Oak Ridge Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Apr 21, 2023

  Based on interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for 1 (Resident #1) of 5 residents reviewed for physician notification. The facility failed to notify the primary physician that Resident #1's wound to her right elbow underneath the splint which led to an infection resulting in hospitalization . An Immediate Jeopardy (IJ) situation was identified on 04/20/2023 at 3:00 PM. […]

• Immediate jeopardy, isolatedF684Apr 21, 2023

  Based on interview, and record review the facility failed to ensure a resident with a wound received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new wounds from developing for 1 of 4 residents (Resident #1) reviewed for wounds related to splints, braces, and immobilizers. The facility failed to remove Resident #1's arm splint to identify, treat, and monitor a wound underneath Resident #1's arm splint to Resident #1's right elbow which led to an infection resulting in hospitalization . An Immediate Jeopardy (IJ) situation was identified on 04/20/2023 at 3:00 PM. […]

• Immediate jeopardy, isolatedF686Apr 21, 2023

  Based on observation, interview, and record review the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers that were avoidable and failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents (Resident #2) reviewed for skin integrity. 1. The facility failed to prevent avoidable pressure ulcers caused by a knee immobilizer for Resident #2 that led to an infection which resulted in hospitalization . 2. […]

• No harm, potential for more than minimal, widespreadF802Dec 30, 2025

  Based on interviews and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 6 of 6 kitchen staff (DC -E, DC-F, DS-G, DS-H, DS-I, and DC-J) reviewed for qualified dietary staff.The facility failed to ensure that DC-E, DC-F, DS-G, DS-H, DS-I, and DC-J met the requirements for food handling by obtaining a current and valid Food Handler's Certificate.This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses.The findings included:Record review of food handlers certificates posted in the main dining room was dated as follows:- DC-E -09/27/2022,-DC-F 12/16/2022,-DS-G… […]

• No harm, potential for more than minimal, widespreadF812Aug 16, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods. These failures could place residents at risk for food borne illness and cross-contamination. Findings included: An observation on [DATE] at 10:20 AM, of the dry storage revealed: 1. 1 gallon bag of cooked cornbread not labeled or dated. 2. 1 gallon bag of dry toast not labeled or dated. 3. 1 gallon bag of croissants not labeled or dated. 4. 1 opened bag of powdered creamer not sealed or dated. 5. […]