Above average — CMS composite of the measures below.
The next survey window likely opens around April 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 Healthcare Center during CMS and state inspections, most recent first.
A resident with heart disease and HF received spironolactone despite low BP readings, and the BP hold order was not clarified. An LN acknowledged the med could further lower BP and said the separate hold parameter was hard to follow. The DON and ADON confirmed the med had been given on multiple occasions when SBP was below the hold threshold, and the facility policy required clarification of confusing or inappropriate orders.
A resident with HTN and CKD had a clonidine patch ordered weekly for BP control, but staff did not have a process to verify patch placement, and the resident reported the patch had fallen off without being reapplied. In addition, CDRs for two residents did not reconcile with MAR documentation for oxycodone and hydrocodone-acetaminophen, and the DON and ADON confirmed the discrepancies.
Unnecessary Insulin Holds and Lack of Monitoring: A resident with DM2 and long-term insulin use received insulin lispro ordered before meals, but staff repeatedly held doses without any documented clinical reason or provider notification. The DON and ADON confirmed multiple held doses across several months, and there was no documentation of monitoring for insulin side effects or assessment for signs or symptoms of hypo- or hyperglycemia.
Medication administration errors exceeded the allowed rate after an LPN gave a resident the wrong doses of vitamin D and magnesium, crushed a delayed-release aspirin and ferrous sulfate despite DO NOT CRUSH orders, and administered insulin glargine from a pen without performing the required safety test. The DON and ADON acknowledged staff are expected to follow provider orders and manufacturer instructions.
A resident with diabetes and long-term insulin use had an order for insulin lispro before meals, but MAR review showed the morning dose was routinely given 1 to 2 hours before breakfast over multiple months. The DON and ADON confirmed the doses were administered before meals, did not follow the prescriber’s orders, facility policy, or manufacturer guidance, and acknowledged that rapid-acting insulin given too early increases the risk of hypoglycemia and side effects.
Medication storage and security failures were identified when the med refrigerator was found out of range and left unchecked for hours, an expired bottle of latanoprost and an undated bottle of glucose test strips were found in a med cart, and a resident’s eye drops were observed at the bedside. The DON and ADON acknowledged the refrigerator temperature excursion, the expired and undated items, and that the bedside medication was not secured as required by facility policy.
Infection control practices were not followed during wound care and medication administration. A wound treatment nurse used the same gauze to cleanse and then dry a resident’s pressure ulcer wound, despite facility policy calling for clean gauze and dry gauze for patting the wound dry. In separate observations, an LPN cleaned a glucometer with an alcohol pad instead of the approved disinfectant between uses and attached a new needle to a Lantus Solostar pen without wiping the rubber seal first, contrary to manufacturer instructions.
Unauthorized Search of Resident Belongings: A resident with intact cognition, a cervical fracture, and frequent falls was observed visibly upset after reporting that staff opened and checked his personal belongings without his permission while he was not in his room. The record showed the DON authorized staff to search the resident’s room and belongings for possible meds or beverages after a statement about narcotics and an alcoholic beverage bottle was found, but there was no documented consent from the resident and no documentation of intoxication or an immediate safety concern.
Smoking Safety Care Plan Not Implemented: A resident with intact cognition, nicotine dependence, repeated falls, and a prior cervical fracture was care planned to have cigarettes kept in the nurses’ cart and not in his room or on his person. However, staff observed him holding cigarettes in his room on multiple occasions, and a CNA confirmed he went out by himself to smoke. The ADON acknowledged the smoking-related care plan intervention, stated there was no smoking safety assessment process because the facility was non-smoking, and confirmed the care plan had not been implemented.
Uncovered Pressure Ulcer Dressing Not Changed as Needed: A resident with sepsis, Fournier gangrene, and a stage 2 coccyx pressure ulcer had an order for daily and PRN wound care with a dry dressing. Staff observations and record review showed no documentation that the dressing was changed as needed, and multiple staff members observed the coccyx wound uncovered during incontinence care and later care, with the WTN and DON confirming that a soiled or dislodged dressing should be changed right away.
Failure to provide enough food/fluids to maintain health occurred when a resident with DM, a stage 2 pressure ulcer, anemia, a fracture, and moderate cognitive impairment had multiple meals at 50% or less intake and no documentation showed a substitute meal was offered. The care plan directed staff to offer a substitute if the meal was taken at 50%, and a CNA stated substitutes were not offered; the ADON confirmed the lack of documentation, and the RD noted the resident was nutritionally at risk due to diabetes and wound healing.
