Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Villages At Oak Ridge, The during CMS and state inspections, most recent first.
A resident with immobility, incontinence, and moderate cognitive impairment, identified as at risk for skin breakdown, developed an open wound on the left buttock after prior documentation of MASD and shearing in the gluteal area. When the open area with yellow material was first noted and the resident complained of pain, nursing staff did not initiate a wound event, complete a full wound assessment with measurements, or obtain new treatment orders until three days later, when the wound was documented as a Stage 3 pressure injury and a new topical dressing was ordered. Staff interviews confirmed that facility procedures required immediate wound assessment and notification of the wound nurse and physician for new wounds, consistent with the written wound and skin care policy.
A resident with a history of falls and moderate cognitive impairment was left without accessible call lights, despite care plan interventions requiring their use. During observation, both call lights were out of reach, and an LPN did not check or assist with call light placement. This failure to follow care plan interventions and facility policy resulted in inadequate supervision and increased fall risk.
A facility failed to prevent UTIs in a resident with a nephrostomy tube, leading to frequent hospitalizations. The resident's care plan lacked interventions for UTI prevention, and the MDS Assessment was incorrectly coded. Antibiotics were administered incorrectly, and follow-up appointments with specialists were not scheduled. Staff interviews revealed a lack of training and failure to reinstate orders post-hospital discharge.
The facility failed to ensure ADLs were provided for dependent residents, resulting in four residents not receiving showers at least twice per week. Observations included greasy, unbrushed hair and strong body odor, with clinical records lacking necessary care plans and documentation.
The facility failed to ensure that a resident was treated with respect and dignity when a CNA was observed feeding the resident at the nurse's station. The resident had diagnoses of cerebral palsy, epilepsy, and dysphagia, and required extensive assistance for eating. The facility's policy emphasized the right of residents to be treated with dignity and respect.
The facility failed to complete proper assessments for a resident who was observed self-administering medications without an order or care plan. The resident was found with unauthorized medications in her room, contrary to the facility's policy.
The facility failed to implement care plans for two residents. One resident's oxygen humidification bottle was repeatedly found empty, and another resident did not receive a prescribed dose of lorazepam due to the drug being unavailable. These deficiencies were confirmed through observations, staff interviews, and clinical record reviews.
The facility failed to maintain safe and secure storage of medications for one of the two medication carts observed. Loose pills were found in the 300 Hall medication cart, and staff interviews confirmed that such pills should be disposed of. The facility's policy requires immediate removal and disposal of contaminated or deteriorated medications.
The facility failed to ensure proper infection control practices during medication administration. A nurse handled medications with bare hands, and a medication aide placed an insulin supply box on a resident's catheter bag and an insulin syringe on a sink before administration.
Delayed Assessment and Treatment of New Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to promptly assess and treat a newly identified pressure ulcer for a resident who was at risk for skin breakdown. The resident had diagnoses including lumbar fracture, polyneuropathy, muscle weakness, need for personal assistance with care, and cognitive communication deficit, and was dependent for mobility with moderate cognitive impairment. The admission MDS indicated no unhealed pressure wounds but identified the resident as at risk for developing pressure ulcers. The care plan noted risk for skin breakdown due to incontinence and need for assistance with mobility/positioning, and later documented a pressure ulcer to the left buttock. Nursing notes showed that on one date, shearing to the left gluteal fold was noted and treated with barrier cream, and on a later date the wound care nurse assessed moisture-associated skin damage (MASD) to the gluteal fold and initiated weekly wound care follow-up with application of a topical cream. Subsequently, the resident complained of buttock pain and an open wound with yellow slough lateral to the midline was documented, but a full wound assessment, staging, and new treatment orders were not completed until three days later. The wound was then documented as a Stage 3 pressure injury to the left buttock with specific measurements, granulation tissue, and MASD to the peri-wound skin, and a new physician order for a wound dressing was obtained on that same later date. During observation, the wound appeared as three open areas with granulation tissue and well-defined edges, and the resident reported pain and burning during treatment. In interviews, nursing staff stated that the nurse who first discovered the open area should have opened a wound event, completed an initial assessment with measurements, and notified the physician and wound nurse for new treatment orders. The facility’s wound and skin care policy required turning/repositioning immobile residents per care plan and notifying the wound care nurse or supervisor for all new Stage II–IV pressure ulcers.
