Deficiencies (last 3 years)
Deficiencies (over 3 years)
13 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 3
Date: Sep 26, 2024
Visit Reason
The inspection was conducted to assess compliance with nursing home regulations including safety, nutrition, and food service standards.
Findings
The facility was found deficient in ensuring safety by failing to keep the tub room door locked, failing to follow the posted menu for meals, and not adhering to proper food storage, preparation, and serving standards, including cross contamination risks and unsanitary conditions.
Deficiencies (3)
Failed to ensure the tub room door on the Memory Unit was locked to prevent resident accidents.
Failed to ensure menus were prepared and followed for 1 of 2 meals observed, resulting in residents not receiving the planned meal.
Failed to store, prepare, distribute and serve food in accordance with professional standards, including improper food storage, unsanitary conditions, and cross contamination risks.
Report Facts
Residents affected: 5
Residents affected: 4
Dates: Sep 23, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Accompanied surveyor to tub room door and explained door should be locked |
| Director of Nursing | DON | Confirmed policy on locked tub room door and risks to residents |
| Dietary Manager | DM | Interviewed regarding food shortages and food safety issues |
| Dietary Consultant | DC | Moved eggs to proper refrigerator shelf and commented on food storage |
| Certified Nurse Assistant #3 | CNA | Observed serving drink with improper handling risking cross contamination |
| Dietary Aide | DA | Observed stacking plates with bare hands causing cross contamination risk |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to safety, nutrition, and food service standards at Oak Ridge Health and Rehabilitation.
Findings
The facility was found deficient in ensuring safety by failing to keep the tub room door locked on the Memory Unit, failing to follow the posted menu for one meal, and not adhering to professional food service standards including improper food storage, cross contamination risks, and unsanitary conditions in the kitchen.
Deficiencies (3)
Failed to ensure the tub room door on the Memory Unit was locked to prevent vulnerable residents from accidents and injuries.
Failed to ensure menus were prepared and followed for 1 of 2 meals observed; residents served chicken nuggets instead of the planned barbeque beef tips.
Failed to store, prepare, distribute and serve food in accordance with professional standards, including improper food storage, undated items, exposed food, mold in ice machine, and cross contamination risks.
Report Facts
Residents affected: 5
Residents affected: 4
Dates observed: Sep 23, 2024
Dates observed: Sep 24, 2024
Dates observed: Sep 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Accompanied surveyor to tub room door and explained door should be locked |
| Director of Nursing | DON | Confirmed tub room door should be locked and explained risks to residents |
| Dietary Manager | DM | Interviewed regarding food shortages and food safety issues |
| Dietary Consultant | DC | Moved eggs to proper refrigerator shelf and commented on food storage |
| Certified Nurse Assistant #3 | CNA | Observed serving drink with improper handling risking cross contamination |
| Dietary Aide | DA | Observed stacking plates with bare hands risking cross contamination |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Nov 3, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Oak Ridge Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy and dignity, incomplete and inaccurate resident assessments, medication management issues including expired and unlabeled medications, dietary management deficiencies including unqualified dietary manager and unsafe food storage and handling practices, and failure to provide pneumococcal vaccinations timely.
Deficiencies (9)
Failed to ensure privacy for residents with catheters and those not fully clothed.
Failed to comprehensively assess resident physical, mental, and psychosocial needs in a timely manner.
Failed to complete a Significant Change Minimum Data Set after decline in resident condition.
Failed to ensure accurate coding of resident restraint status in Minimum Data Set.
Failed to reassess and revise care plans to meet resident needs.
Failed to remove expired and unlabeled medications from medication cart.
Failed to employ a qualified dietitian to oversee dietary operations.
Failed to ensure safe food storage, handling, and sanitation in the kitchen.
Failed to provide pneumococcal immunizations as required or appropriate for sampled residents.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 19
Residents affected: 72
Residents affected: 3
Total census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Not certified dietary manager, in process of certification |
| Certified Nursing Assistant #2 | CNA | Interviewed about catheter bag placement and resident privacy |
| Licensed Practical Nurse #3 | LPN | Interviewed about catheter bag placement and resident privacy |
| Director of Nursing | DON | Interviewed about catheter bag placement, MDS coding, and immunization policies |
| MDS Coordinator #2 | MDS Coordinator | Interviewed about MDS purpose and care plan review |
| Dietary Worker #1 | Dietary Worker | Observed washing dishes improperly and ice scoop use |
| Dietary Worker #3 | Dietary Worker | Interviewed about food storage, cleaning, and dishwashing procedures |
| Nurse Consultant | Nurse Consultant | Provided personal hygiene documentation report |
| Certified Nursing Assistant #1 | CNA | Interviewed about care for Resident #42 |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Nov 3, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Oak Ridge Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy and dignity, incomplete and inaccurate resident assessments, medication management issues including expired and unlabeled medications, dietary management deficiencies including lack of certified dietary manager and food safety violations, and failure to provide pneumococcal vaccinations timely.
