowel continence, dialysis coordination, tracheostomy care, and medication administration. The facility also failed to maintain complete and accurate medical records and failed to ensure infection control measures during a scabies outbreak.

Complaint #15246 was substantiated with related and unrelated deficiencies cited, including failure to provide appropriate diabetic management and other care issues.

The document is a plan of correction related to a prior Minimum Data Set (MDS)/Staffing Survey concluding on 09/11/15, submitted in lieu of an onsite revisit.

The facility, Oak Ridge Center, is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and with previously cited deficient practices.

An unannounced minimum data set (MDS) focus survey was conducted at Oak Ridge Center from September 10, 2015 through September 11, 2015, based on observations, clinical record reviews, staff interviews, and other documentation.

The facility failed to provide necessary care to prevent pressure ulcers and infections, ensure appropriate incontinence care to prevent urinary tract infections, and demonstrate nurse aide competency in perineal care. Specific deficiencies were noted in wound care technique, hand hygiene, and incontinence management for Resident #1.

The investigation was complaint-related focusing on Resident #1's care, including pressure ulcer treatment, incontinence care, and prevention of urinary tract infections. The complaint was substantiated with findings of improper care and infection control practices.

An unannounced revisit was conducted at Oak Ridge Center on September 8 to September 9, 2015 for the Quality Indicator Survey concluding on June 26, 2015.

The facility was found to have corrected the previously cited deficient practices as reflected on the CMS-2567B.

The inspection was conducted to assess compliance with NFPA Life Safety Code standards, including fire alarm systems, sprinkler systems, cooking facility fire protection, emergency generator maintenance, and electrical wiring safety.

The facility was found deficient in multiple areas including failure to maintain fire alarm smoke detector coverage, sprinkler system maintenance and inspection, range hood extinguishing system inspections, emergency generator battery testing, and electrical wiring safety issues such as broken ground fault receptacle covers.

Unannounced annual Quality Indicator and Licensure Surveys were conducted at Oakridge Center from June 23, 2015 through June 26, 2015 to assess compliance with federal and state regulations.

The facility was found deficient in multiple areas including failure to provide timely notice of Medicare service termination, failure to notify physicians of lab refusals, failure to address resident council grievances about food temperatures, failure to implement care plans for positioning and behavior monitoring, failure to obtain ordered lab tests leading to delayed treatment, failure to manage pain effectively, failure to prevent pressure ulcers, failure to ensure psychotropic medications were used appropriately, and failure to maintain sanitary food handling practices.

The inspection was conducted as a complaint investigation, with a review of plans of correction and credible evidence accepted in lieu of an onsite revisit for the complaint investigation concluding on 2015-05-28.

The facility, Oak Ridge Center, was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and West Virginia Division of Health Nursing Home Licensure Rule, with previously cited deficient practices corrected.

Complaint Reference: 13369. The facility was in substantial compliance with previously cited deficient practices following the complaint investigation.

An unannounced complaint survey was conducted at Oak Ridge Center from May 26, 2015 through May 28, 2015, triggered by complaint #13369 which was substantiated with related and unrelated deficiencies cited.

The facility was found deficient in multiple areas including failure to maintain resident dignity during transfers and meal service, improper infection control practices including hand hygiene and use of personal protective equipment, failure to prevent urinary tract infections, failure to use assistive devices for safe transfers, failure to maintain nutritional status, and failure of the quality assessment and assurance committee to address ongoing infection control issues.

Complaint #13369 was substantiated with related and unrelated deficiencies cited. The complaint sample consisted of 8 residents.

An unannounced complaint investigation was conducted at Oak Ridge Center for Complaint Reference 12017.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with applicable regulations.

The complaint allegations were unsubstantiated.

An unannounced complaint investigation was conducted from September 2, 2014 to September 4, 2014 at Oak Ridge Center for Complaint References 11890 and 11914.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified. The facility was in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and 64 CSR 13 Legislative Rules West Virginia Division of Health Nursing Home Licensure Rule.

The allegations were unsubstantiated and no related or unrelated deficient practices were identified.

The inspection was conducted as part of the Quality Indicator and Licensure Surveys concluding on 02/14/14, with review of plans of correction and credible evidence accepted in lieu of an onsite revisit.

Oak Ridge Center is in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities and with previously cited deficient practices.

The inspection was conducted to assess compliance with NFPA 101 Life Safety Code standards, specifically focusing on the maintenance and inspection of the range hood extinguishing system and the proper storage of oxygen cylinders.