A resident with a healing femur fracture, difficulty walking, and moderate cognitive impairment was observed seated on a bedside commode and calling for help while the call light was placed on the opposite side of the bed, out of reach, despite a care plan directive that the call light be kept within reach. The CNA who transferred the resident to the commode, an LN, and the DON all acknowledged that the call light should always be accessible to the resident, and facility policy required call lights to be accessible from the bed, toilet, shower, and floor.
A resident with an indwelling urinary catheter did not receive required Enhanced Barrier Precautions (EBP) when a Physical Therapy Assistant provided care without wearing a gown, and no EBP signage was posted outside the resident's room. Both the Infection Preventionist Nurse and DON confirmed that EBP and appropriate signage were expected for residents with indwelling catheters.
The facility's Dietary Manager lacked the required qualifications, leading to deficiencies in meal distribution and sanitation. The Registered Dietitian was only part-time, resulting in insufficient oversight of food services for all residents.
The facility failed to adhere to food safety and sanitation standards, with issues including an unclean ice machine, improper storage of kitchenware and deli meats, and inadequate handwashing and dishwashing practices. These deficiencies were confirmed by the Dietary Manager and Maintenance Supervisor, indicating a lack of compliance with facility policies and FDA guidelines.
The facility failed to maintain pharmacy services by not replacing emergency medications in the E-kit in a timely manner. Medications were removed for three residents, but replacements were not made within the expected timeframe, as confirmed by the DON. The facility's policy required replacement within 72 hours, which was not followed.
The facility failed to follow prescribed therapeutic diets during lunch meals, affecting 19 residents. Two residents on a CCHO diet received incorrect portions of garlic bread, while six residents on a fortified diet did not receive additional shredded cheese. Five residents on a 2-gram sodium diet received full servings of dessert, and five residents on a mechanical soft diet were given regular dessert. The Dietary Manager and Registered Dietitian confirmed these discrepancies, highlighting a failure to adhere to the menu spreadsheet.
The facility failed to follow infection control practices in three instances: uncovered meal trays were transported, a shared glucometer was not sanitized between uses on two residents with diabetes, and a foley catheter collection bag was found on the floor instead of being hooked onto the bed rail. These actions were against the facility's policies and posed potential infection risks.
A resident with intact cognition and multiple health conditions experienced disrespect and rough handling during a blood draw by an LN, who refused to perform a central venous access device blood draw and was rude to both the resident and a phlebotomy technician. The facility's policy on dignity was not upheld, as confirmed by the DON and the LN's performance review.
The facility failed to follow its medication self-administration policies for two residents, lacking assessments and physician's orders for safe self-administration and bedside storage. One resident stored calcium carbonate without proper labeling or documentation, while another kept an inhaler at the bedside without informing staff. Staff interviews confirmed the absence of necessary orders and assessments, contrary to facility policies.
A resident's medication administration was not accurately documented in the MAR, leading to potential risks of overmedication. The facility's policy requires immediate documentation after administration, but discrepancies were found in the records for Vancomycin and Oxycodone. Interviews with the DON and ADON confirmed the medications were given but not recorded, highlighting a risk of miscommunication and unsafe practices.
The facility failed to offer activities that met the interests and preferences of two residents, as outlined in their care plans. One resident with a femur fracture received only one activity visit in five weeks, while another resident with Alzheimer's and depression was not engaged in group or 1:1 activities. The Activities Director and DON acknowledged the insufficiency of activity visits, which did not meet the residents' needs.
Failure to Clarify Blood Pressure Hold Parameters for Spironolactone
Penalty
Summary
The facility failed to deliver care within professional standards of practice when spironolactone was administered to a resident despite low blood pressure readings, and the order was not clarified. The resident was admitted with hypertensive heart disease with heart failure and myocardial infarction. The medication administration record showed an order for spironolactone 25 mg daily for heart disease, along with a blood pressure monitoring order to hold blood pressure medication if systolic blood pressure was less than 110 or pulse was less than 60. On the morning of 5/7/26, the resident's blood pressure was 100/59 and pulse was 61, yet spironolactone was given. During interview and record review, the LN acknowledged that spironolactone had been administered despite the low blood pressure and stated it could further lower the resident's blood pressure. The LN also stated the blood pressure monitoring order was separate and hard to follow and said it needed clarification. The DON and ADON later reviewed the record and confirmed spironolactone had been administered on multiple occasions when the resident's systolic blood pressure was below 110, and the DON stated she would have clarified the order with the physician before giving the medication. The facility policy required verification or clarification of orders that appeared inappropriate or confusing, and the prescribing information for spironolactone noted warnings for hypotension and worsening renal function.
