Oak Ridge Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Oak Ridge Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Sep 13, 2023

  Based on observation, record review and interview, the facility failed to ensure a resident who wore an (electronic wander management device), did not exit the building unattended for 1 (Resident #1) of 3 (Residents #1, #2 and #3) case mix residents and had the potential to affect 14 residents who wore an (electronic wander management device) and were at risk for elopement. This failed practice resulted in past noncompliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #1. The Administrator was notified of the Past Immediate Jeopardy on 09/13/23 at 11:28 AM. The findings are: 1. On 09/12/23 at 11:07 AM, observed the Main Dining Room was on the parking side of the facility and was noted to have an exit door with a keypad. […]

• Actual harm, isolatedF689Jul 28, 2022

  Based on observation, record review, and interview the facility failed to ensure care planned interventions to prevent unsupervised smoking were implemented and failed to provide adequate supervision to prevent excessive exposure to the sun for 1 (Resident #2) of 3 (Resident #2, #3 and #4) sampled residents that required supervision for smoking. The failed practice resulted in actual harm for Resident #2 who was left outside unsupervised in temperatures ranging from 94.5 degrees Fahrenheit to 96.7 degrees Fahrenheit for an extended period of time resulting in the resident experiencing a temperature of 104 degree Fahrenheit and subsequent skin eruptions with blistering of skin, and had had potential to cause more than minimal harm to 13 residents who required supervision for smoking as… […]

• No harm, potential for more than minimal, widespreadF812Sep 26, 2024

  Based on observations, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The finding are: On 9/23/24 at 10:16 AM, and again on 9/24/24 at 10:15 AM, a half-cut watermelon dated 9/18/24 was observed stored on the top shelf of the refrigerator. On 09/23/24 at 10:18 AM, the surveyor observed two boxes of ice cream that were not dated. The Dietary Manager (DM) dated the boxes and said they were for activity. On 09/24/24 at 10:15 AM, the surveyor observed eggs stored on the 2nd shelf of the refrigerator with a large bin of prepared potato salad sitting below the eggs. […]

• No harm, potential for more than minimal, widespreadF801Nov 3, 2023

  Based on observation, and interview, the facility failed to ensure a qualified dietitian was utilized in overseeing meal preparation, menu planning, and managing dietary operations to prevent foodborne illnesses, and sanitation. This failed practice had the potential to affect 72 residents that receive meals from the kitchen according to a list provided by the administrator on 11/02/23 at 3:34PM . The findings are: 1. On 11/01/23 at 02:32 PM The Dietary Manager [DM] told the surveyor that she is not a certified dietary manager. DM said, I'm currently in classes for Safe Serve then I'll take other classes. 2. On 11/01/23 at 02:32 PM The surveyor spoke with the Administrator and asked what their process was for ensuring the dietary manager received certification. […]

• No harm, potential for more than minimal, widespreadF812Nov 3, 2023

  Based on observation, record review and interview, failed to ensure dented food cans were promptly removed/ discarded to prevent the growth of bacteria; 1of 1 ice scoops were maintained in a clean and sanitary condition to prevent potential contamination of residents' beverages for residents who received meals from 1 of 1 kitchen; foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired food items were promptly removed /discarded on or before the expiration or use by date to prevent the growth of bacteria; fan in preparation area and air conditioner above clean dish washing area were not maintained in a clean and sanitary condition to prevent… […]