The facility failed to maintain and inspect the range hood extinguishing system as required by NFPA 96, with no inspections conducted in the previous six months. Additionally, the facility failed to store all oxygen cylinders in accordance with NFPA 99, with full oxygen bottles stored in compartments designated for empty bottles.

Unannounced annual Quality Indicator and State Licensure Surveys were conducted at Oak Ridge Center from February 10, 2014 through February 14, 2014.

The facility was found deficient in multiple areas including conveyance of personal funds upon death, reasonable accommodation of resident needs, housekeeping and maintenance, resident rights to make choices, care plan revisions, accident hazards related to water temperature and medication security, food sanitation, and clinical record accuracy. Water temperatures were frequently above safe levels and the Quality Assurance and Assessment Committee failed to address this issue.

Complaint investigation triggered by complaint reference 14002 / 9545, with an off-hours entrance on 01/23/14 at 3:00 a.m. and exit on 01/24/14.

The complaint was found to be unsubstantiated with no related or unrelated citations. Oak Ridge Center was found to be in compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

Unsubstantiated complaint record with no related or unrelated citations.

The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for a nursing facility.

The facility was cited for deficiencies related to informing residents of their rights, rules, services, and charges in accordance with regulatory requirements.

The inspection was conducted in response to a complaint alleging that Resident #50 was taken from the facility by an unauthorized person without permission, and that facility staff were dishonest about the resident's whereabouts.

The facility failed to acknowledge and investigate the complaint regarding Resident #50 leaving with an unauthorized person. The resident, who was court-appointed as a protected person, left the facility without proper supervision or notification to the legal guardian. The facility also failed to follow proper sign-out procedures and did not have adequate supervision to prevent the resident from leaving with an unauthorized individual.

The complaint was substantiated. Resident #50's legal decision maker reported that the resident was taken from the facility by an unauthorized person without permission, and that staff were dishonest about the resident's location. The facility did not record or investigate the complaint or take corrective action prior to the survey.

The inspection was conducted as a complaint investigation based on complaint references 7390 and 12241.

The complaint was unsubstantiated and no citations were issued as a result of the investigation.

Complaint Reference: 7390 / 12241. The complaint was unsubstantiated with no citations.

The document is a plan of correction submitted in response to citations from a facility inspection.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges in writing and orally in a language they understand. The facility must also provide written descriptions of legal rights and Medicaid-related information.

The inspection was conducted as a Quality Indicator and Licensure Survey from 06/11/12 to 06/14/12 to assess compliance with federal regulations for nursing facilities.

The facility was found deficient in multiple areas including failure to conduct comprehensive assessments related to urinary incontinence, failure to revise care plans according to medical changes, inadequate personal hygiene care, unsafe storage of hazardous chemicals, failure to act on pharmacist recommendations regarding medications, improper food storage and sanitation, failure to dispose of expired medications, improper infection control practices, and failure to maintain a safe and sanitary environment.

The inspection was conducted to evaluate compliance with the NFPA 101 Life Safety Code Standard, specifically regarding the construction and maintenance of smoke barrier walls to provide at least a one half hour fire resistance rating.

The facility failed to maintain smoke barrier walls with the required fire resistance rating due to unsealed openings around communication wires and cables in multiple locations, including the attic near room 101 and above drop ceilings near rooms 101 and 201. These deficiencies were confirmed through observation and staff interview.

The inspection was conducted in response to two complaint references (7078 and 7107) to investigate allegations at the facility.

Both complaints were found to be unsubstantiated with no citations issued during the inspection.

Complaint Reference 7078 and 7107 were investigated and found to be unsubstantiated with no citations.

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance of the facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, including Medicaid-related information.

The inspection was an onsite revisit conducted from 04/16/12 to 04/17/12 related to complaint reference IDs #12019, #12020, and #12028.

The facility failed to ensure accurate medical records for four of nine sampled residents, with missing documentation of physician-ordered treatments on treatment administration records for residents #34, #17, #40, and #48. Nursing staff did not consistently document treatments or reasons for missed treatments.

Complaint Reference ID: #12019, #12020, and #12028. The visit was a complaint-related onsite revisit.

The document is a plan of correction related to deficiencies identified during a facility inspection.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand.

The inspection was conducted in response to substantiated and unsubstantiated complaints regarding resident care and facility practices from 02/27/12 to 03/01/12.

The facility was found deficient in multiple areas including failure to maintain resident privacy, failure to investigate and report neglect allegations, failure to develop comprehensive care plans, failure to implement physician orders, environmental safety hazards, infection control deficiencies, inadequate staffing levels, and failure to obtain ordered laboratory services.