Patch Monitoring and Controlled Substance Recordkeeping Failures
Penalty
Summary
The facility failed to ensure pharmaceutical procedures were in place to meet the needs of a resident receiving a clonidine transdermal patch and failed to ensure accurate accounting of controlled substances for two residents. Resident 26 had diagnoses including hypertension and chronic kidney disease stage 2, and his MDS dated 3/5/2026 showed a BIMS score of 15, indicating intact cognition. His physician order directed clonidine transdermal patch 0.2 mg to be applied weekly every Wednesday for high blood pressure. During observation and interview on 5/7/2026, Resident 26 stated the patch had come off in the shower a day or so earlier, and the nurse confirmed the patch was not on the resident. The nurse stated the expectation was for the resident to tell her if the patch was missing, that the off-going nurse had not reported the missing patch at shift change, and that there was no facility procedure requiring patch skin assessments. The nurse also confirmed the patch had been placed the previous day and had not been reapplied after it came off. The DON later confirmed there was no current process for daily patch placement checks. The clonidine prescribing information stated the patch is designed to deliver medication consistently for one full week and must be replaced if it significantly loosens or falls off. For controlled substances, the CDRs did not reconcile for two sampled residents. For Resident 57, the MAR documented administrations of oxycodone 5 mg and oxycodone 10 mg, but the CDRs for both oxycodone cards had no corresponding sign-out entries for those doses. The DON and ADON confirmed the MAR entries did not reconcile with the controlled substance records. For Resident 45, the CDR showed hydrocodone-acetaminophen 5-325 mg was removed from the CDR on 4/19/26 at 5:46 a.m., but there was no corresponding documentation on the MAR that the medication had been administered. The DON and ADON acknowledged the missing MAR documentation, and the facility policy stated that when a controlled medication is administered, the nurse must immediately enter the date, time, amount administered, and signature on both the accountability record and the MAR.
Unnecessary Insulin Holds and Lack of Monitoring
Penalty
Summary
The facility failed to ensure Resident 45’s drug regimen was free from unnecessary drugs. Resident 45 was admitted with diagnoses including type 2 diabetes, long-term insulin use, type 2 diabetes with circulatory complications, and polyneuropathy. Physician orders included insulin lispro 3 units three times daily before meals and fingerstick blood sugar monitoring with instructions to notify the physician if blood sugar was below 60 or above 300. During interview and record review, nursing staff confirmed the insulin was ordered before meals with no parameters to hold the dose, and that blood sugars were being checked, but they also stated that insulin monitoring consisted only of checking blood sugars and assessing diet intake. Review of the MARs for March, April, and May 2026 showed multiple insulin lispro doses documented as held, including one dose in May, 14 doses in April, and 9 doses in March. The DON and ADON confirmed there were no nursing notes documenting a reason for the held doses and no documentation that the physician was notified. They also confirmed there were no MAR entries documenting monitoring for insulin side effects or assessment for signs or symptoms of hypoglycemia or hyperglycemia. Facility policies required medications to be administered as prescribed and required clarification of orders that appeared inappropriate or unrelated to the resident’s condition, and the prescribing information for insulin lispro stated it should be used under close medical supervision with increased blood glucose monitoring.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure its medication error rate remained below 5%, with a calculated error rate of 13.89% based on 5 medication errors out of 36 opportunities observed during medication administration for 2 sampled residents. The report states that Resident 81 received a lower-than-prescribed dose of cholecalciferol and a higher-than-prescribed dose of magnesium during a medication pass at the Station 2 med cart. The nurse administering the medications confirmed she gave one 400 mg magnesium tablet when the order was for 200 mg, and she also confirmed she administered one 25 mcg vitamin D tablet even though the order was for 125 mcg. For Resident 62, a nurse prepared and administered multiple oral medications and, after the resident had difficulty swallowing a liquid medication, asked whether the medications should be crushed. The resident agreed, and the nurse crushed each of the oral medications individually and mixed them with applesauce. Among the medications crushed were aspirin delayed-release 81 mg and ferrous sulfate 325 mg, both of which had physician orders stating DO NOT CRUSH. The nurse acknowledged the medications were crushed despite those orders, and the ADON acknowledged that an alternative dosage form should have been obtained. The report also states that Resident 62 received insulin glargine from a Lantus SoloStar pen without the nurse performing the required safety test or priming step. During the observation, the nurse attached a new needle, dialed the pen to 23 units, and administered the insulin, then stated she had been taught priming was unnecessary because the pen is ready to go. The DON and ADON stated staff are expected to follow the manufacturer’s guidelines for administration, and the manufacturer instructions reviewed by surveyors required a safety test before each injection.
