Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Ridge Care Center during CMS and state inspections, most recent first.
Three residents at risk for or with pressure injuries did not receive necessary care, including timely RN assessment, care plan updates, and implementation of aggressive interventions such as repositioning and use of support surfaces. One resident developed a stage 4 pressure injury that became infected and required surgical debridement after the facility failed to revise the care plan or implement alternative interventions when the resident refused an air mattress. Other residents were not consistently repositioned or assessed according to their care plans, and the facility did not follow its own wound management policy.
Surveyors identified that five CNAs did not have documented completion of the required 12 hours of annual in-service training, as the facility lacked a system to track or verify individual training records. Available documentation was incomplete or not properly dated, and leadership confirmed there was no process to ensure compliance with training requirements, potentially affecting all residents.
A registered nurse did not perform hand hygiene or change gloves before applying a clean dressing to a resident's stage 4 sacral pressure wound after coming into contact with the wound during care, contrary to facility policy and CDC guidelines. This lapse was observed by a surveyor and confirmed through staff interviews.
A resident expressed feelings of depression and self-harm, but the facility failed to provide necessary support, leading to the resident's death. Despite policy requirements for immediate intervention, staff delayed action, misinterpreting the resident's statements. This neglect resulted in a finding of immediate jeopardy.
A resident on Coumadin was not monitored with necessary lab tests, leading to over anticoagulation and subsequent death. The facility failed to ensure ongoing lab testing, resulting in critical lab values and signs of bleeding being overlooked. Staff interviews revealed systemic failures in monitoring and managing the resident's medication therapy.
A resident died of a presumed suicide, and the facility failed to conduct a thorough investigation as required by its policies. The resident was found with a plastic bag over their head and oxygen tubing around their neck. The facility only gathered statements from three staff members, and no resident interviews were conducted, leading to a deficiency in the investigation process.
A resident with unspecified dementia and severely impaired cognitive skills received another resident's anti-seizure and laxative medications due to a student nurse's error. The medications included Depakote, Keppra, and lactulose. The resident was monitored for drowsiness and aspiration but did not have an adverse reaction. The nurse instructor was subsequently barred from the facility.
A resident with dementia and a Stage 4 pressure injury was found with her air mattress unplugged for over two hours, leading to a rapid deterioration of her condition. The care plan to ensure the air mattress was plugged in was not followed, as confirmed by the Director of Nurses.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and promote the healing of pressure injuries for three residents who were either at risk for or had existing pressure injuries. One resident was admitted without any pressure injuries but was assessed as at risk. Ten days after admission, this resident developed a blister on the left buttock that was not assessed by a Registered Nurse, and the care plan was not revised when the area declined. Aggressive interventions, such as repositioning, were not implemented even after the resident refused an air mattress. The wound continued to deteriorate, eventually becoming infected and requiring antibiotics and surgical debridement, after which it was staged as a stage 4 pressure injury. The facility's documentation and care planning were inconsistent and incomplete. There was a lack of comprehensive assessment and timely updates to care plans following changes in the residents' conditions. For the resident who developed the stage 4 pressure injury, there was no evidence of a Registered Nurse or physician assessment upon discovery of the wound, and the care plan did not address repositioning or alternative interventions after the resident refused the air mattress. Additionally, there was no documentation of the resident refusing to be repositioned, and no interventions were added to address this aspect of care. The facility also failed to assess or offer alternative support surfaces beyond the standard mattress and air mattress. Other residents at risk for or with pressure injuries were also not consistently repositioned according to their care plans, as observed by surveyors and reported by family members. One resident was not repositioned during multiple observations, and another was readmitted without a comprehensive assessment of their pressure injury and was not offloaded or repositioned as required. The facility's own wound management policy, which requires comprehensive assessment and interdisciplinary care planning, was not followed, contributing to the deficient practice.