Deficiencies (8)
Failure to ensure privacy for residents with catheters and residents not fully clothed, compromising dignity.
Failure to comprehensively assess resident physical, mental, and psychosocial needs timely and accurately.
Failure to complete a Significant Change Minimum Data Set (MDS) after decline in resident condition.
Inaccurate coding of resident restraint status in Minimum Data Set (MDS).
Failure to reassess and revise care plans to meet resident needs based on condition changes.
Expired and unlabeled medications were not removed from medication carts, risking administration errors.
Dietary manager not certified; food safety violations including improper food storage, expired items, unclean equipment, and improper dishwashing temperatures.
Failure to provide pneumococcal vaccinations timely to eligible residents despite consent.
Report Facts
Residents affected: 1
Residents affected: 16
Residents affected: 17
Residents affected: 1
Residents affected: 16
Residents affected: 19
Residents affected: 72
Residents affected: 3
Total census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding catheter privacy, MDS coding, care plan review, and vaccination documentation |
| Certified Nursing Assistant #2 | CNA | Interviewed about catheter bag placement and resident privacy |
| Licensed Practical Nurse #3 | LPN | Interviewed about catheter bag placement and resident privacy |
| MDS Coordinator #2 | Minimum Data Set Coordinator | Interviewed about MDS accuracy and care plan review |
| Dietary Manager | Dietary Manager | Interviewed about certification status and food safety practices |
| Dietary Worker #1 | Dietary Worker | Observed washing dishes and interviewed about food storage and dishwashing procedures |
| Dietary Worker #3 | Dietary Worker | Interviewed about food storage, expiration checks, and dishwashing procedures |
| CNA #1 | Certified Nursing Assistant | Interviewed about care for Resident #42 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 13, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to report an elopement incident involving Resident #1, who was at risk for elopement.
Complaint Details
The complaint investigation found that Resident #1, an elopement risk, exited the facility through a door with a keypad override that malfunctioned. The resident sustained abrasions and was sent to the emergency room. The facility did not report the elopement to the Office of Long-Term Care, deciding it was not neglect after review. The Administrator was notified of immediate jeopardy on 09/13/23.
Findings
The facility failed to report the elopement of Resident #1 to the Office of Long-Term Care and had a malfunctioning Secure Care System that allowed the resident to exit the building unattended. Resident #1 sustained injuries after exiting the facility, and the facility did not follow proper reporting protocols despite the risk and harm.
Deficiencies (2)
Facility staff failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities related to an elopement incident.
Facility failed to ensure a resident wearing an electronic wander management device did not exit the building unattended, resulting in immediate jeopardy to resident health or safety.
Report Facts
Residents affected: 3
Residents potentially affected: 14
Date of survey completed: Sep 13, 2023
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to report an elopement incident involving Resident #1, who was at risk for elopement.
Complaint Details
The complaint investigation found that Resident #1, who was an elopement risk, exited the facility through a dining room door that was improperly secured due to an override on the Secure Care System. The resident sustained abrasions after falling outside. The facility did not report the elopement to the Office of Long Term Care, deciding it was not neglect after review. The Administrator was notified of the Immediate Jeopardy on 09/13/23.
Findings
The facility failed to report an elopement of Resident #1 to the Office of Long Term Care and had a malfunctioning Secure Care System that allowed the resident to exit the building unattended, resulting in immediate jeopardy to resident health and safety. Resident #1 sustained injuries after exiting the facility unsupervised.
Deficiencies (2)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities related to an elopement incident.
Failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in immediate jeopardy to resident health or safety.
Report Facts
Residents affected: 1
Residents at risk: 14
Date of survey completion: Sep 13, 2023
Inspection Report
Routine
Census: 79
Deficiencies: 6
Date: Aug 19, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, activities of daily living, pain management, food service, and dietary practices at Oak Ridge Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to ensure residents had access to their personal funds after hours, lack of care plan meetings involving residents and families, inadequate personal hygiene care related to nail grooming, failure to provide physician-ordered pain medication timely, serving food at unsafe temperatures, and poor dietary hygiene and food storage practices.