Insulin Lispro Given Too Early Before Meals
Penalty
Summary
Resident 45, who was admitted with diagnoses including type 2 diabetes, long-term insulin use, type 2 diabetes with circulatory complications, polyneuropathy, and other diabetic neurological complications, had physician orders for insulin lispro 3 units three times daily before meals at 6 a.m., 11 a.m., and 4 p.m. The record also included an order for daily fingerstick blood sugar monitoring with instructions to notify the physician if blood sugar was less than 60 or greater than 300 and to treat hypoglycemia per protocol. During interview and record review, the DON and ADON reviewed the resident’s MARs, progress notes, and physician orders and confirmed the facility’s mealtimes were 7 a.m., noon, and 5 p.m., and that insulin lispro was expected to be administered within 30 minutes of the meal. The MAR review showed the resident’s morning insulin lispro was routinely given 1 to 2 hours before the scheduled 7 a.m. breakfast time across March, April, and May 2026, with multiple administrations documented between about 5:06 a.m. and 6:35 a.m.; one dose was held on 5/7/2026. The DON and ADON acknowledged these early-morning administrations occurred before breakfast and in some cases 2 hours before the meal, and stated that insulin lispro should be administered within 15 minutes before a meal or immediately after a meal. They further acknowledged the administrations did not follow the prescriber’s orders, the facility’s medication administration policies, or manufacturer guidelines, and that giving rapid-acting insulin earlier than mealtime increases the risk of hypoglycemia and side effects.
Medication Storage and Security Failures
Penalty
Summary
Medications and biologicals were not stored in accordance with manufacturer guidelines and facility policy when the medication refrigerator was found out of temperature range and was not rechecked for over five hours. During an inspection of the medication storage room, the refrigerator was observed at 54 degrees F, outside the required 36 to 46 degrees F range. On follow-up the same day, the thermometer was in the red spoilage zone at 64 degrees F and the temperature control dial was in the off position. The ADON stated the refrigerator had likely been turned off that morning and acknowledged staff had not rechecked the temperature after it was first noted out of range. The refrigerator contained two emergency kits with lorazepam injection vials and insulin vials, one vial of tuberculin, one bottle of lorazepam oral solution, two Mounjaro pens, and several bisacodyl suppositories. The ADON stated the refrigerator had been out of range for approximately six hours, and the DON and ADON later stated their expectation was for staff to re-check an out-of-range refrigerator within 30 minutes. The facility also had expired and improperly maintained medications in the Station 3 medication cart. Surveyors observed one bottle of latanoprost eye drops labeled for Resident 66 with an expiration date of 4/30/26, and an opened bottle of glucose test strips that was not dated. The nurse confirmed the latanoprost was expired and stated it would be removed from stock. The nurse also read the glucose strip label, which indicated use within 6 months after first opening, and confirmed the bottle had not been dated. Facility policy stated outdated, contaminated, or deteriorated medications are to be immediately removed from stock and that drugs shall not be kept after the expiration date on the label. Resident 81, who had been admitted with a left femur fracture and had moderate cognitive impairment on the MDS, was observed with a bottle of eye drops on top of the bedside table. The resident stated the eye drops were used for dry eyes. The ADON confirmed the bottle was at the bedside and stated the goal was to have medications from home reviewed and secured in the locked medication cart. Facility policy stated medications and biologicals are to be stored safely, securely, and properly, and that medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or other staff lawfully authorized to administer medications.