Failure to Document and Track Required CNA In-Service Training
Penalty
Summary
The facility failed to maintain documentation showing that five reviewed Certified Nursing Assistants (CNAs) completed the required 12 hours of annual in-service training, as mandated by facility policy and federal regulations. During interviews and record reviews, surveyors found that the facility did not keep individual records of completed training for CNAs, and the available documentation, such as sign-in sheets and quizzes, was incomplete, undated, or lacked necessary signatures. The spreadsheet provided by the Executive Director listed education topics and hours but did not align with the rolling 12-month period based on each CNA's hire date, making it impossible to verify compliance for the required timeframe. When asked, the Director of Nursing acknowledged that there was no system in place to monitor or track the completion of required training for each employee. The lack of proper documentation and tracking potentially affected all 71 residents in the facility, as there was no assurance that CNAs had received ongoing education in critical areas such as dementia care and abuse prevention. The deficiency was identified through a review of employee files and direct communication with facility leadership, who confirmed the absence of a reliable process to ensure and document annual training compliance.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
During a wound care procedure for a resident with multiple pressure ulcers, including a stage 4 sacral pressure wound and other significant comorbidities such as osteomyelitis and diabetes, a registered nurse failed to follow established infection prevention and control protocols. Specifically, after cleansing the wound and applying calcium alginate, the nurse did not change gloves or perform hand hygiene before placing a new border dressing on the wound. This action was observed by a surveyor, who noted that the nurse had come into contact with the wound and its exudate prior to applying the clean dressing, thereby not adhering to both facility policy and CDC guidelines for hand hygiene during wound care. Facility policies require hand hygiene before and after wound care, after glove removal, and when moving from a soiled to a clean body site. The CDC also recommends hand hygiene immediately before touching a patient, after contact with blood or body fluids, and after glove removal. The nurse's failure to perform hand hygiene at the appropriate step during the dressing change was confirmed through observation and staff interviews, which indicated that staff are expected to follow these protocols during wound care procedures.
Failure to Address Resident's Mental Health Needs Leads to Tragic Outcome
Penalty
Summary
The facility failed to provide medically related social services to a resident, leading to a finding of immediate jeopardy. The resident, identified as R4, reported feeling depressed and having thoughts of self-harm almost daily. Despite these alarming statements, the facility did not provide the necessary support or services to address these concerns. Approximately eight hours after expressing these thoughts, R4 was found deceased with a plastic bag over his head and oxygen tubing wrapped around his neck. The facility's policy required immediate intervention when a resident voiced intent to harm themselves, including initiating 1:1 care, conducting 15-minute checks, and possibly sending the resident to the hospital. However, these steps were not taken for R4. The Advanced Practice Social Worker (APSW) was informed of R4's statements but chose to delay action until the next day, citing the end of the workday as the reason. This inaction was compounded by a lack of documentation and communication among staff regarding R4's mental health status. Interviews with staff revealed a misunderstanding and misinterpretation of R4's statements, with some staff believing the statements were taken out of context due to R4's age and demeanor. This misjudgment led to a failure to recognize the resident's responses as a cry for help and to implement necessary interventions. The facility's neglect to address R4's mental health needs and the subsequent tragic outcome resulted in a finding of immediate jeopardy.
Failure to Monitor Anticoagulation Therapy Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident, identified as R2, who was receiving Coumadin, an anticoagulation medication, was monitored with ongoing laboratory testing to maintain a therapeutic dose. R2 was admitted with an order for Coumadin, which requires frequent lab tests to ensure proper dosing. However, the last test was conducted on a specific date, and no further tests were ordered. This oversight led to R2 developing multiple bruises, a sign of over anticoagulation, which went unnoticed by both nursing and pharmacy staff. R2's condition worsened, and he developed hematuria, indicating potential internal bleeding. Subsequent lab tests revealed critical low hemoglobin and hematocrit levels, along with critically high prothrombin time and INR, confirming over anticoagulation. Despite these alarming results, there was no evidence of a standing order for PT/INR tests, and the facility failed to monitor R2's condition adequately. This lack of monitoring and failure to act on the signs of over anticoagulation resulted in R2 being sent to the hospital, where he later died. Interviews with facility staff, including the Director of Nursing, Registered Pharmacist, Medical Director, and Advanced Practice Nurse Practitioner, revealed a systemic failure in monitoring and managing R2's Coumadin therapy. The staff acknowledged the absence of specific orders for monitoring Coumadin side effects and lab work, and the pharmacy's failure to notice the lack of lab tests. The Medical Director admitted that the incident was a system failure, and the facility had to revise their anticoagulation policy following the incident.
Removal Plan
- The facility began an investigation and identified all residents in the building who could potentially be affected and ensured that all labs and medications were up-to-date and accurate.
- The leadership team, including the NHA A, DON B, ADON L, ANHA F, MedDir K, Nurse Manager, and Quality Care Coordinator conducted an Ad-Hoc Quality Assurance and Performance Improvement (QAPI) meeting. The passing of the resident was reviewed.
- The anticoagulation policy was reviewed and updated to ensure resident safety. The policy was adjusted to include standing orders for residents on Coumadin for weekly PT/INR draws upon admission to the facility.
- The team decided to add new monitoring orders upon admission, including monitoring for signs or symptoms for bleeding.
- A Coumadin log was initiated by the nurse manager team for daily review during clinical meetings. At each clinical meeting, the clinical team reviews all residents who are prescribed Coumadin.
