Oak Ridge Rehabilitation & Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, patternF812Aug 7, 2023

  Based on observations, staff interviews, and select facility policy and documentation it was determined the facility failed to consistently store perishable (foods likely to spoil, decay or become unsafe to consume if not kept refrigerated at 40 F or below, or frozen at 0 F or below. Examples of foods that must be kept refrigerated for safety include meat, poultry, fish, dairy products, some fruits and vegetables and all cooked leftovers) and potentially hazardous foods (Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens, such as bacterial or viral organisms capable of causing a disease or toxin formation) at safe temperatures to prevent potential food borne… […]

• Immediate jeopardy, isolatedF600Jun 23, 2022

  Based on a review of clinical records, select facility policies, and incident/accident reports and observations and staff interviews it was determined that the facility failed to ensure that one resident (Resident 2) out of six sampled was free from sexual abuse and harassment perpetrated by another resident (Resident 1). The failure of the facility to prevent Resident 1 from repeatedly sexually abusing Resident 2 placed Resident 2 and other female residents residing on the dementia unit in immediate jeopardy to their safety due to the potential for future episodes of sexual abuse and harassment to occur. […]

• Actual harm, isolatedF600Feb 6, 2026

  Based on a review of clinical records, the facility's abuse prohibition policy, facility investigative documentation, and staff interviews, it was determined the facility failed to ensure a resident was free from neglect by failing to provide care and services in accordance with the resident's plan of care. Specifically, staff failed to utilize the required sliding board with assistance of one staff member during a transfer from wheelchair to bed, as planned to ensure safety and prevent injury. As a result of this failure, one resident (Resident CR147) sustained an acute distal femur fracture that progressed to an above-the-knee amputation, representing actual harm to one resident out of 3 discharged residents sampled. […]

• Actual harm, isolatedF684Feb 6, 2026

  Based on observation, review of clinical records, review of hospital records, and resident and staff interview, it was determined that the facility failed to provide care and services consistent with professional standards of practice by failing to follow physician-ordered bowel protocol for one of 26 residents (Resident 75) reviewed, which resulted in hospitalization and actual harm. Additionally, the facility failed to follow professional standards of practice related to medication administration management for one of three closed residents (Resident CR3) sampled.Findings include: According to the American Academy of Family Physicians (The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine)… […]

• Actual harm, isolatedF744Jan 25, 2024

  Based on a review of clinical records, information submitted by the facility, and select incident reports and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms displayed by one resident (Resident CR1) which, resulted in one resident (Resident 4) out of 6 residents sampled sustaining a serious injury, a fractured hip, caused by Resident CR1's dementia-related behavioral symptoms. Findings include: A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses to include dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). […]