Below 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 Diversicare Of Oak Ridge during CMS and state inspections, most recent first.
During a lunch meal service, the facility did not maintain safe food temperatures for several prepared items after a gas leak rendered the gas range and dishwasher inoperable. Foods were heated in electric convection ovens and held in disposable aluminum pans on the steam table, but temperatures for items like baked chicken, barbeque pork, pureed corn, and cooked spinach were found to be below the safe holding range. The Certified Dietary Manager confirmed that food temperatures were not monitored throughout the meal service.
A facility failed to protect a resident from sexual abuse when two residents with cognitive impairments were found engaging in sexual intercourse. Despite the facility's policy against abuse, there was no documentation of discussions with family members about consensual sexual activity. The incident was reported due to the low cognitive score of one resident, and staff assessments indicated the situation was consensual. However, the lack of documented family discussions highlights a deficiency in handling residents' rights and safety.
A facility failed to provide a homelike environment for a resident with paraplegia and other health issues, as their room had damaged drywall and a significant hole that was not repaired despite being reported. Additionally, a strong, foul odor persisted in one of the hallways, which was confirmed by the DON and Administrator, indicating a failure to maintain a comfortable environment.
A facility failed to protect residents from abuse, with incidents involving physical and verbal aggression among residents. A cognitively intact resident was struck by a confused resident, resulting in slight redness but no lasting injury. Another resident with dementia was verbally and physically aggressed by a roommate, with no physical injuries reported. Despite cognitive impairments and lack of recollection, the facility's investigation confirmed abuse, highlighting a deficiency in resident protection.
A resident with cognitive impairments reported a sexual assault by a staff member to her physician, but the facility failed to report the allegation to the State Agency within the required 2-hour timeframe. The Medical Director documented the allegation, but the previous Administrator did not recall being informed, leading to a delay in reporting.
A facility failed to complete a Minimum Data Set (MDS) assessment accurately for a resident with multiple diagnoses, including Dementia and Psychosis. The resident's quarterly MDS assessment lacked a Brief Interview for Mental Status (BIMS) or a staff assessment. The RN/MDS Coordinator confirmed the omission, noting that the mental status section should have been completed but was not due to an oversight in the computer-generated process.
The facility failed to provide transportation for two residents to their scheduled outpatient appointments, resulting in missed medical visits. Both residents were cognitively intact and had specific medical conditions requiring follow-up care. The Transportation Director and DON were unaware of the missed appointments, and there was no documentation in the transportation log or residents' charts. The Medical Director noted the need for better follow-up on scheduling and transportation for outside appointments.
Failure to Maintain Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to maintain prepared foods within safe serving temperature ranges during a lunch meal service. On the day of the observation, the gas range and commercial dishwasher were inoperable due to a gas leak, resulting in the gas supply being shut off. As a result, foods were heated using electric convection ovens and placed into disposable aluminum pans, which were then set inside steam table pans for temperature management. During the latter part of the tray pass, it was observed that the steam table was set to high, but food temperatures measured with calibrated thermometers showed that several items were below the safe holding temperature threshold. Specifically, baked chicken was at 107°F, barbeque pork at 120.4°F, pureed corn at 108°F, and cooked spinach at 104°F, all of which are within the unsafe food holding temperature range of 41-135°F. Only the regular cooked corn and mashed potatoes were within safe temperature ranges. The Certified Dietary Manager (CDM) confirmed that food temperatures were only checked prior to the start of the lunch meal service and not monitored throughout the remainder of the service. The CDM explained that the use of disposable pans was intended to reduce the amount of equipment needing washing, as the dishwashing system and hot water were also inoperable due to the gas supply issue. The CDM acknowledged that the facility did not maintain safe food temperatures for the entire lunch meal service.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, as evidenced by an incident involving two residents. Resident #1, who has severe cognitive impairment due to dementia, was found in a compromising situation with Resident #2, who has moderate cognitive impairment. The incident occurred in Resident #2's room, where a Certified Nursing Assistant (CNA) discovered the two residents engaged in sexual intercourse. Despite the facility's policy to prohibit and prevent abuse, there was no documentation of a discussion with either resident's family or representative regarding consensual sexual activity within the facility. Resident #1 was admitted with diagnoses including Dementia, Anxiety, and Schizoaffective Disorder, and scored a 4 on the Brief Interview of Mental Status (BIMS), indicating severe cognitive impairment. The resident's care plan noted a history of sexually inappropriate behaviors but did not include provisions for consensual sexual activity. Interviews with the resident and staff revealed that Resident #1 felt safe and did not report any abuse or trauma. However, the resident's sister expressed uncertainty about Resident #1's ability to consent due to her cognitive condition. Resident #2, who was admitted with Dementia, Anxiety, and Depression, scored a 9 on the BIMS, indicating moderate cognitive impairment. The facility's investigation revealed that the incident was reported due to Resident #1's low BIMS score, and staff interviews indicated that both residents appeared calm and not distressed following the incident. The facility's administrator and psychiatric nurse practitioner assessed the situation as consensual, but the lack of documented discussions with family members about consensual sexual activity highlights a deficiency in the facility's handling of the residents' rights and safety.
