Oak Ridge Healthcare Center Faces Multiple Safety Violations
ROSEVILLE, CA - Oak Ridge Healthcare Center received multiple citations during a February 2025 federal inspection that revealed widespread food safety and infection control deficiencies affecting all 60 residents at the skilled nursing facility.
Federal inspectors conducting the annual recertification survey from February 25-28, 2025, documented violations ranging from an unqualified dietary manager to contaminated kitchen equipment and improper infection control practices. The findings raised concerns about the facility's ability to protect medically vulnerable residents from foodborne illness and infection.
Unqualified Dietary Leadership Raises Concerns
Inspectors found the facility operated without properly qualified dietary leadership. The Dietary Manager, who had been working at the facility for three months, lacked the required Certified Dietary Manager (CDM) or Dietary Services Supervisor (DSS) credentials mandated by California Health and Safety Code 1265.4.
During interviews on February 25, the Administrator acknowledged awareness that the Dietary Manager did not hold the required certifications. The Dietary Manager had only a high school diploma, four years of experience at another healthcare facility, and a ServSafe certificate from the National Restaurant Association. While ServSafe provides food handling training, it does not satisfy California's regulatory requirements for overseeing dietary operations in skilled nursing facilities.
The facility's Registered Dietitian worked on a part-time basis, splitting her time between two facilities and working at Oak Ridge only two to three days per week. This arrangement left the facility without adequate qualified oversight during much of the week.
Proper dietary leadership is essential in nursing homes where residents often have complex medical conditions requiring therapeutic diets. Without qualified personnel, facilities face increased risk of menu errors, food safety lapses, and nutritional deficiencies that can compromise resident health.
Therapeutic Diet Violations Documented
Inspectors observed significant failures to follow prescribed therapeutic diets during meal service observations on February 25 and 26. These violations affected 19 residents with specific medical dietary needs.
On February 25, two residents with Consistent Carbohydrate diets received one full slice of garlic bread instead of the prescribed half slice. Consistent Carbohydrate diets are designed for diabetic residents who require careful management of carbohydrate intake to stabilize blood sugar levels. Receiving double the prescribed portion could cause dangerous blood sugar spikes.
During the February 26 lunch service, inspectors documented multiple menu deviations. Six residents prescribed fortified diets did not receive the extra one ounce of shredded cheese required to meet their caloric needs. Fortified diets are prescribed for residents who cannot consume adequate calories to maintain weight or nutritional status. Missing these supplemental calories can contribute to malnutrition and weight loss.
Five residents on 2-gram sodium restriction diets received full servings of dessert instead of half servings. Sodium-restricted diets are prescribed for residents with heart disease, kidney disease, and hypertension. Excess sodium intake can cause fluid retention, elevated blood pressure, and cardiac complications.
Additional menu errors included five residents with mechanical soft diets receiving regular-texture dessert instead of softened dessert, and four residents on regular diets receiving mechanical soft dessert. Mechanical soft diets are prescribed for residents with chewing or swallowing difficulties. Receiving inappropriate food textures creates choking hazards.
The Dietary Manager acknowledged these errors during interviews, stating staff needed to pay more attention to following the menu spreadsheet. The Registered Dietitian emphasized that fortified diets are specifically designed for residents needing additional calories in portions small enough not to be overwhelming.
Contaminated Kitchen Equipment Discovered
Inspectors found multiple food safety violations in the facility kitchen that created risk of foodborne illness for all 60 residents consuming meals from the facility.
The ice machine, which supplies ice for resident beverages and food preparation, was found to be significantly contaminated. When the Maintenance Supervisor opened the machine's top panel, inspectors observed black sticky substances on the bottom of the evaporator unit and water trough. The substances were rough to touch and difficult to remove with paper towels.
Ice machines can harbor bacteria, mold, and slime if not properly cleaned and sanitized. According to the 2022 FDA Food Code, equipment like ice makers must be cleaned routinely to prevent microorganism accumulation. Once established, bacterial biofilms can release pathogens into ice that comes into contact with food and beverages.
The facility's cleaning log indicated the ice machine had been deep cleaned on February 3, just three weeks before the inspection. However, the Maintenance Supervisor acknowledged the machine was not adequately cleaned. The Dietary Manager admitted he did not inspect the ice machine after cleaning to verify it was sanitary.