Deficiencies (6)
Failed to ensure residents who authorized the facility to manage their personal funds had access after hours and on weekends.
Failed to ensure care plan meetings were held and residents and families were invited to participate for 2 sampled residents.
Failed to ensure fingernails were cleaned and groomed to promote good personal hygiene for 2 of 16 sampled residents requiring staff assistance.
Failed to ensure physician-ordered narcotic pain medication was available for administration as ordered for 1 sampled resident.
Failed to ensure food was served at safe and appetizing temperatures for multiple meals across several units.
Failed to ensure dietary staff washed hands before handling clean equipment or food, and failed to ensure proper food storage, sanitation, and removal of expired items.
Report Facts
Residents affected: 48
Residents affected: 79
Residents affected: 42
Residents affected: 7
Residents affected: 17
Residents affected: 72
Resident census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in nail care deficiency and interview about resident nail grooming |
| Licensed Practical Nurse #2 | LPN | Named in pain medication deficiency and interview about narcotic availability |
| Registered Nurse #1 | RN | Named in pain medication deficiency and interview about narcotic availability |
| Director of Nursing | DON | Named in multiple deficiencies including care plan meetings, nail care, and pain medication availability |
| Business Office Manager | BOM | Named in deficiency related to resident access to personal funds |
| Business Office Consultant | Named in deficiency related to resident access to personal funds | |
| Certified Nursing Assistant #1 | CNA | Named in nail care deficiency and interview about resident nail grooming |
| Certified Nursing Assistant #2 | CNA | Named in food service temperature observations |
| Assistant Dietary Supervisor #1 | Named in food temperature observations and dietary hygiene deficiencies | |
| Dietary Employee #1 | Named in dietary hygiene deficiencies related to handwashing and food handling | |
| Dietary Employee #2 | Named in dietary hygiene deficiencies related to handwashing and food handling | |
| Dietary Employee #3 | Named in dietary hygiene deficiencies related to handwashing and food handling | |
| Dietary Employee #5 | Named in dietary hygiene deficiencies related to handwashing and food handling | |
| Dietary Employee #7 | Named in dietary hygiene deficiencies related to handwashing and food handling |
Inspection Report
Complaint Investigation
Census: 74
Deficiencies: 6
Date: Aug 19, 2022
Visit Reason
The inspection was conducted to investigate complaints regarding residents' access to personal funds after hours and weekends, care plan meetings, personal hygiene and grooming, pain management, food temperature and quality, and dietary sanitation practices.
Complaint Details
The visit was complaint-related, investigating issues including residents' access to personal funds after hours, failure to hold care plan meetings, inadequate personal hygiene care, lack of pain medication availability, improper food temperature maintenance, and dietary sanitation violations. Substantiation status is not explicitly stated.
Findings
The facility failed to ensure residents had access to their personal funds after hours and weekends, failed to hold timely care plan meetings involving residents and families, did not maintain proper personal hygiene for some residents, lacked availability of physician-ordered pain medication, served food at unsafe temperatures, and did not follow proper dietary sanitation and food storage protocols.
Deficiencies (6)
Failed to ensure residents who authorized the facility to manage their personal funds had access after hours and weekends.
Failed to ensure care plan meetings were held and residents/families invited for 2 sampled residents.
Failed to ensure fingernails were cleaned and groomed for residents requiring staff assistance.
Failed to ensure physician-ordered narcotic pain medication was available as ordered.
Failed to ensure food was served at safe and appetizing temperatures to maintain palatability.
Failed to ensure dietary staff washed hands before handling clean equipment or food, and failed to properly store, date, and monitor food items for safety.
Report Facts
Residents affected: 48
Residents affected: 79
Residents affected: 42
Residents affected: 7
Residents affected: 17
Total census: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Mentioned in relation to management of residents' personal funds and lack of knowledge of after-hours access process. | |
| Administrator | Interviewed about residents' access to personal funds and care plan meetings. | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about lack of process for residents to access funds after hours and nail care responsibilities. | |
| Registered Nurse (RN) #1 | Interviewed about lack of process for residents to access funds after hours. | |
| Director of Nursing (DON) | Interviewed about care plan meetings, nail care responsibilities, and pain medication availability. | |
| Certified Nursing Assistant (CNA) #1 | Interviewed about nail care for Resident #11. | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about pain medication availability for Resident #27. | |
| Registered Dietitian | Conducted food temperature checks and provided dietary policy. | |
| Dietary Employees (DE) #1, #2, #3, #5, #7 | Observed for improper handwashing and food handling practices. |
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