Villages at Oak Ridge, The

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF812Jun 18, 2026

  Based on interview and observation the facility failed to ensure food was stored in accordance with professional standards for 2 of 2 kitchen observations. Expired foods were not disposed of, debris was caked on the dishwasher, and the drink machine had a white and brown substance on the grate. Findings include:On 6/14/26 from 9:15 A.M. through 9:35 A.M., the following was observed in the kitchen:1. Walk in refrigerator had containers of food with the following labels:-- Production entree pork in a clear container with a red lid--prepared on: 6/7/26,must use by end of day (EOD) on 6/9/26. --meatloaf in clear container with red lid--prepared on 6/9/26, must use by EOD on 6/12/26.--mashed potatoes with clear container with red lid--prepared on 6/10/26, must use by EOD on 6/12/26. […]

• No harm, potential for more than minimal, patternF690Apr 2, 2025

  Based on observation, interview, and record review, the facility failed to ensure appropriate care and services were provided to prevent urinary tract infections for residents with urinary catheters or were incontinent of bladder for 4 of 4 residents reviewed for incontinence/catheter care. (Resident B, Resident E, Resident D, Resident C) Findings include: 1. On 3/31/25 at 9:57 A.M., Resident B's clinical record was reviewed. Resident was admitted [DATE]. Diagnosis included, but were not limited to, dementia and kidney failure. The most recent Admission Minimum Data Set (MDS) assessment, dated 3/17/25, indicated a severe cognitive impairment and no behaviors. Resident was dependent on staff for eating, toileting, and bathing. […]

• No harm, potential for more than minimal, patternF725Apr 2, 2025

  Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff was provided for 7 of 7 days reviewed and 1 of 1 Resident Council meeting. Oxygen orders were not in place, catheter care was not provided, antibiotics given were not indicated for uti, and showers were not given. (Resident 33, Resident E, Resident B, Resident D, Resident C) Finding includes: 1. During the survey dates of 3/25/25 through 4/2/25, the following interviews were completed. a. The confidential interview indicated it was dependent on the hall assigned and if everyone showed up whether there was enough help or not. She frequently stayed after her shift ended to chart. […]

• No harm, potential for more than minimal, patternF880Apr 2, 2025

  Based on observation, record review, and interview, the facility failed to ensure infection control practices were implemented for a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for 2 of 2 random observations. (100 Hall, 300 Hall) Findings include: 1. On 4/1/25 at 10:14 A.M., a laundry cart was observed against a wall on the 100 Hall. Clothes were observed on hangers hanging from the top of the cart and folded items observed in the bottom basket. The cart was not covered. Laundry 3 and Laundry 7 were observed wheeling the cart down the hall while the clothes on the hangers were rubbing against the wall, resident doors, and hand sanitizer dispensers. […]

• No harm, potential for more than minimal, patternF677Mar 27, 2024

  Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADLs) were provided for dependent residents for 4 of 4 residents reviewed for ADLs. Residents did not receive showers at least twice per week. (Resident 15, Resident 107, Resident 51, Resident 44) Findings include: 1. On 3/19/24 at 11:00 A.M., Resident 15 was observed with greasy, unbrushed hair. On 3/21/24 at 10:17 A.M., Resident 15 was observed sitting in the common area with greasy, unbrushed hair. On 3/25/24 at 9:22 A.M., Resident 15 was observed sitting in the common area with unbrushed hair. On 3/21/24 at 11:24 A.M., Resident 15's clinical record was reviewed. Diagnosis included, but were not limited to, dementia. […]