Failure to Ensure Call Light Accessibility and Supervision for Fall-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to prevent falls for a resident with a history of repeated falls, chronic pain, and moderate cognitive impairment. The resident's care plan included interventions such as ensuring call light attendants were in place and functioning, and staff were to ensure the resident was in bed or a recliner with the call light accessible. Despite these interventions, after a fall in which the call light was found unplugged and the resident was unable to call for help, new interventions were added to ensure the call light was properly connected and functioning at all times. However, during a subsequent observation, the resident was found sitting in a wheelchair with both call lights out of reach—one hanging off a recliner and another in a bedside table drawer. An LPN entered and exited the room without checking the call light placement or offering assistance to the resident, and later stated being unaware of the resident's call light needs. The facility's policy required staff to monitor and document the effectiveness of interventions and to carry out physician orders, but these were not followed, resulting in inadequate supervision and failure to maintain a hazard-free environment for the resident.
Failure to Prevent UTIs in Resident with Nephrostomy Tube
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTIs) for a resident with a nephrostomy tube. The resident, who had a history of frequent hospitalizations due to UTIs, reported that the facility only changed the dressing on the nephrostomy tube on shower days or when it fell off. The resident also indicated that she occasionally sat in a wet brief until staff assistance was available. The clinical record lacked current orders related to the nephrostomy tube and follow-up appointments with specialists, such as a nephrologist and urologist, were not scheduled or documented. The resident's Minimum Data Set (MDS) Assessment was incorrectly coded, failing to indicate a UTI in the last 30 days, despite the resident having multiple UTIs since April 2024. The care plan did not include interventions specific to the prevention of recurrent UTIs. Additionally, there were discrepancies in the administration of antibiotics, with the resident receiving an extra dose of Keflex and Merrem than ordered. The facility also failed to reschedule a nephrology appointment after the resident missed it due to hospitalization. Interviews with facility staff revealed a lack of in-service training related to nephrostomy tubes and a failure to reinstate orders after the resident's hospital discharge. The MDS Coordinator acknowledged the need for a care plan addressing the resident's recurrent UTIs and the necessity of marking the UTI in the MDS Assessment. The facility did not provide a policy for following physician orders before the survey exit, highlighting a gap in ensuring comprehensive care planning and follow-up for residents with complex medical needs.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to ensure that Activities of Daily Living (ADLs) were provided for dependent residents, specifically in the area of bathing. Four residents were observed with greasy, unbrushed hair or strong body odor, indicating they had not received showers at least twice per week as required. Resident 15, who has dementia, was observed multiple times with greasy, unbrushed hair, and their clinical record lacked care plans or physician orders related to shower assistance. The records showed inconsistent shower dates, and staff confirmed the resident required total assistance but did not refuse showers. Resident 107, admitted with diagnoses including dementia, anxiety, and depression, was also observed with greasy hair. Their clinical record lacked care plans or physician orders for shower assistance, and the records indicated only one shower since admission. Staff were unsure about the resident's resistance to showers, but the ADON confirmed the resident did not refuse showers. Similarly, Resident 51, with severe cognitive impairment, was observed with a strong body odor and had an inconsistent shower schedule. Their clinical record also lacked necessary care plans and physician orders. Resident 44, diagnosed with dementia, anxiety, and depression, was observed with greasy hair and had a clinical record that lacked care plans or physician orders for shower assistance. The records showed inconsistent bathing dates and refusals that were not properly documented. Staff indicated that Resident 44 sometimes refused bathing, and proper documentation of refusals was not consistently maintained. The facility's policy required ADL services to be documented by CNAs each shift, but this was not adhered to, leading to the observed deficiencies.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that Resident 47 was treated with respect and dignity. On 3/19/24 at 9:30 A.M., CNA 33 was observed feeding Resident 47 at the nurse's station while the resident was sitting in a wheelchair. Resident 47's clinical records indicated diagnoses of cerebral palsy, epilepsy, and dysphagia, and required extensive assistance for various activities, including eating. During an interview, CNA 25 confirmed that residents should be fed in their rooms or in a private dining room to maintain dignity. The facility's Resident Rights Guidelines Policy, provided by the DON, emphasized the right of residents to be treated with dignity and respect.
