Oak Ridge Healthcare: Infection Control Failures - CA
The 67-bed facility failed to follow its own Enhanced Barrier Precautions protocol, designed to reduce transmission of multi-drug resistant organisms through targeted use of gowns and gloves during high-contact patient care.
Resident 1 was admitted to the facility in mid-2025 with kidney failure, kidney stones and difficulty urinating. The resident required an indwelling catheter — a thin, flexible tube inserted into the bladder to continuously drain urine.
On August 27 at 10:34 a.m., inspectors observed the physical therapy assistant transferring Resident 1 to a wheelchair in the therapy room. The assistant was in close contact with the resident but wore no protective gown, despite the facility's policy requiring such equipment for residents with indwelling catheters.
When questioned 16 minutes later, the physical therapy assistant acknowledged the violation. He confirmed that Resident 1 was on Enhanced Barrier Precautions because of the indwelling catheter and admitted "he should have worn a gown when he worked with Resident 1."
The facility's own policy, dated June 2024, explicitly states that Enhanced Barrier Precautions "are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization." The policy lists transferring as an example of high-contact resident care requiring gown and glove use.
Indwelling urinary catheters appear specifically in the facility's examples of medical devices requiring enhanced precautions.
But the infection control breakdown extended beyond the therapy room. When inspectors checked Resident 1's room at 11:31 a.m., they found no signage outside indicating the resident required Enhanced Barrier Precautions.
The facility's Infection Preventionist Nurse confirmed the missing warning sign during a concurrent interview at 11:40 a.m. She acknowledged that Enhanced Barrier Precautions included residents with indwelling catheters and that "a sign should have been placed outside of the resident's room to inform staff of the precautions."
"We need to keep up with the EBP to keep infections from spreading," the Infection Preventionist told inspectors.
The Director of Nursing echoed this concern during a 3 p.m. interview the same day. She stated she expected residents with indwelling catheters to have Enhanced Barrier Precautions "to prevent the spread of infection."
Enhanced Barrier Precautions represent a targeted approach to infection control, employing gown and glove use during specific high-contact activities when standard contact precautions don't apply. The protocol aims to prevent spread of multi-drug resistant organisms — bacteria that have developed resistance to antibiotics.
Federal inspectors determined the facility's failures increased "the risk of higher infection rates, outbreaks, and potential resident harm" at the facility.
The inspection was conducted in response to a complaint. Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
Resident 1's case illustrates the challenges facilities face implementing infection control protocols consistently across different departments. While nursing staff may follow enhanced precautions during routine care, the breakdown occurred in the therapy department during what should have been a routine transfer.
The missing room signage compounded the problem. Without visible indicators of a resident's Enhanced Barrier Precautions status, staff members from different departments may unknowingly violate infection control protocols.
Indwelling catheters pose particular infection risks. The devices provide a direct pathway for bacteria to enter the urinary system, making enhanced precautions critical for preventing catheter-associated urinary tract infections and potential spread of resistant organisms to other residents.
The facility's own policies recognized these risks, requiring enhanced precautions regardless of whether residents had confirmed colonization with multi-drug resistant organisms. The preventive approach acknowledges that colonization status may be unknown or change over time.
Oak Ridge Healthcare Center must now develop a plan of correction addressing both the missing protective equipment use and the absent warning signage. The facility has 14 days from receiving the inspection report to make its correction plan publicly available.
The August inspection findings highlight ongoing challenges in nursing home infection control, particularly ensuring consistent implementation of enhanced precautions across all care departments and maintaining proper resident identification systems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Ridge Healthcare Center from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Oak Ridge Healthcare Center in Roseville, CA was cited for violations during a health inspection on August 27, 2025.
Resident 1 was admitted to the facility in mid-2025 with kidney failure, kidney stones and difficulty urinating.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.