CHARLESTON, WV - A comprehensive inspection of Oak Ridge Center uncovered significant deficiencies in multiple areas of facility operations, including failures to report alleged abuse, incomplete care planning, inadequate nutritional monitoring, and lapses in infection control protocols.
Unreported Allegations and Investigation Failures
Facility administrators failed to report allegations of abuse and neglect to appropriate state agencies as required by federal regulations. In one case, a Physical Therapist Assistant reported concerns that a Physical Therapist was documenting and billing for therapy services that residents never received. When Resident #12, described by staff as cognitively intact, stated she had not received therapy on a particular day, facility records showed the therapist had documented providing those services.
Rather than reporting the allegation to state authorities, administrators referred the matter to the therapy department's corporate compliance office. The internal investigation concluded that interviews with patients "did not substantiate allegations," though the facility removed billing for one questionable session. The investigation summary noted that the reporting Physical Therapist Assistant may have interviewed residents during a weekend, "potentially skewing the investigation process," and that the PTA "refused to meet with the compliance office and cooperate with the investigation."
In a separate incident involving Resident #5, a Nursing Assistant admitted in a written statement to finding the resident on the floor calling for help, then lifting the resident back into bed without allowing a licensed nurse to assess for injuries. The NA stated she personally checked the resident for marks, bruises, or skin tears before returning the resident to bed. Administrators initially viewed this as a policy violation rather than a reportable incident of neglect. The administrator acknowledged during the survey that he had "an obligation to reporting this incident" only after surveyors explained how the NA's actions created potential harm by denying the resident necessary nursing assessment services.
Incomplete Care Planning and Assessment Documentation
Surveyors identified multiple instances where care plans failed to accurately reflect residents' current conditions. Resident #37's care plan indicated concerns about "obvious or likely cavity or broken natural teeth," but an examination by the Director of Nursing revealed the resident had no natural teeth remaining—only a partial denture with visible metal pieces that had nothing left to hook onto. The care plan had not been updated to reflect this dental status.
For Resident #64, who developed a deep tissue injury (DTI) pressure ulcer measuring 4.00 cm by 5.00 cm on the left heel on June 28, 2024, the care plan made no mention of the wound despite active physician orders for heel protector boots, skin inspections every shift, and specific wound care protocols. This omission meant nursing staff lacked documented guidance for managing a significant skin integrity issue.
The facility also failed to maintain accurate Pre-Admission Screening and Resident Review (PASRR) documentation for residents with mental health diagnoses. Resident #1's PASRR completed in August 2021 did not include the resident's diagnosis of major depressive disorder from July 2021 or psychotic disorder with delusions from October 2021. Similarly, Resident #20's PASRR from March 2020 omitted diagnoses of bipolar disorder and major depressive disorder from January 2020. These screening documents are required to ensure residents with mental illness receive appropriate specialized services.
Critical Nutritional Monitoring Failures
The facility's most serious deficiency involved Resident #14, who experienced severe, unaddressed weight loss over several months. Between March 5 and April 3, 2024, the resident lost 14 pounds—a 6.95% loss in one month, which meets clinical criteria for severe weight loss. Over six months (January through July 2024), the resident's weight dropped from 205.6 pounds to 182.6 pounds, a 12.95% loss also classified as severe.
Despite these alarming trends, facility staff failed to implement basic interventions. Medical records contained a July 12 notation stating nursing would refer the resident to speech therapy for "poor appetite and weight loss," but this referral was never completed. The resident's physician was never notified of either the one-month or six-month severe weight loss. No nutritional supplements were ordered or provided.
Care aide documentation revealed the resident consumed only 0-25% of meals on seven occasions in the 30 days preceding the survey. The resident's care plan specified the need for "extensive assistance and cueing" with eating, yet documentation showed the resident received only supervision or encouragement at 15 of 90 meals, with the remaining 75 meals documented as requiring no assistance. No evening snacks were documented as provided or consumed.
The facility's Registered Dietician acknowledged identifying the weight loss in April 2024 but did not intervene until June, when double portions were added to the diet order. The dietician stated she did not communicate with the physician because "the nursing department usually handled" such communications, and she assumed the resident's overweight status meant intervention could wait. The dietician could not explain how she determined an underlying medical condition was not causing the weight loss without physician assessment.
When surveyors reviewed facility policies on nutritional management and weight monitoring, administrators confirmed that physician notification of significant weight changes was required but had not occurred. Laboratory tests to assess nutritional status were never ordered.
