Diversicare of Oak Ridge

In the surveyor’s words

From the most serious findings on record at Diversicare of Oak Ridge, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Sep 22, 2023

  Based on facility policy review, medical record review, facility investigation review, observation, and interview, the facility failed to implement appropriate fall interventions to prevent falls for 4 residents (#74, #253, #149, and #89) of 6 residents reviewed for falls. The facility's failure placed residents (#74, #253, #149 and #89) in Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more conditions of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) when Resident #74 sustained a shattered Left Acetabulum (the socket of the hipbone) and Simple Fracture of the Left Pubic Ramus (Pelvic fracture) after a fall on 8/2/2023, when Resident #253 sustained a Left Femoral Fracture (break in the thigh… […]

• Immediate jeopardy, isolatedF656Sep 22, 2023

  Based on facility policy review, medical record review, and interview, the facility failed to develop an individualized care plan to prevent falls for 4 residents (#74, #253, #149, and #89) of 6 residents reviewed for falls. The facility's failure resulted in Resident #74 sustaining a shattered Left Acetabulum (socket of hipbone) and Fracture of the Left Pubic Ramus (Pelvic break). Resident #253 sustaining a Left Femoral Fracture (break in the thigh bone). Resident #149 sustaining a Right Epidural Hematoma (blood accumulation between the skull and the brain) and Extra Axial Intracranial Hemorrhage (bleeding inside the skull but outside the brain) and went home on palliative care which placed these residents ( #74, # 253, #149, and #89) in Immediate Jeopardy (IJ) (a situation in which the… […]

• Immediate jeopardy, isolatedF657Sep 22, 2023

  Based on facility policy review, medical record review, and interview the facility failed to revise a comprehensive care plan timely for 3 residents (Resident #202, #61, and #16) of 28 care plans reviewed. The facility failed to revise interventions to the care plan timely for Resident #202 after the resident's family brought cigarettes and lit them, which led to 3 residents smoking unsupervised on 11/28/2023. Resident #61's care plan was not updated timely after the resident was discovered smoking unsupervised on 11/28/2022. […]

• Immediate jeopardy, isolatedF660Sep 22, 2023

  Based on facility policy review, medical record review, and interview, the facility failed to ensure a safe discharge for 2 residents (Resident #249 and Resident #250) of 5 residents reviewed for discharge. The facility's failure resulted in Resident #249, who was homeless, being discharged to an unknown friend's house who did not allow the resident to stay, Resident #249 then walked to another friend's house who drove him to a motel where Resident #249 resided for approximately 2 months at which time he was evicted from the motel and hitchhiked to another friend's house. Additionally, the facility's failure resulted in Resident #250 being home alone where she sat in a wheelchair for 4 days in urine and feces before she was provided incontinence care by a home health staff. […]

• Immediate jeopardy, isolatedF835Sep 22, 2023

  Based on facility policy review, medical record review, review of facility documentation, observation and interview, the facility's Administration failed to follow facility policy and procedures to ensure safe discharges for Residents #249 and #250; failed to provide adequate supervision for falls prevention, investigating, and implementing resident-centered interventions for 3 Residents (#149, #253, and #74); failed to provide effective leadership to address the elopement of 1 resident (#252); placing the Residents [#249, #250, #149, #253 and #74] in Immediate Jeopardy (IJ) , (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). […]