Infection Control Failures During Wound Care, Glucose Monitoring, and Insulin Preparation
Penalty
Summary
Proper infection prevention and control practices were not followed during wound care for a resident admitted with pressure ulcers of the sacral region, right buttock, and left buttock. The resident had an order for treatment to cleanse the left gluteus wound with normal saline, apply Medi honey, and cover with a dry dressing daily and as needed until resolved. During observation of the wound treatment, the WTN removed the old dressing, poured normal saline over a prepared stack of gauze, used that gauze to cleanse the wound, then folded the same stack of gauze in half and used it to dry the wound. During interviews, the IP stated that clean gauze should be used to dry a wound because used gauze, even if folded, is considered contaminated. The DON also stated that used gauze should not be used to dry a wound and that staff should use clean gauze to clean the wound with normal saline and a separate clean gauze to dry the wound. The facility policy titled, Dressings, Dry/Clean, stated to use clean gauze for each cleaning stroke and to use dry gauze to pat the wound dry. In a separate observation during medication administration, an LN checked a resident's blood sugar using a glucometer and cleaned the device with an alcohol pad before the fingerstick, then returned it to the medication cart. The LN stated she used the same type of alcohol pad that was used to clean the resident's finger. The LN later confirmed she did not clean the glucometer after use. In another medication pass observation, the same LN removed a Lantus Solostar insulin pen, attached a new needle, and dialed the dose without first wiping the rubber seal with an alcohol swab. The LN confirmed she did not swab the rubber seal before attaching the needle, and the DON and ADON confirmed staff are expected to follow manufacturer guidelines when preparing insulin.
Unauthorized Search of Resident Belongings
Penalty
Summary
The facility failed to respect Resident 26’s right to privacy and personal property when staff searched and took items from the resident’s belongings without consent. Resident 26 was admitted with diagnoses including a fracture of the second cervical vertebra and frequent falls, and the MDS dated 3/5/26 indicated intact cognition. On 5/6/26, the resident was observed pacing in his room, visibly upset, angry, and frustrated, and stated that he did not like the facility and wanted to leave. He reported that staff had opened and checked his personal belongings without his permission while he was not in his room. A progress note dated 5/4/26 documented that the resident had made a statement about reaching out to narcotics while on LOA, and that, with permission from the DON, staff checked the resident’s room and belongings for possible medications or beverages. An alcoholic beverage bottle was found in his bag and placed in the med room. The record contained no documented evidence that Resident 26 consented to the search, and no specific documentation was found showing that he was intoxicated, under the influence of drugs or alcohol, or exhibiting behavioral changes indicating an immediate safety concern at the time the belongings were searched. During interview, the DON confirmed she authorized staff to check the resident’s belongings without his consent.
Smoking Safety Care Plan Not Implemented
Penalty
Summary
The facility failed to ensure smoking safety interventions in Resident 26’s care plan were implemented and that adequate supervision was provided to prevent smoking-related accidents. Resident 26 was admitted with diagnoses including fracture of the second cervical vertebra, repeated falls, and nicotine dependence. The MDS dated 3/5/26 indicated the resident had intact cognition. The care plan revised 5/5/26 identified a focus of potential for injury related to noncompliance, with interventions stating that cigarettes were to be held in the nurses’ cart and that the resident was not to have cigarettes in the room or on self. During observation on 5/5/26 at 10:47 a.m., Resident 26 was pacing in his room, appeared visibly upset, and stated he was upset, did not like the facility, and wanted to leave. He was observed holding a pack of cigarettes in his room. During a concurrent observation and interview on 5/6/26 at 9:30 a.m., the resident was again holding a pack of cigarettes in his room. A CNA confirmed the resident goes out by himself to smoke outside and confirmed he was holding cigarettes in his room. The resident stated he always has his cigarettes in his possession and goes out to smoke a few times a day. During interview and record review on 5/7/26, the ADON acknowledged the care plan intervention but stated the resident had done it again, that the facility did not have a safety assessment specific to smoking practices, and that no smoking assessment process interventions were done because the facility is a non-smoking facility. The ADON also acknowledged there was no updated care plan and that the care plan had not been implemented despite repeated observations of the resident possessing cigarettes.
Uncovered Pressure Ulcer Dressing Not Changed as Needed
Penalty
Summary
The facility failed to ensure that Resident 53 received necessary treatment and services to promote healing and prevent infection when the coccyx pressure ulcer dressing was not changed as needed. Resident 53 was admitted with diagnoses including sepsis, Fournier gangrene, and a stage 2 pressure ulcer of the buttock. The physician order required the coccyx pressure ulcer to be cleansed with normal saline, treated with Santyl, and covered with a dry dressing daily and as needed if loose or soiled. Review of the TAR for 5/1/26 through 5/31/26 showed no documentation that the coccyx dressing was changed as needed. During observation on 5/7/26, the WTN found the coccyx wound uncovered and confirmed there was no dry dressing in place, stating that if the wound was not covered, contaminants could come into contact with it. CNA 1 stated she provided incontinence care around 7:00 a.m. and the dressing was no longer on the wound at that time. On 5/8/26, LN 4 again observed that there was no dry dressing on the coccyx wound, and CNA 2 stated she had seen no dressing during incontinence care at about 6:35 a.m. and still no dressing during a bed bath at about 8:45 a.m. The DON stated that when a dressing was soiled or dislodged, it should be changed right away, and any licensed nurse could change it as needed.
