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Oak Ridge Center: Severe Weight Loss, Failed Reporting - WV
The facility's response proved inadequate at multiple levels....
Latest reports, citations, and penalties from CMS data
The facility's response proved inadequate at multiple levels....
## Formula Substitution Without Medical Authorization The violation occurred when the facility's original tube feeding formula went on backorder....
"The food at the facility was terrible as it was sometimes cold when it arrives," Resident 173 told inspectors....
Despite having a comprehensive behavior care plan in place, staff failed to implement critical interventions that could have prevented the attack....
Despite these clear medical directives, facility records show that insulin was discontinued on the day of admission....
The modified assessment painted a dramatically different picture, documenting serious wounds that extended through multiple layers of skin and tissue....
The violations occurred despite the facility's own policy requiring comprehensive pain assessment and management based on professional standards....
In one resident's room, inspectors observed **"a large area of the floor covered in mouse droppings"** behind a nightstand....
Federal regulations require nursing homes to promptly notify residents' representatives of changes in condition and transfers to hospitals....
The medication errors occurred despite the facility having established protocols requiring proper drug administration according to physician orders....
This represents a systematic failure in the facility's quality oversight mechanisms designed to protect resident welfare....
The absence of proper training for this critical position compromises the facility's entire infection prevention program....
## G-tube Administration Complications The inspection documented a particularly problematic situation when the nurse encountered a clogged feeding tube....
The hospital completed a Level 1 screening on December 6, 2024, and sent a referral for the required Level 2 evaluation....
Staff found her sitting on the floor between the bed and scooter with no apparent injuries or head trauma....
## Food Storage Systems Compromised Inspectors found significant problems with the facility's food storage systems during their April 1, 2025 visit....
This represents a systemic failure in the facility's oversight mechanisms that are designed to protect resident safety and care quality....
Despite his cognitive impairment and history of impulsive behavior, the facility failed to implement adequate supervision measures....
The condition requires careful monitoring and management to prevent deterioration....
The 30-milligram antidepressant, which she had been receiving twice daily since May 2022, was abruptly stopped without proper medical protocols....