Oak Ridge Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF801Feb 28, 2025

  Based on observation, interview and record review, the facility failed to ensure the full-time Director of Food and Nutrition Services (Dietary Manager-DM) met the state's education qualification requirements, as required per federal regulation, to be in the DM to carry out the functions of the food and nutrition while the Registered Dietitian (RD) was on site as part-time consulting basis. As a result, there were lapses in the delivery of food and nutrition services associated with meal distribution accuracy (cross refer to F803), and safe food handling and sanitation (cross refer to F812), which lacked the benefit of a qualified Food and Nutrition Services Director (DM) responsible for the day-to-day food service operation for the skilled nursing facility. […]

• No harm, potential for more than minimal, widespreadF812Feb 28, 2025

  Based on observation, interview, and record review, the facility to prepare, store, serve, and distribute food in accordance with professional standards of food service safety when: 1. The ice machine was not clean; 2. Several various kitchenware in the clean and ready-to-use storage areas: a. Were stacked and stored wet b. Had brown sticky liquid; 3. Found two boxes of slice turkey deli meat required frozen upon receiving from delivery that stored in the walk-in refrigerator; 4. The clean dishes splashed with water during handwashing procedure caused cross contamination since the handwashing sink was adjacent to the clean side of the dishwashing machine; 5. [NAME] (CK) 1 was not practiced sanitary manner during puree making when: a. […]

• No harm, potential for more than minimal, patternF658May 8, 2026

  Based on interview and record review, the facility failed to deliver care within professional standards of practice when spironolactone (a medication used to manage high blood pressure and heart failure) was administered to Resident 45 despite low blood pressure readings, and the order was not clarified.This failure increased the risk for disease complications and adverse effects associated with hypotension (low blood pressure).Findings:A review of Resident 45's clinical record showed the resident was admitted on [DATE] with the following diagnoses: hypertensive heart disease with heart failure (high blood pressure that has weakened the heart) and myocardial infarction (heart attack).A review of Resident 45's Medication Administration Record (MAR) from April 2026 through May 7, 2026,… […]

• No harm, potential for more than minimal, patternF755May 8, 2026

  Based on observation, interview, and record review, the facility failed to ensure pharmaceutical procedures were in place to meet the needs of a resident and to ensure accurate accounting of controlled substance medications (medications under tight government control due to high addiction and abuse potential) when:The facility did not have a procedure to ensure Resident 26's weekly clonidine patch (a medication patch used to help manage high blood pressure) was in place for continued delivery of the medication.Controlled Drug Record (CDR) sheets (an inventory log used to track the receipt, administration, and remaining inventory of controlled substances) did not reconcile for 2 out of 4 sampled records (Resident 45 and Resident 57).These failures increased the risk for medication errors,… […]

• No harm, potential for more than minimal, patternF757May 8, 2026

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 45) was free from unnecessary medication. The resident received insulin lispro without monitoring for potential side effects and doses were held without clinical indication. These failures had the potential to result in uncontrolled blood sugars and complications related to hypoglycemia and hyperglycemia.Findings:A review of Resident 45's clinical record showed the resident was admitted on [DATE] with multiple diagnoses, that included: type 2 diabetes (a chronic disease causing high blood sugar), long term insulin use (ongoing need for insulin injections), type 2 diabetes with circulatory complications (blood vessel damage), and polyneuropathy (nerve damage causing numbness or… […]