Failure to Offer Substitute Meals When Intake Was 50% or Less
Penalty
Summary
Provide enough food and fluids to maintain a resident's health was not met for one resident with diabetes, a stage 2 pressure ulcer, a humerus fracture, anemia, and moderate cognitive impairment. The resident was admitted in April 2026, and the MDS dated 4/21/26 documented moderate cognitive impairment. The care plan dated 4/16/26 included an intervention to honor food preferences within diet parameters and to offer a substitute if the meal was taken at 50%. Record review of the nutrition task sheet showed that from 4/15/26 through 5/7/26 the resident had multiple meals where 50% or less was eaten, but there was no documentation that a substitute meal was offered. During interview, a CNA stated the resident eats less than 50% for most meals and that a substitute meal is not offered. The ADON reviewed the record and confirmed there was no documentation of a substitute meal being offered, and the RD stated the resident was at nutritional risk due to diabetes and wound healing and that a substitute meal would be expected when intake was 50% or less.
Call Light Not Kept Within Reach for Resident on Bedside Commode
Penalty
Summary
The facility failed to ensure a resident’s call light was within reach as required by the resident’s care plan and facility policy. The resident had diagnoses including a fall, a healing left femur fracture, difficulty walking, and a communication deficit, with a BIMS score of 11 indicating moderate cognitive impairment. The resident’s care plan for fall risk, dated 10/18/25, specified that the call light should be within reach when the resident was in the room. During an observation in the resident’s room, the resident was seated on a bedside commode on the right side of the bed and stated a need for help, while the call light was positioned on the left side of the bed, out of the resident’s reach. In interviews, the CNA who had transferred the resident to the bedside commode acknowledged that the call light was out of reach and stated that the call light should always be within reach, and that the resident should have been able to press it after finishing on the commode. The resident stated that the call light should be within reach and that if it was not, it would take a while for someone to help. A licensed nurse confirmed that the call light should be within the resident’s reach and that otherwise the resident would wait longer. The DON stated that residents should be able to reach their call lights at all times and that without this it would be impossible for residents to ask for help. The facility’s “Answering the Call Light” policy required that the call light be accessible to residents when in bed, on the toilet, in the shower or bathing facility, and from the floor.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident who had an indwelling urinary catheter, a condition that requires Enhanced Barrier Precautions (EBP) according to facility policy. During an observation, a Physical Therapy Assistant (PTA) transferred the resident without wearing a gown, despite being in close contact and being aware that EBP was required for residents with indwelling catheters. The PTA confirmed during an interview that a gown should have been worn during the care activity. Additionally, there was no signage outside the resident's room to indicate that EBP was in place, as required by the facility's policy. The Infection Preventionist Nurse confirmed the absence of signage and acknowledged that residents with indwelling catheters should have EBP signage to inform staff of the necessary precautions. The Director of Nursing also stated that EBP was expected for residents with indwelling catheters to prevent the spread of infection.
Unqualified Dietary Manager Leads to Food Service Deficiencies
Penalty
Summary
The facility failed to ensure that the full-time Director of Food and Nutrition Services (Dietary Manager) met the state's educational qualification requirements as mandated by federal regulation. The Dietary Manager, who had been employed for three months, did not possess the necessary credentials such as Certified Dietary Manager (CDM) or Dietary Services Supervisor (DSS) certification. This lack of qualification led to lapses in the delivery of food and nutrition services, including inaccuracies in meal distribution and issues with safe food handling and sanitation. The Registered Dietitian (RD) was only available on a part-time consulting basis, which further contributed to insufficient oversight of the dietary department. During the survey, several deficiencies were identified, including incorrect serving sizes, failure to provide fortified food as ordered, and various sanitation issues such as an unclean ice machine and improper handwashing practices. The facility's Administrator was aware of the Dietary Manager's lack of certification but relied on his previous experience and ServSafe certification, which did not meet state requirements. The RD, who worked part-time at the facility, was also unaware of the Dietary Manager's lack of qualifications. The facility's failure to employ a qualified Dietary Manager resulted in compromised food service operations for all 60 residents receiving meals from the facility kitchen.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain food service safety standards, as evidenced by several deficiencies observed during a survey. The ice machine was found to be unclean, with significant black substances on the evaporator unit, indicating a lack of proper cleaning and maintenance. The Dietary Manager (DM) and Maintenance Supervisor (MS) confirmed the ice machine's condition, acknowledging that the deep cleaning process was not adequately verified. The facility's policy required regular cleaning of the ice machine, but the last recorded cleaning was not effective, leading to potential contamination risks. In the kitchen, various kitchenware items were improperly stored, with some stacked while still wet and others having brown sticky liquid residues. The DM confirmed these findings, stating that the staff responsible for storing the dishes failed to ensure they were clean and dry, which could promote bacterial growth. Additionally, two boxes of sliced turkey deli meat, which required freezing, were improperly stored in the walk-in refrigerator instead of the freezer, as per the storage instructions. This oversight was attributed to the staff responsible for receiving deliveries not following the proper storage procedures. Further deficiencies were noted in handwashing practices and dishwashing procedures. The handwashing sink's location led to water splashing onto clean dishes, causing potential cross-contamination. A cook was observed washing hands at a prep sink without proper facilities for handwashing, and a dietary aide was unable to correctly verbalize the manual dishwashing process. These practices were contrary to the facility's policies and the FDA Food Code, highlighting a lack of adherence to proper sanitation and hygiene protocols.