The investigation included substantiated complaints #12019 and #12020 with citations, and an unsubstantiated complaint #12028 with unrelated citations. The complaints involved neglect allegations, privacy violations, and infection control issues.

The inspection was conducted as a complaint investigation (Complaint Reference ID: 12005) from 01/16/12 to 01/17/12 regarding concerns about the facility's provision of care and pharmaceutical services.

The facility failed to provide necessary care and services to maintain the highest practicable physical well-being for one resident with multiple sclerosis by delaying administration of prescribed medication due to pharmacy supply issues. Additionally, the facility did not notify the attending physician of the medication delays as required.

Complaint Reference ID: 12005. The complaint was substantiated with related deficiencies found during the investigation.

Complaint investigation for complaint #11314 conducted from 12/27/11 to 12/28/11.

The complaint was unsubstantiated and no citations were issued.

Complaint #11314 was unsubstantiated with no citations issued.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of the facility.

The report identifies a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, including Medicaid-related information.

The inspection was conducted as a complaint investigation related to substantiated allegations of neglect reported by residents and their families.

The facility failed to immediately report all allegations of neglect to State officials as required by law, affecting two residents. The investigation revealed concerns about resident care, including inaccessible call lights, empty water pitchers, improperly connected oxygen, and unresolved pain management issues.

Complaint reference #11273 substantiated with deficiencies cited. The facility failed to report allegations of neglect involving two residents (#10 and #17) to State officials in a timely manner.

The document is a Plan of Correction related to deficiencies identified during a prior inspection of the facility Complete Care at Oak Ridge LLC.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted as a complaint investigation (reference #11204) which was unsubstantiated but resulted in unrelated deficiencies being cited.

The facility was found deficient in multiple areas including failure of direct care staff to wear identification badges, failure to provide appropriate care for a resident experiencing respiratory distress, and failure to follow physician orders to prevent falls by ensuring safety mats were in place and beds were in the lowest position for four residents.

Complaint reference #11204 was unsubstantiated but unrelated deficiencies were cited during the investigation.

Complaint investigation triggered by complaint reference #11123, substantiated with deficiencies cited related to resident care and facility compliance.

The facility was found deficient in multiple areas including failure to revise care plans after identifying resident constipation, failure to provide timely medication administration, failure to provide care according to residents' care plans (e.g., aspiration precautions), failure to maintain resident bowel protocols, and failure to prevent accident hazards related to gastrostomy tube care.

Complaint reference #11123 was substantiated with deficiencies cited related to resident care and facility compliance.

The inspection was conducted as a complaint investigation related to complaint reference #11019.

The complaint was substantiated; however, no deficiencies were cited during the investigation.

Complaint reference #11019 was substantiated with no deficiencies cited.

The inspection was conducted in response to complaint reference #10322.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #10322 was investigated and found to be unsubstantiated with no deficiencies cited.

Complaint investigation triggered by substantiated complaints #10194 and #10195 regarding resident-to-resident altercations and care concerns.

The facility failed to report resident-to-resident altercations resulting in injuries, did not provide care respecting residents' dignity regarding bathing preferences, failed to conduct comprehensive assessments and develop care plans for residents with aggressive behaviors, and failed to provide proper treatment and monitoring for a diabetic resident's infected toe wound. Additionally, nurse staffing data was incomplete and clinical records were not fully accurate or complete.

Complaint references #10194 and #10195 were substantiated with deficiencies cited related to resident-to-resident altercations and care issues.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of the facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

This document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for the facility Complete Care at Oak Ridge LLC.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, including Medicaid-related information.

The inspection was conducted in response to complaint references #10136 and #10146 which were substantiated with deficiencies cited, and complaint reference #10147 which was unsubstantiated with no related deficiencies.

The facility was found deficient in multiple areas including failure to monitor and assess signs of eye infection, failure to provide timely feeding assistance, inadequate pressure sore assessment and care, failure to provide proper respiratory care including oxygen administration, and failure to obtain ordered laboratory services.

Complaint references #10136 and #10146 were substantiated with deficiencies cited. Complaint reference #10147 was unsubstantiated with no related deficiencies cited.

The inspection was conducted as a complaint investigation based on complaint reference #10125, which was substantiated with deficiencies cited.

The facility was found deficient in multiple areas including failure to ensure the legal representative's rights to make medical decisions for a resident, inadequate supervision leading to resident accidents, failure to maintain an infection control program, and failure to provide proper notice of resident rights and services.