Medication Management and Documentation Concerns
The facility failed to ensure proper oversight of controlled substance administration. For Resident #10, who had an order for Hydrocodone 5mg-325mg as needed, the controlled substance log showed the medication signed out on five occasions between April and May 2024 (April 24, April 30, May 9, May 13, and May 21), but the medication administration record contained no documentation that the medication was actually given to the resident on those dates. This discrepancy raises questions about medication diversion or documentation accuracy for a Schedule II controlled substance.
Monthly medication regimen reviews were incomplete for Resident #1, with no October 2023 review on file. The Director of Nursing acknowledged that while the pharmacy made recommendations again in November, the ordering physician did not address them until December 4, 2024—meaning the resident went more than two months without required medication oversight.
Temperature monitoring logs for the medication refrigerator showed multiple gaps, with missing staff initials, room temperatures, and exact times for several dates in July 2024. Facility policy required temperature checks twice daily with full documentation, but staff had not consistently followed these protocols designed to ensure medication safety and efficacy.
Regarding weight monitoring for Resident #40, who had an active diagnosis of congestive heart failure, the facility documented a 17.6-pound weight gain in just seven days (from July 9 to July 16, 2024). This rapid fluid accumulation in a heart failure patient represents a potentially serious medical development requiring immediate physician notification and assessment for decompensation. However, staff failed to complete a change-in-condition form or alert the physician to this clinically significant finding.
Additionally, facility policy required reweighing when any resident showed a five-pound fluctuation from the previous weight, yet Resident #40's records showed nine instances since January 2024 when weight fluctuations of 6.5 to 17.6 pounds occurred without the mandated reweigh being performed and documented. The facility also missed four weekly weight measurements for this resident despite an active physician order for weekly weights to monitor the heart failure.
Infection Control Protocol Violations
During medication administration observations, a Registered Nurse was observed placing a glucometer directly on a resident's bed without any barrier, then wiping it with an alcohol prep pad between patients. When questioned about dwell time for disinfection, the nurse responded, "I don't know. I usually just let it dry between patients." Facility policy required use of an EPA-registered disinfectant effective against HIV, Hepatitis C, and Hepatitis B—not alcohol prep pads. The Director of Nursing confirmed the policy had not been followed and that alcohol pads are not effective for preventing transmission of bloodborne pathogens.
In another incident, two Licensed Practical Nurses transferred Resident #5 from a geri-chair to bed using a mechanical lift without wearing gowns, despite a sign on the resident's door requiring Enhanced Barrier Precautions. The resident was on these precautions due to colonization with a multidrug-resistant organism (ESBL) and having a feeding tube. When questioned, one nurse stated she would "have to ask" if a gown was needed for transfers, then acknowledged after seeing the posted sign that gowns should have been worn. Facility policy clearly identified transferring as a "high-contact resident care activity" requiring gown and glove use for residents with indwelling medical devices or MDRO colonization.
Staffing and Training Deficiencies
The facility's nurse staffing information posted for public viewing contained inaccuracies. On two dates reviewed (July 6, 2023, and April 21, 2024), the total number of Registered Nurses included administrative nursing hours that should not have been counted as direct care staff. The Schedule Manager acknowledged being unaware that positions like Nurse Practice Educator/Infection Preventionist should not be included in direct care RN counts.
Additionally, eight daily staffing posting forms reviewed showed only which shifts were scheduled, not the actual total hours worked by each staff category—information required to be posted for families and the public to understand actual staffing levels.
Training records revealed that five of five nursing assistants reviewed had not completed all required competencies for the care they were providing. Missing competencies included safe oxygen handling, total lift operation, sit-to-stand lift operation, eating assistance, and handling dirty laundry. One nursing assistant hired in September 2009 had completed only one hour of training between May 2023 and July 2024, far short of the required minimum 12 hours of annual continuing education.
The facility's assessment tool, which should identify what staff competencies are necessary for the resident population, had not been customized from a generic template. The Administrator acknowledged the staff training and competencies section "had not been revised to be center specific for this facility."
Additional Issues Identified
Inspectors documented problems with maintaining proper temperatures for resident food storage, with freezer temperatures in three resident rooms not being monitored daily as required by policy. The facility also failed to ensure that refrigerator and freezer thermometers were read and recorded according to established food safety protocols.
Guardian notification procedures broke down when staff recognized that Resident #68's court-appointed guardian (who was also a resident at the facility) had lost decision-making capacity. Rather than notifying the court or Adult Protective Services, social services staff allowed family members who were not legal guardians to make medical decisions, including hospice referral. The hospice agency declined to accept the referral specifically because the person providing consent lacked legal authority.
These inspection findings reflect systemic issues in oversight, staff training, policy implementation, and clinical judgment that affected multiple aspects of resident care and safety at Oak Ridge Center during the July 2024 survey period.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Ridge Center from 2024-07-25 including all violations, facility responses, and corrective action plans.
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