Oakridge Nursing Center

In the surveyor’s words

From the most serious findings on record at Oakridge Nursing Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Sep 12, 2025

  A past noncompliance Immediate Jeopardy (IJ) situation was determined to exist effective [DATE], related to the facility's failure to ensure:a. CPR was not stopped for a resident who was a full code, b. staff members could definitively identify a resident's code status, andc. effective cardiopulmonary resuscitation was provided by the use of a backboard and providing rescue breaths. A progress note, dated [DATE] at 4:07 a.m., showed a code had been called for Res #1 and CPR had been started. […]

• No harm, potential for more than minimal, patternF583Jan 29, 2025

  Based on observation, record review, and interview, the facility failed to ensure: a. privacy was provided during care for one (#31) of four sampled residents reviewed for privacy; and b. protected health information was secured for three (#10, 170, and #173) of four sampled residents observed during medication pass. The administrator identified 65 residents resided in the facility. Findings: The Confidentiality of Information and Personal Privacy policy, revised 10/2017, read in part, Our facility will protect and safeguard resident confidentiality and personal privacy. 1. Resident #31 had diagnoses which included dementia and generalized edema. A quarterly assessment, dated 11/09/24, documented the resident had moderately impaired cognition. […]

• No harm, potential for more than minimal, patternF688Jan 29, 2025

  Based on record review and interview, the facility failed to ensure restorative therapy was provided to residents with limited ROM for two (#33 and #51) of two sampled residents reviewed for restorative services. The regional survey consultant identified 27 residents who received restorative therapy resided in the facility. Findings: The Restorative Nursing Services policy, revised 07/2017, read in part, Residents will receive restorative nursing care as needed to help promote optimal safety and independence. 1. Resident #33 had diagnoses which included congestive heart failure, Parkinson's, COPD, and atrial fibrillation. The MDS, dated [DATE], documented Resident #33 needed substantial/maximum assistance from staff. On 01/28/25 at 11:01 a.m., two staff provided resident care. […]

• No harm, potential for more than minimal, patternF759Jan 29, 2025

  Based on observation, record review, and interview, the facility failed to ensure a medication error rate of less than five percent during the medication pass observation. The medication error rate was 15.38%. The administrator identified 65 residents resided in the facility. Findings: The Medication Administration policy, dated 06/21/17, read in part, Medications will be administered by legally-authorized and trained persons in accordance to applicable State, Local and Federal laws and consistent with accepted standards of practice. 1. […]

• No harm, potential for more than minimal, patternF880Jan 29, 2025

  Based on observation, record review, and interview, the facility failed to ensure: a. the required PPE was worn when providing care to a resident on transmission based precautions for one (#46) of four sampled residents who were reviewed for transmission based precautions; and b. infection control practices were maintained during medication administration observation. The administrator identified 65 residents resided in the facility. The infection preventionist identified 19 residents were on transmission based precautions. Findings: The Facility COVID-19 Plan, dated 05/16/23. […]