Failure to Replace Emergency Medications in E-kit
Penalty
Summary
The facility failed to maintain adequate pharmacy services for its residents, as evidenced by the improper management of emergency medications in the E-kit. During an observation and interview, it was found that the E-kit had a broken seal and contained medications that had been removed but not replaced in a timely manner. Specifically, Vancomycin tablets were removed on two separate occasions for one resident, while Potassium KCL and Levofloxacin tablets were removed for another resident, and Doxycycline was removed for a third resident. The Licensed Nurse confirmed that the process required notifying the pharmacy for replacement, which should occur the next day. Further investigation with the Director of Nursing revealed that the medications had been removed several days prior and had not been replaced, either due to a failure to notify the pharmacy or the pharmacy's failure to replace them. The facility's policy stated that replacement doses should be added to the kit within 72 hours, but this was not adhered to, potentially leaving residents without necessary emergency medications.
Failure to Follow Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to adhere to prescribed therapeutic diets during lunch meals on two consecutive days, affecting 19 residents. On the first day, two residents on a Consistent Carbohydrate (CCHO) diet received a full slice of garlic bread instead of the prescribed half slice. The Registered Dietitian confirmed that the menu was not followed as per the facility's spreadsheet. On the second day, six residents on a fortified diet did not receive the additional one ounce of shredded cheese required for their meal. Additionally, five residents on a 2-gram sodium diet received a full serving of dessert instead of the prescribed half serving. Furthermore, five residents on a mechanical soft diet were given regular dessert instead of the modified version, while four residents on a regular diet received the mechanical soft dessert instead of the regular one. The Dietary Manager acknowledged these discrepancies during an interview, confirming that the staff did not follow the menu spreadsheet, which led to the incorrect meal distributions. The Registered Dietitian also acknowledged the findings and emphasized the importance of following the menu to meet the residents' nutritional needs. The facility's job description for the Director of Food and Nutrition and the menu planning document both highlight the necessity of adhering to prescribed diets, which was not done in these instances, potentially compromising the medical and nutritional status of the affected residents.
Infection Control Lapses in Food Transport, Glucometer Use, and Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices in three distinct instances. First, four meal trays with uncovered desserts were transported from the dining room to resident rooms using a utility cart, contrary to the facility's policy that requires food items to be covered during transport to prevent contamination. This was confirmed by both the Certified Nursing Assistant and the Dietary Manager, who acknowledged the risk of foodborne illness due to uncovered food. Second, a shared glucometer was not sanitized between uses on two residents with type 2 diabetes mellitus, as observed with a Licensed Nurse. The nurse admitted to not cleaning the glucometer between uses, which was against the facility's policy and posed a potential infection control issue. Lastly, a foley catheter collection bag for a resident with a lumbar vertebrae fracture was found on the floor, which was acknowledged by a Certified Nursing Assistant and the Director of Nursing as a breach of infection control procedures, as the bag should have been hooked onto the bed rail to prevent contamination.