Failure to Ensure Proper Assessment for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure proper assessments were completed for a resident who was observed self-administering medications. During an observation, Resident 34 was found alone in her room with two medication cups, one containing applesauce and the other containing various pills. The medications were later confirmed by an LPN to be Resident 34's morning medications, which were not supposed to be in the room. A review of Resident 34's clinical record revealed no order or care plans for self-administration of medications, except for a previous assessment allowing the use of Vick's products only. Further interviews and record reviews indicated that Resident 34 required limited assistance with activities of daily living and had no cognitive impairments or behaviors according to the most recent MDS assessment. The facility's policy on self-administration of medications required an assessment and physician's order, which were not present in Resident 34's case. This oversight led to the resident having unauthorized access to medications in her room.
Failure to Implement Care Plans for Oxygen Therapy and Medication Administration
Penalty
Summary
The facility failed to implement the care plan for two residents. For Resident 30, the oxygen humidification bottle was observed to be empty on multiple occasions, and the oxygen tubing was found lying on the floor. Despite the physician's orders and care plan interventions to administer oxygen and monitor for signs of shortness of breath, the humidification bottle was not consistently filled, and the oxygen equipment was not properly maintained. This was confirmed through observations, interviews with staff, and a review of Resident 30's clinical records, which indicated diagnoses of chronic obstructive pulmonary disease and pulmonary fibrosis. For Resident 29, the facility failed to administer a prescribed dose of lorazepam, an antianxiety medication, due to the drug being unavailable. The medication was not given as ordered on a specific date, and there were no progress notes documenting the unavailability of the medication. Resident 29's care plan included an intervention to administer medication per order, but this was not followed. The resident's clinical record indicated a diagnosis of traumatic brain injury and significant cognitive impairment. The failure to administer the medication as prescribed was documented in the Medication Administration Record.
Failure to Maintain Safe and Secure Storage of Medications
Penalty
Summary
The facility failed to maintain safe and secure storage of medications for one of the two medication carts observed. During an observation, loose pills were found in the drawers of the 300 Hall medication cart, including a round yellow pill, a round white pill marked with HH210, two oblong white tablets marked with L484, a round pink pill marked with L21, and a round light yellow pill. In an interview, a Qualified Medication Aide (QMA) indicated that all nursing staff were responsible for cleaning out medication carts every other day and that loose pills should be disposed of. The Infection Preventionist (IP) confirmed that there should not be loose pills in the medication cart. The facility's Medication Storage policy, revised in November 2018, states that contaminated or deteriorated medications and those in containers that are cracked, soiled, or without secure closures should be immediately removed from inventory and disposed of according to procedures for medication disposal.
Infection Control Deficiencies in Medication Administration
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for two residents. In one instance, a Registered Nurse (RN) was observed preparing medications by popping pills into her bare hand before placing them into a medication cup and administering them to a resident. In another instance, a Qualified Medication Aide (QMA) placed an insulin supply box on a resident's catheter bag and an insulin syringe on a sink before administering the insulin to the resident. The Infection Preventionist (IP) confirmed that staff should not handle medications with bare hands and that insulin supply containers should be placed on a bedside table with a protective layer between the syringe and the surface. The facility's current medication administration policy, dated 12/31/23, also indicated that staff should not handle medications with bare hands. However, a basic infection control policy was requested but not provided.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillside Manor Nursing Home | 1.5 mi | ★★★★★ | 31 | 1 |
| Eastgate Manor Nursing And Rehabilitation | 1.8 mi | ★★★★★ | 0 | 0 |
| Prairie Village Nursing And Rehabilitation | 1.9 mi | ★★★★★ | 0 | 0 |
| Amber Manor Care Center | 11.6 mi | ★★★★★ | 4 | 0 |
| Brickyard Healthcare - Petersburg Care Center | 12.1 mi | ★★★★★ | 13 | 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.