Complaint reference #10125 was substantiated with deficiencies cited related to resident rights, supervision, and infection control.

The inspection was conducted in response to complaint reference #10062.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #10062 was investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted concurrently with complaint investigations and the facility's annual Federal Medicare/Medicaid certification resurvey and State licensure inspection.

The facility was found deficient in multiple areas including failure to ensure health care decisions were made by the appointed representative, failure to resolve resident grievances, incorrect transfer/discharge notices, failure to conduct thorough abuse investigations and report to state agencies, failure to obtain required criminal background checks, incomplete comprehensive assessments and care plans, failure to revise care plans as needed, failure to provide care to maintain highest practicable well-being including failure to initiate CPR as ordered, failure to provide services to maintain or improve residents' ability to eat, failure to provide ordered treatment for pressure ulcers, failure to provide appropriate urinary incontinence treatment and assessment, and failure to properly label and discard insulin vials.

Complaint reference #9302 was substantiated with deficiencies cited. Complaint reference #9368 was unsubstantiated with unrelated deficiencies cited.

The inspection was a routine survey to assess compliance with life safety code standards and other regulatory requirements at the facility.

The facility failed to maintain corridor doors to close and latch without impediment, had obstructed exit access due to equipment and extension cords in egress paths, and used a relocatable power tap in a patient care area, violating NFPA 101 Life Safety Code and National Electrical Code standards.

The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for Complete Care at Oak Ridge LLC.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted as a complaint investigation, including substantiated and unsubstantiated complaints, to assess compliance with care standards.

The facility failed to ensure that residents receiving oxygen therapy were provided oxygen in accordance with physician's orders, as evidenced by multiple residents having empty portable oxygen tanks and not wearing nasal cannulas during the inspection.

Complaint reference #9087 was substantiated with deficiencies cited; complaint reference #9150 was unsubstantiated with no related deficiencies.

The document is a Statement of Deficiencies and Plan of Correction related to regulatory compliance for a healthcare facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted to evaluate compliance with NFPA 101 Life Safety Code standards, specifically the maintenance, testing, and inspection of the fire alarm system in the facility.

The facility failed to inspect and test all components of the fire alarm system in accordance with NFPA 72, specifically the exit doors equipped with magnetic locking devices were not inspected and tested as required.

The inspection was conducted concurrently with complaint investigations and the facility's annual Federal Medicare/Medicaid certification resurvey and State licensure inspection.

The facility was cited for multiple deficiencies including failure to thoroughly investigate a neglect allegation, inconsistent care by temporary agency staff, dignity and respect issues, inadequate activities, inaccurate assessments and care plans, improper delegation of nursing assessments, medication administration errors, failure to maintain highest practicable well-being, inadequate ADL care, improper pressure sore assessment and treatment, failure to prevent urinary tract infections, and failure to maintain proper nurse staffing postings.

Complaint references #2-8265, #2-8276, and #2-8277 were unsubstantiated with no related deficiencies cited. Complaint reference #2-8272 was substantiated with deficiencies cited.

The inspection was conducted in response to complaint reference #2-8194.

The complaint was unsubstantiated and no deficiencies were cited during the inspection.

Complaint reference #2-8194 was investigated and found to be unsubstantiated with no deficiencies cited.

The visit was a paper revisit to review compliance and corrective actions.

The document is a statement of deficiencies and plan of correction related to resident rights and notification requirements. Specific deficiencies are noted but detailed findings are not fully provided in this excerpt.

The inspection was conducted as a complaint investigation referenced as #2-8115, which was substantiated with deficiencies cited.

The facility failed to provide adequate supervision and assistance devices to prevent accidents, specifically failing to provide staff with proper lift and transfer information for nine sampled residents, resulting in an injury to one resident. Additionally, the facility failed to accurately document clinical records related to meal intake for residents on an oral diet.

Complaint reference #2-8115 was substantiated with deficiencies cited.

The inspection visit was a third follow-up survey conducted to verify compliance with previously cited deficiencies.

The tags F309 and F334 were found to be in compliance during this follow-up survey. No deficiencies were cited during this visit.

The inspection was conducted to assess compliance with quality of care standards, resident rights, and immunization policies at the nursing facility.

The facility was found deficient in providing necessary care to Resident #26, specifically failing to maintain proper fingernail care and hand protection. Additionally, the facility failed to ensure that nine residents were offered influenza immunizations according to policy.

The visit was conducted as a complaint investigation referenced as #2-8056, which was unsubstantiated with no related deficiencies cited. The investigation was conducted concurrently with a second revisit to the facility's annual Medicare/Medicaid certification survey.

