Villages At Oak Ridge, The

F-F677.

9. The lack of sufficient nursing staff resulted in a resident receiving an antibiotic that was not indicated for treatment of a urinary tract infection.

Cross Reference

F-F690.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 23 155837 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155837 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Villages at Oak Ridge, The 1694 Troy Road Washington, IN 47501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 11. The lack of sufficient nursing staff resulted in oxygen orders not being put in and not being followed.

Level of Harm - Minimal harm or Cross Reference

F-F695. potential for actual harm

This citation relates to Complaint IN00456575. Residents Affected - Some 3.1-17(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 23 155837 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155837 B. Wing 04/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Villages at Oak Ridge, The 1694 Troy Road Washington, IN 47501

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38770 potential for actual harm Based on observation, record review, and interview, the facility failed to ensure infection control practices Residents Affected - Some were implemented for a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for 2 of 2 random observations. (100 Hall, 300 Hall)

Findings include:

1. On 4/1/25 at 10:14 A.M., a laundry cart was observed against a wall on the 100 Hall. Clothes were observed on hangers hanging from the top of the cart and folded items observed in the bottom basket. The cart was not covered. Laundry 3 and Laundry 7 were observed wheeling the cart down the hall while the clothes on the hangers were rubbing against the wall, resident doors, and hand sanitizer dispensers. Laundry 3 and Laundry 7 were observed taking the folded items from the basket and hugging them against their uniform tops taking them into the resident rooms.

2. On 4/1/25 at 2:14 P.M., Laundry 7 was observed on the 300 Hall holding resident clothing against her uniform top and entering room [ROOM NUMBER]. Laundry 7 was then observed holding resident clothing in her left arm against her uniform top, obtained clothing that was on hangers from the laundry cart, and bent down, dragging the clothes on the hangers along the floor. She then took the items to room [ROOM NUMBER].

On 4/2/25 at 11:06 A.M., the Infection Preventionist indicated clean clothing should not be against staff uniform shirts, and should be kept away from the body. He further indicated clean clothing should never drag along the floor before taken to a resident's room.

On 4/2/25 at 10:57 A.M., the Interim Director of Nursing provided a current Handling Linen policy, dated 12/17/24, that indicated Linens should be carried away from the body to prevent contamination from clothing

3.1-18(b)

3.1-19(g)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 23 155837