Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Ridge Health And Rehabilitation during CMS and state inspections, most recent first.
Oxygen Flow Rate Not Set Per Order: A resident with COPD, respiratory failure, and sleep apnea was observed multiple times with oxygen running at 4 L/min by NC even though the physician ordered 2 L/min PRN for SOB. The resident said they put the oxygen on themselves but did not set the rate. An LPN and the DON both confirmed the ordered flow rate was 2 L/min and that nurses were responsible for checking it.
The facility exhibited multiple food safety and hygiene deficiencies, including improper food storage, handling, and sanitation. Observations included undated and improperly stored food items, mold in the ice machine, and staff handling food and utensils with bare hands, risking cross-contamination. A rust-colored substance was also noted on a wall near the dishwasher room, indicating potential sanitation issues.
The facility failed to lock the tub room door in the Memory Unit, posing a risk of accidents to vulnerable residents. The policy requires such doors to be locked, but during an observation, the door was found ajar with a resident at risk of elopement nearby. An LPN confirmed the door should be locked to prevent access, as dirty linens were stored inside, and residents could fall and get hurt. The DON confirmed the need to keep these rooms locked to prevent resident access.
The facility did not follow the planned menu for a noon meal, resulting in some residents receiving chicken nuggets instead of the scheduled barbeque beef tips. A resident expressed a preference for the beef tips, and the Dietary Manager was unsure why the shortage occurred, as the usual amount of beef was prepared. Staff acknowledged the importance of serving the planned menu but could not explain the shortage.
Oxygen Flow Rate Not Set Per Physician Order
Penalty
Summary
The facility failed to ensure oxygen was administered at the flow rate ordered by the physician for one resident with COPD, respiratory failure, and sleep apnea. The resident’s quarterly MDS showed the resident was cognitively intact, independent with transfers and ambulation, and receiving oxygen therapy. The physician’s order directed oxygen at 2 liters per minute by nasal cannula as needed for shortness of breath, with pulse oximetry checks every shift. The resident’s care plan addressed altered respiratory status related to COPD and included interventions for medications/puffers, with a goal that pulse oximetry remain above 90%. The care plan did not indicate the resident was able to, or had been known to, adjust the oxygen flow rate independently. The March MAR did not show oxygen use or pulse oximeter results, and nurse progress notes from early February through mid-March did not document that the resident had previously adjusted the oxygen flow rate themselves. During multiple observations, the resident was found in bed with oxygen in use at 4 liters per minute by nasal cannula, which was above the ordered 2 liters per minute. In interviews, the resident stated they wore oxygen all the time and put it on themselves, but said they did not set the rate. An LPN confirmed the flow rate was set at 4 liters and stated it should have been 2 liters per the physician’s order. The DON also confirmed the ordered rate was 2 liters and stated nurses were responsible for checking the flow rate, noting it was not care planned for the resident to self-administer the oxygen.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of improper food storage and handling. A half-cut watermelon was stored in the refrigerator for several days beyond its date, and ice cream boxes were undated. Eggs were improperly stored above a bin of potato salad, posing a risk of contamination. Additionally, a freezer bag of waffles was left unsealed, and dry cereal bowls and a sugar bin were not properly sealed, leaving them exposed. A dented can of evaporated milk was also found in the pantry. The ice machine was found to have mold, despite a sign indicating it had been cleaned a month prior. Further deficiencies were noted in food handling practices. A CNA was observed serving a drink with fingers on the rim of the cup, risking cross-contamination. A staff member failed to wash hands between tasks and used bare hands to prepare sandwiches. A dietary aide handled dinner plates with bare hands, touching the surfaces that residents would eat from. Additionally, a rust-colored substance was observed on the wall adjacent to the dishwasher room, indicating potential sanitation issues. These observations highlight significant lapses in maintaining food safety and hygiene standards within the facility.
Failure to Lock Tub Room Door in Memory Unit
Penalty
Summary
The facility failed to ensure the tub room door on the Memory Unit was locked, which posed a risk of accidents and injuries to vulnerable residents. This deficiency affected five sampled residents. The facility's policy, as outlined in the Secure Neighborhood Policy & Procedure Manual, mandates that doors to exits, janitor closets, mechanical rooms, and shower rooms must not be left unlocked, disengaged, or propped open. However, during an observation, the tub room door across from the nurse's station was found ajar, with a resident considered an elopement risk wandering the hallway. A Licensed Practical Nurse (LPN) confirmed that dirty linens were stored in the tub room and acknowledged that the door should be locked to prevent residents from entering and potentially falling in the tub or getting hurt. The Director of Nursing (DON) also confirmed that the process for maintaining the tub and shower rooms includes keeping them clean and locked to prevent resident access, as residents could fall and harm themselves if the door shuts behind them.
Menu Not Followed Due to Food Shortage
Penalty
Summary
The facility failed to ensure that the menu for the noon meal was prepared and followed as planned. On the observed date, the menu included barbeque beef tips, baked potato salad, fried okra, Texas toast, and ice cream. However, the kitchen ran out of barbeque beef tips before all residents were served, resulting in the last four meal trays being served with chicken nuggets instead. A resident who received chicken nuggets expressed a preference for the barbeque beef tips as indicated on the menu. The Dietary Manager was unaware of how the shortage occurred, as the usual amount of beef packages was prepared. The staff member interviewed acknowledged the importance of serving the planned menu, as it is considered the residents' home, but could not explain the shortage.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near El Dorado
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Springs Of El Dorado | 0.2 mi | ★★★★★ | 2 | 0 |
| Timberlane Health & Rehabilitation | 1.4 mi | ★★★★★ | 1 | 0 |
| Hudson Memorial Nursing Home | 2 mi | ★★★★★ | 1 | 0 |
| Courtyard Rehabilitation And Health Center, Llc | 3.2 mi | ★★★★★ | 4 | 0 |
| Silver Oaks Health And Rehabilitation | 26.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.