The complaint was found to be unsubstantiated with no deficiencies cited related to the complaint. Any deficiencies resulting from non-compliance with certification requirements found during the concurrent revisit will appear on a separate Statement of Deficiencies.

Complaint reference #2-8056 was unsubstantiated with no related deficiencies cited.

The inspection was conducted as a complaint investigation referenced as #2-8046.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-8046 was unsubstantiated with no deficiencies cited.

The inspection was conducted as a complaint investigation referenced as #2-8010.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-8010 was unsubstantiated with no deficiencies cited.

Revisit survey to verify correction of previously cited deficiencies and assess ongoing compliance with regulatory requirements.

The facility was found to have multiple deficiencies including failure to notify physicians timely, failure to post survey results, improper enteral feeding procedures, inadequate pain management, delayed lab testing, unsecured medication carts, incomplete infection control practices, poor hand hygiene, and ineffective quality assurance processes. Some deficiencies were repeated from prior surveys and some resulted in actual harm to residents.

The inspection was conducted as part of a comprehensive annual survey to assess compliance with federal regulations regarding resident rights, protection of resident funds, transfer and discharge requirements, staff treatment of residents, resident assessments, care planning, medication administration, pharmacy services, environmental conditions, and laboratory services.

The facility was found deficient in multiple areas including improper authorization for handling resident funds, failure to provide required transfer/discharge information, incomplete abuse registry checks, failure to report and investigate neglect complaints, incomplete and inaccurate resident assessments, inadequate care planning, medication errors including failure to administer medications with food and failure to maintain accurate controlled drug records, failure to obtain ordered stool cultures, and environmental issues such as water leakage and damaged shower floors.

The inspection was conducted to assess compliance with NFPA life safety code standards related to fire safety, ventilation, electrical wiring, and resident rights in the facility.

The facility failed to maintain and inspect the range hood extinguishing system within the required six-month interval, did not maintain penetrations of smoke barrier walls by ventilation ducts as required, and had electrical wiring issues including the use of an extension cord in the Nurse Lounge. The facility also had deficiencies related to informing residents of their rights and services.

This document is a Plan of Correction submitted in response to deficiencies identified during a prior inspection of the facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b).

The inspection was conducted as a complaint investigation referenced as #2-7037.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-7037 was unsubstantiated with no deficiencies cited.

This document is a Plan of Correction related to deficiencies identified during a prior inspection of the facility.

The report includes a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges both orally and in writing in a language they understand, as required by regulation 483.10(b)(5)-(10).

The inspection was conducted concurrently with the facility's annual Medicare/Medicaid certification survey and included a complaint investigation which was unsubstantiated.

The facility was found deficient in several areas including failure to involve a resident with capacity in formulating advance directives, failure to obtain written authorization to handle resident funds, failure to immediately report and investigate an incident of neglect resulting in a resident fall with injury, failure to develop comprehensive care plans addressing identified issues for two residents, and failure to provide adequate supervision to prevent a resident from falling out of bed.

Complaint reference #2-6225 was unsubstantiated with no related deficiencies cited.

The inspection was conducted as a routine annual survey to assess compliance with health, safety, and regulatory standards at the facility.

The facility was found deficient in maintaining readily accessible exits and egress paths, failing to perform required sensitivity testing on smoke detectors, and not providing metal containers with self-closing covers in designated smoking areas.

The inspection was conducted in response to a complaint referenced as #2-6173.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference: #2-6173. The complaint was unsubstantiated with no deficiencies cited.

The inspection was conducted in response to complaint reference #2-6125.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-6125 was investigated and found to be unsubstantiated with no deficiencies cited.

The inspection was conducted as a complaint investigation referenced as #2-6086.

The complaint was unsubstantiated and no deficiencies were cited during the investigation.

Complaint reference #2-6086 was unsubstantiated with no deficiencies cited.

This document is a plan of correction submitted in response to deficiencies identified during a prior survey of the facility.

The document references a deficiency related to the facility's obligation to inform residents of their rights, rules, services, and charges in writing and orally, but does not provide detailed findings beyond this.

The inspection was conducted as a complaint investigation referenced as #2-6029, which was substantiated with unrelated deficiencies cited.

The facility was found to have not honored a resident's request for prescribed sleeping medication, withheld at the family's request, and failed to have a physician sign and date a progress note. Additionally, clinical records lacked proper dating on activities of daily living flow records for the resident.

Complaint reference #2-6029 was substantiated with unrelated deficiencies cited.