Failure to Maintain Homelike Environment and Address Foul Odors
Penalty
Summary
The facility failed to provide a homelike environment for a resident in room 512 and failed to prevent foul odors in one of the hallways. The facility's policy on Resident's Rights and Quality of Life emphasizes the right of residents to a dignified existence in a safe, clean, and comfortable environment. However, observations and interviews revealed that the facility did not adhere to this policy. Resident #40, who was admitted with diagnoses including paraplegia, pressure ulcer, severe protein-calorie malnutrition, and muscle weakness, was found to be living in a room with damaged and peeling drywall, including a significant hole behind the bed. The resident confirmed that the damage was present upon their transfer to the room and had been shown to maintenance staff weeks prior, yet no repairs had been made. Additionally, the facility failed to maintain a homelike environment in the 600 Wing, where a strong, foul odor was observed on multiple occasions. The odor persisted throughout the observations and could not be identified. During an interview and observation with the Director of Nursing and the Administrator, both confirmed the presence of the foul smell and acknowledged the failure to maintain a homelike environment in that area. These deficiencies highlight the facility's failure to uphold its policy of providing a safe, clean, and comfortable environment for its residents.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving physical and verbal abuse among residents. Resident #1, who was cognitively intact, reported being struck in the face by Resident #2, who was confused and had a history of behavioral disturbances. The incident was witnessed by another resident, and slight redness was observed on Resident #1's cheeks. Despite the lack of visible injuries or emotional distress, the facility's investigation confirmed that Resident #2 had entered Resident #1's room and struck him, leading to Resident #2 being sent for a psychiatric evaluation. In another incident, Resident #7, who had dementia with behavioral disturbance, was verbally and physically aggressed by Resident #8. The altercation occurred in the dayroom, where Resident #8 struck Resident #7's hand with a closed fist. Although there were no physical injuries and Resident #7 did not recall the event, the facility's investigation substantiated the occurrence of abuse. Resident #8, who also had dementia, did not remember the incident, and staff noted that neither resident displayed signs of fear or distress. The facility's policy on abuse, neglect, and exploitation defines abuse as the willful infliction of injury or intimidation resulting in harm or mental anguish. Despite the residents' cognitive impairments and lack of recollection, the facility determined that the incidents constituted abuse due to the deliberate actions of the aggressors. The facility's failure to prevent these incidents highlights a deficiency in protecting residents from abuse, as required by their policy.
Failure to Timely Report Allegation of Sexual Assault
Penalty
Summary
The facility failed to report an allegation of sexual assault involving a resident to the State Agency within the required 2-hour timeframe. The facility's policy mandates immediate reporting of alleged violations to the Administrator, state agency, and other required agencies. However, the allegation made by the resident was not reported promptly. The resident, who had a history of cognitive impairments including Dementia with Behavioral Disturbance and Schizoaffective Disorder, reported to her physician that she was sexually assaulted by a staff member. This report was made on 1/26/2024, but the facility's previous Director of Nursing and Administrator only became aware of the allegation on 1/28/2024, two days later. Interviews conducted during the investigation revealed that the Medical Director was informed of the allegation and documented it in the resident's medical record on the same day it was reported. Despite this, the Administrator confirmed that the allegation was not reported to the State Agency within the required timeframe, acknowledging a failure to adhere to the facility's abuse policy. The previous Administrator, during a telephone interview, stated that he did not recall being informed of the allegation by the resident's physician or any staff member, despite having multiple conversations with the resident about her increasing confusion and similar past allegations.
Incomplete MDS Assessment for a Resident
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident, identified as Resident #8, among the 13 residents reviewed. The deficiency was identified through a review of facility documents, the Resident Assessment Instrument (RAI) Manual 3.0, medical records, and staff interviews. Resident #8, who was admitted with diagnoses including Dementia with behavioral disturbance, Psychosis, Major Depressive Disorder, Anxiety Disorder, Senile Degeneration of Brain, and Cerebellar Ataxia, did not have a Brief Interview for Mental Status (BIMS) or a staff assessment completed in their quarterly MDS assessment. During an interview, the RN/MDS Coordinator confirmed that the mental status section of the MDS, which should have been completed, was not filled out due to an oversight in the computer-generated assessment process.
Failure to Provide Transportation for Scheduled Appointments
Penalty
Summary
The facility failed to ensure professional standards of practice were followed by not providing transportation for two residents to their scheduled outpatient appointments. Resident #25, who was cognitively intact, was discharged with orders for a cardiology appointment, which was missed due to the facility's failure to arrange transportation. Similarly, Resident #34, also cognitively intact, had to cancel a scheduled appointment at a Brain and Spine Center because she was not informed that the facility could provide transportation. Interviews with the Transportation Director and the Director of Nursing revealed a lack of awareness and documentation regarding the missed appointments for both residents. The Transportation Director was unaware of the missed appointments, and the transportation log did not reflect any scheduled or missed appointments for these residents. The Director of Nursing confirmed the absence of documentation in the residents' charts indicating they had attended their appointments. The Medical Director acknowledged the need for improvement in scheduling and transportation follow-up for outside appointments.
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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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Nursing homes near Oak Ridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Oak Ridge | 0.6 mi | ★★★★★ | 3 | 0 |
| Senator Ben Atchley State Veterans' Home | 7.1 mi | ★★★★★ | 2 | 0 |
| The Waters Of Clinton, Llc | 9.2 mi | ★★★★★ | 7 | 0 |
| Wellpark Health And Rehabilitation | 11.7 mi | ★★★★★ | 2 | 0 |
| Legacy Park Health And Rehabilitation | 11.7 mi | ★★★★★ | 7 | 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.