Inspection Reports for
The Villages at Oak Ridge

This citation relates to complaint 1841867.3.1-45(a)(1).

The facility failed to prevent falls for one resident reviewed, as care plan interventions were not fully implemented to prevent additional falls. Observations and interviews revealed issues with call light attendants being unplugged or out of reach, and staff not ensuring residents had proper supervision or assistance.

This citation relates to Complaint IN00456575 and Complaint IN00456619. The investigation found substantiated issues with catheter care, staffing shortages, and failure to follow physician orders.

The facility failed to provide appropriate catheter care, resulting in urinary tract infections and complications for multiple residents. Nursing staff shortages led to unmet resident care needs including missed showers and delayed responses to call lights. Antibiotics were administered without proper indication, and oxygen orders were not followed.

Complaint IN00456575 cited deficiencies at F725 and F690 related to allegations of insufficient nursing staff, bathing, catheter care, antibiotic use, and oxygen order compliance. Complaint IN00456619 cited deficiencies at F677 and F690 related to bathing and catheter care.

The facility was found to have deficiencies related to insufficient nursing staff, failure to provide adequate ADL care including bathing, improper catheter care, inappropriate antibiotic use, oxygen order noncompliance, and infection control lapses. Several residents were affected but no ill effects were reported. The facility submitted plans of correction and requested a desk review for substantial compliance.

The investigation was triggered by complaints IN00456575 and IN00456619 concerning inadequate bathing, catheter care, urinary tract infections, respiratory care, and staffing shortages.

The facility failed to provide adequate assistance with activities of daily living including bathing, failed to provide appropriate catheter care and prevent urinary tract infections, did not follow oxygen supplementation orders, and lacked sufficient nursing staff to meet resident needs. Infection control practices were also deficient.

The investigation was complaint-driven, focusing on Resident B's recurrent UTIs and related care deficiencies. The complaint was substantiated based on observations, interviews, and record reviews.

The facility failed to ensure appropriate treatment and services to prevent UTIs for Resident B, including incorrect MDS assessment coding, lack of resident-centered care plans, antibiotic administration errors, and failure to follow up with specialists. Multiple UTIs and hospitalizations were documented with inadequate follow-up care and care plan interventions.

Complaint IN00441261 and IN00442088 were investigated with no deficiencies related to the allegations cited. The unrelated deficiency cited was at F-690.

No deficiencies were cited related to the allegations of the complaints. However, an unrelated deficiency was cited regarding failure to ensure appropriate treatment and services to prevent UTIs for a resident with a nephrostomy tube, including inaccurate MDS coding, lack of resident-centered care plan, medication administration errors, and missed specialist follow-ups.

Complaint IN00429428 was investigated with no deficiencies related to the allegations cited.

The facility was found to have multiple deficiencies including failure to ensure resident dignity during feeding, incomplete assessments for self-administered medications, failure to implement care plans, inadequate ADL care, unsafe medication storage, improper infection control during medication administration, missing signed service plans, lack of prior authorization for PRN medications administered by QMAs, and missing annual health statements for residents.

The facility was found deficient in multiple areas including failure to treat residents with dignity, incomplete assessments for self-administration of medications, failure to implement care plans, inadequate assistance with activities of daily living, unsafe medication storage, and lapses in infection prevention and control practices.

This Federal tag relates to Complaint IN00405855.

The facility failed to ensure medication and treatment carts were kept locked when unattended, posing accident hazards. Additionally, the facility failed to properly dispose of expired medications, with an expired medication found discarded in an open trash container accessible to residents.

Complaint IN00405855 was investigated, with federal and state deficiencies cited related to the allegations.

The facility was found deficient in ensuring resident environments were free of accident hazards, proper medication storage and disposal, and that the Director of the Alzheimer's and dementia special care unit met state qualifications. Specific issues included unlocked medication and treatment carts, improper disposal of expired medications, and the dementia care unit director lacking required educational qualifications.