- The facility's pharmacy was contacted and a medication audit for all residents in the facility was completed. No other medication issues were discovered during this facility-wide medication audit. The pharmacy continues with monthly audits for all residents, and the residents on Coumadin are being monitored routinely by the pharmacy.
- New admissions to the facility will have a prospective medication review completed by the pharmacy and the pharmacy will make note of medication that requires close monitoring. The consultant pharmacist will evaluate residents on Coumadin and clinically determine if INRs are being monitored routinely. Clinical judgement with regard to past stability of patient INR's will determine if consultant pharmacist recommends an INR for a resident for that month.
- DON B began education on Coumadin with the nursing staff. All nursing staff were educated and provided with information about Coumadin. After reading and having a discussion, staff independently completed a quiz to show competency. The DON held small groups to complete this education with the nurses; additionally, the nurses were informed that if they had additional questions or concerns, they should seek out information from DON B or the ADON L accordingly. The staff were then informed about the changes being implemented regarding Coumadin.
- The nursing staff's admission checklist and requirements include standing orders for weekly PT/INR draws for residents with Coumadin prescribed. Education began and all staff were educated before they began working their next shift on the floor. The nursing department had been educated about Coumadin and informed of the Anticoagulation policy and procedure. Upon hire, new staff members are now trained on this policy during their training period at orientation.
- The team had contacted all parties involved to address the issue and make needed corrections. The plans put in place have thus far ensured that this mistake is prevented from occurring again. No other residents were affected, and the updated policy and procedure will keep residents safe. The facility made the necessary corrections and began monitoring immediately.
Failure to Investigate Resident's Death
Penalty
Summary
The facility failed to thoroughly investigate the death of a resident, identified as R4, who died of a presumed suicide. The facility's policy on the investigation and reporting of alleged incidents of abuse, neglect, and misappropriation requires all alleged violations to be taken seriously and investigated. However, the documentation and medical records for R4 did not show evidence of a thorough investigation into the resident's death, including interviews with all staff and residents about possible causes. R4 was admitted with diagnoses including fractures and was last seen alive by a nurse at 10:45 PM, who confirmed the resident was breathing. At 11:25 PM, a CNA found R4 with a plastic bag over his head and oxygen tubing tightly wrapped around his neck, and the resident was nonresponsive and not breathing. The facility's response to the incident included notifying the Director of Nursing, Assistant Nursing Home Administrator, and Nursing Home Administrator, as well as calling the police and the Medical Examiner, who determined the cause of death as probable suicide. The Assistant Nursing Home Administrator confirmed that the only actions taken were gathering statements from three staff members present with R4, and no statements were taken from other residents. The Sheriff's office collected statements from the staff involved. The lack of a comprehensive investigation into the resident's death constitutes a deficiency in the facility's adherence to its own policies and procedures for handling such incidents.
Significant Medication Error Involving a Resident
Penalty
Summary
The facility failed to ensure accurate medication administration for one of three residents, resulting in a significant medication error. The resident, who was admitted with unspecified dementia and assessed as having severely impaired cognitive skills, received another resident's anti-seizure and laxative medications in error. This error was made by a student nurse under the supervision of her instructor. The medications administered in error included Depakote 875 mg, Keppra 500 mg, and lactulose 45 ml/30 g. The physician's action was to monitor the resident for drowsiness and aspiration. Despite the error, the resident did not experience an adverse reaction. Following the incident, the nurse instructor was not allowed back in the facility.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development and promote the healing of pressure injuries for a resident with a Stage 4 pressure injury. The resident, who was admitted with dementia and receiving hospice services, was observed in bed with her air mattress unplugged for over two hours. This lapse in care was verified by the Director of Nurses, who subsequently plugged in the air mattress, allowing it to inflate. The resident's pressure injury, initially noted as moisture-associated dermatitis, had rapidly deteriorated to a Stage 4 pressure injury, as assessed by the wound physician. The resident's care plan, which included ensuring the air mattress was plugged in and set to the appropriate weight setting, was not followed. The wound physician indicated that due to the resident's condition and rapid deterioration, the goal was to keep the resident as comfortable as possible. The deficiency was confirmed through observation, interview, and record review, and was shared with the facility's Administrator and Director of Nurses, who did not provide additional information when requested.
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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 Union Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wi Veterans Home-boland Hall | 1.2 mi | ★★★★★ | 22 | 4 |
| Burlington Health And Rehabilitation Center | 10.4 mi | ★★★★★ | 3 | 0 |
| Lincoln Park Nursing And Rehab Llc | 10.7 mi | ★★★★★ | 11 | 0 |
| Complete Care At Ridgewood Llc | 10.7 mi | ★★★★★ | 6 | 0 |
| Complete Care At Grande Prairie | 10.9 mi | ★★★★★ | 11 | 0 |
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