Inspectors also discovered multiple metal sheet pans stored in clean, ready-to-use areas that were either wet or contaminated with brown sticky food residue. Storing wet dishes promotes bacterial growth, while food residue on supposedly clean equipment creates direct contamination risk.
Two boxes of frozen sliced turkey deli meat were found stored in the walk-in refrigerator instead of the freezer. The product packaging clearly stated "Keep frozen at 0 degrees Fahrenheit or below." The Dietary Manager confirmed the turkey had been delivered the previous day and the receiving staff had failed to follow storage instructions. Improper temperature storage allows rapid bacterial multiplication that can cause food poisoning.
Cross-Contamination Risks Identified
The kitchen's physical layout created cross-contamination hazards. The handwashing sink was located directly adjacent to the clean dish area of the dishwashing machine. Inspectors observed water splashing onto clean dishes during handwashing and water dripping onto clean dishes when staff reached for paper towels. The Dietary Manager agreed this configuration caused contamination of clean dishes.
During food preparation observations on February 26, inspectors watched a cook preparing pureed food for lunch. The cook repeatedly washed her hands at the food preparation sink rather than the designated handwashing sink. The preparation sink lacked soap and paper towel dispensers required for proper handwashing. The cook was observed wiping her wet hands on her clothing before continuing food preparation.
Proper handwashing requires washing with soap and water for 20 seconds, rinsing, and drying with paper towels. Using food preparation sinks for handwashing and wiping hands on clothing can transfer bacteria directly to food products.
When interviewed, a Dietary Aide could not correctly verbalize the manual dishwashing procedure using the facility's two-compartment sink. She stated dishes should be immersed in sanitizer solution for 10 seconds, when facility policy requires 60 seconds of contact time to effectively kill pathogens.
Infection Control Failures Documented
Beyond the kitchen, inspectors found infection control violations in resident care areas. On February 26, a Licensed Nurse was observed using a shared glucometer to check blood sugar levels for two diabetic residents without sanitizing the device between uses.
Glucometers that contact resident blood must be cleaned and sanitized between each use to prevent transmission of bloodborne pathogens. The nurse acknowledged the device should have been cleaned and confirmed the failure created infection control risk.
Inspectors also observed four meal trays with uncovered dessert bowls being transported from the dining room through hallways to resident rooms. The Dietary Manager confirmed food items should be covered during transport to prevent contamination and reduce foodborne illness risk.
In one resident's room, inspectors found a urinary catheter drainage bag lying on the floor next to the bed rather than secured to the bed rail. The Director of Nursing acknowledged this violated infection control procedures and created infection risk. Catheter bags that contact the floor can pick up bacteria that can travel up the catheter tubing and cause urinary tract infections.
Regulatory Context and Standards
Federal regulations require nursing homes to provide therapeutic diets as prescribed by physicians and to prepare, store, and serve food according to professional food service safety standards. California requires facilities to employ qualified dietary personnel with specific credentials to oversee food service operations.
The violations documented at Oak Ridge Healthcare Center represent systemic failures across multiple areas of operation rather than isolated incidents. The combination of unqualified leadership, inadequate staff training, and insufficient oversight created an environment where food safety and infection control standards were consistently not met.
The facility received citations for violation of federal requirements F801 (qualified dietary personnel), F803 (following prescribed menus), F812 (food safety and sanitation), and F880 (infection prevention and control). Each citation was classified as having potential for minimal harm or actual harm to residents.
Facility Response Required
Following the inspection, Oak Ridge Healthcare Center must submit a plan of correction detailing how it will address each deficiency and prevent recurrence. The facility must ensure its Dietary Manager obtains required credentials or hire qualified personnel, implement staff training on therapeutic diet requirements and food safety procedures, and correct physical plant issues that create contamination hazards.
State and federal regulators will conduct follow-up inspections to verify compliance with correction plans. Facilities that fail to correct deficiencies face potential enforcement actions including civil monetary penalties, denial of payment for new admissions, and in severe cases, termination from Medicare and Medicaid programs.
The complete inspection report is available through Medicare's Nursing Home Compare website, where families can review detailed findings and compare facilities based on health inspections, staffing levels, and quality measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Ridge Healthcare Center from 2025-02-28 including all violations, facility responses, and corrective action plans.
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