CHARLESTON, WV - Federal inspectors discovered multiple serious care failures at Oak Ridge Center, including a resident who experienced severe weight loss for months without adequate intervention.
Resident Lost 23 Pounds Without Proper Medical Response
The most concerning violation involved a resident who lost 23 pounds over six months, dropping from 205.6 pounds in January 2024 to 182.6 pounds by July - a 12.95% weight loss considered severe by medical standards. The facility's response proved inadequate at multiple levels.
Critical care failures included: - No physician notification of the severe weight loss - Failed speech therapy referral despite documented plans - Inconsistent meal assistance despite care plan requirements - No dietary supplements ordered to address ongoing weight loss - Missing nutritional lab work to assess the resident's condition
The resident's care plan specified extensive assistance and cueing for eating, yet documentation showed they received help with only 15 of 90 meals over a 30-day period. Staff recorded the remaining 75 meals as "independent" despite the resident's documented need for assistance.
Medical Significance of Weight Loss in Nursing Home Residents
Unintentional weight loss in nursing home residents creates serious health risks. A loss exceeding 10% over six months indicates potential malnutrition, which can lead to decreased immune function, delayed wound healing, increased fall risk, and higher mortality rates.
Weight loss of this magnitude requires immediate medical evaluation to identify underlying causes such as medication side effects, dental problems, depression, or other medical conditions. The facility's registered dietitian acknowledged identifying the weight loss in April but waited until June to implement interventions, citing the resident's overweight status as justification for delay.
This approach contradicts established medical protocols requiring prompt physician notification and comprehensive assessment regardless of baseline weight status. Severe weight loss patterns indicate systemic problems requiring immediate intervention.
Failed Reporting of Suspected Abuse and Fraud
Oak Ridge Center violated federal reporting requirements by failing to notify authorities of suspected abuse and potential therapy billing fraud. Two separate incidents went unreported:
Physical Therapist Billing Investigation: Staff reported that a physical therapist documented and billed for therapy services residents never received. When a Physical Therapist Assistant reported that a cognitively intact resident denied receiving therapy despite documentation claiming otherwise, administrators failed to report the allegation to proper authorities. Instead, they referred the matter only to the therapy department's corporate compliance office.
Nursing Assistant Negligence: A nursing assistant admitted to placing a fallen resident back in bed without allowing a licensed nurse to assess for injuries, directly violating facility fall protocols. The administrator acknowledged this created potential harm but failed to report the incident until confronted by inspectors during the survey.
Federal regulations require nursing homes to report suspected abuse, neglect, or exploitation to the state survey agency and other appropriate authorities within 24 hours. These reporting requirements exist to protect residents and ensure proper investigation of potential harm.
Medication Management and Infection Control Lapses
Inspectors identified concerning medication storage and infection control practices that could compromise resident safety:
Temperature Monitoring Failures: The facility failed to maintain required daily temperature logs for medication refrigerators, missing documentation on multiple dates for staff initials, room temperature readings, and exact times. These logs ensure medications requiring refrigeration remain effective and safe.
Infection Control Violations: Nursing staff improperly cleaned blood glucose monitoring equipment using alcohol pads instead of EPA-registered disinfectants as required by facility policy. This creates potential for blood-borne pathogen transmission between residents.
Staff also failed to follow enhanced barrier precautions when transferring a resident with a multi-drug resistant organism, not wearing required gowns during high-contact care activities despite clear signage and established protocols.
Care Planning and Documentation Deficiencies
The facility demonstrated systematic problems with care planning accuracy and medication documentation:
Inaccurate Care Plans: Care plans failed to reflect residents' actual conditions, including dental status documentation showing natural teeth when none remained, and missing pressure ulcer care despite active wound orders.
Controlled Substance Discrepancies: Documentation showed controlled pain medication removed from locked storage on five separate dates without corresponding administration records, creating accountability gaps for scheduled narcotics.
Missing Drug Reviews: Required monthly medication reviews were incomplete, with October 2023 review missing entirely and subsequent reviews delayed until December implementation.
Staffing and Training Inadequacies
Oak Ridge Center failed to ensure adequate staff competencies and training:
Incomplete Competency Training: Five nursing assistants lacked required competency validations for oxygen handling, lift operations, and other essential skills despite caring for residents requiring these services.
Insufficient Annual Training: One nursing assistant with 15 years of service completed only one hour of required annual training instead of the mandated 12 hours, representing a 92% shortfall in continuing education requirements.
Inaccurate Staffing Reports: Daily nursing staff postings contained errors in staff counts and failed to show actual hours worked, preventing accurate assessment of care coverage levels.
Facility Assessment and Social Services Failures
The facility's assessment processes showed concerning gaps:
Outdated Assessment Tools: The facility assessment tool used generic templates without modification for specific resident population needs and care requirements, failing to identify necessary staff competencies.
Guardianship Issues: Social services staff failed to notify courts when a resident's court-appointed guardian lost decision-making capacity, leaving another resident without proper legal representation for medical decisions including hospice care.
Industry Standards and Expected Care
Nursing homes must provide comprehensive assessment, appropriate care planning, and timely intervention for residents' changing conditions. Weight monitoring protocols require physician notification for significant changes, while infection control measures protect all residents from preventable infections.
These violations indicate systematic failures in fundamental nursing home operations. Proper weight management includes regular monitoring, prompt medical evaluation of concerning patterns, and coordinated interventions involving nursing, dietary, and medical staff.
Federal regulations establish minimum standards for resident protection, staff competency, and care quality. Oak Ridge Center's violations demonstrate failures across multiple critical areas affecting resident health and safety.
The facility must implement comprehensive corrective actions addressing staff training, care planning accuracy, reporting procedures, and quality assurance systems to ensure resident protection and regulatory compliance.
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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