Resident Dignity Compromised During Blood Draw
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during a blood draw procedure. The resident, who had intact cognition and was admitted with conditions including infection due to a knee prosthesis and chronic systolic heart failure, reported that a Licensed Nurse (LN 3) was disrespectful and rough during the procedure. The resident stated that LN 3 refused to perform a central venous access device blood draw, citing other tasks, and was rough during the lab draw. Despite the resident's request to try the other lumen of the central line after an unsuccessful attempt, LN 3 refused. Further investigation revealed that LN 3 was rude to both the resident and the phlebotomy technician, blaming the resident for the timing of the blood draw and causing the resident distress. The Director of Nursing (DON) confirmed that only registered nurses are permitted to draw blood from a CVAD/PICC line and emphasized the expectation for staff to be kind and respectful. LN 3's performance review indicated a need for improvement in communication, as she could be punitive. The facility's policy on dignity requires that residents are treated with respect at all times, which was not upheld in this instance.
Failure to Follow Medication Self-Administration Policies
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding medication self-administration for two residents, Resident 29 and Resident 43. There were no assessments conducted to determine the safety of self-administration and storage of medications at the bedside for these residents. Additionally, the facility did not obtain physician's orders for the self-administration and bedside storage of medications for both residents. This lack of documentation and assessment led to potential risks associated with unsafe medication administration. Resident 29, who was admitted with diagnoses including Parkinson's disease and sepsis, was observed with an unlabeled bottle of tablets on the bedside table. The resident confirmed storing calcium carbonate at the bedside for acid reflux, but there was no documented evidence of an assessment for self-administration or safe storage, nor a physician's order for such practices. Similarly, Resident 43, admitted with asthma and chronic respiratory failure, had an inhaler stored in a bag at the bedside without original packaging or labeling. The resident admitted to not always informing staff about self-administration, and there was no documented evidence of assessment or progress notes confirming self-administration. Interviews with staff, including a Licensed Nurse and the Pharmacist Consultant, confirmed the absence of necessary orders and assessments. The Director of Nursing acknowledged the expectation for evaluations and orders for bedside medication storage and self-administration, which were not consistently followed. The facility's policies required assessments and documentation for self-administration and safe storage, which were not adhered to, leading to potential risks of medication misuse and access by other residents.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to follow physician orders for a resident, identified as Resident 35, by not accurately documenting medications administered on the Medication Administration Records (MAR). This deficiency was identified during a review of Resident 35's records, which showed discrepancies in the documentation of medication administration. Specifically, the MAR for a particular date indicated that the 8:00 p.m. dose of Vancomycin was not documented as administered, although the Director of Nursing (DON) confirmed that the dose was given. Additionally, the MAR for another date showed that no doses of Oxycodone were documented as administered, despite the Assistant Director of Nursing (ADON) stating that the medication was given. The facility's policy and procedure for medication administration, dated March 2018, requires that the individual administering the medication records the administration on the MAR immediately after giving the medication. The failure to document the administration of medications as per the facility's policy posed a risk of miscommunication among nursing staff and the potential for the resident to receive more medication than ordered, which could lead to adverse side effects. Interviews with the DON and ADON highlighted the expectation for licensed staff to accurately document medication administration to prevent inaccurate and unsafe medication practices.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide activities that met the interests and preferences of two residents, Resident 39 and Resident 33, as outlined in their care plans and assessments. Resident 39, admitted with a fracture of the right femur, was not offered activities in her room despite her care plan indicating the need for encouragement in activities of interest and socialization. The Activities Director confirmed that Resident 39 received only one activity visit in five weeks, which was insufficient to meet her needs. The lack of documented activity notes or logs further highlighted the deficiency in providing adequate activities for Resident 39. Similarly, Resident 33, who has Alzheimer's Disease and major depressive disorder, was not engaged in activities as per her care plan, which included group activities and 1:1 visits. Observations showed Resident 33 frequently asleep in her room, with no evidence of 1:1 activities being provided. The Activities Director acknowledged that staff did not get Resident 33 up for group activities and confirmed that the few documented visits were inadequate. The Director of Nursing also recognized that the frequency of activity visits did not meet the residents' physical, mental, and psychosocial needs, as required by the facility's policy.
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What surveyors actually found near you
We read the 676 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Roseville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Roseville Point Health & Wellness Center | 0.3 mi | ★★★★★ | 9 | 0 |
| Roseville Care Center | 0.9 mi | ★★★★★ | 2 | 0 |
| Pine Creek Care Center | 0.9 mi | ★★★★★ | 1 | 0 |
| Citrus Heights Post Acute | 5.3 mi | ★★★★★ | 13 | 0 |
| Fair Oaks Healthcare Center | 6 mi | ★★★★★ | 23 | 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.