Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Ridge Healthcare Center during CMS and state inspections, most recent first.
A resident with a healing femur fracture, difficulty walking, and moderate cognitive impairment was observed seated on a bedside commode and calling for help while the call light was placed on the opposite side of the bed, out of reach, despite a care plan directive that the call light be kept within reach. The CNA who transferred the resident to the commode, an LN, and the DON all acknowledged that the call light should always be accessible to the resident, and facility policy required call lights to be accessible from the bed, toilet, shower, and floor.
A resident with an indwelling urinary catheter did not receive required Enhanced Barrier Precautions (EBP) when a Physical Therapy Assistant provided care without wearing a gown, and no EBP signage was posted outside the resident's room. Both the Infection Preventionist Nurse and DON confirmed that EBP and appropriate signage were expected for residents with indwelling catheters.
The facility's Dietary Manager lacked the required qualifications, leading to deficiencies in meal distribution and sanitation. The Registered Dietitian was only part-time, resulting in insufficient oversight of food services for all residents.
The facility failed to adhere to food safety and sanitation standards, with issues including an unclean ice machine, improper storage of kitchenware and deli meats, and inadequate handwashing and dishwashing practices. These deficiencies were confirmed by the Dietary Manager and Maintenance Supervisor, indicating a lack of compliance with facility policies and FDA guidelines.
The facility failed to maintain pharmacy services by not replacing emergency medications in the E-kit in a timely manner. Medications were removed for three residents, but replacements were not made within the expected timeframe, as confirmed by the DON. The facility's policy required replacement within 72 hours, which was not followed.
The facility failed to follow prescribed therapeutic diets during lunch meals, affecting 19 residents. Two residents on a CCHO diet received incorrect portions of garlic bread, while six residents on a fortified diet did not receive additional shredded cheese. Five residents on a 2-gram sodium diet received full servings of dessert, and five residents on a mechanical soft diet were given regular dessert. The Dietary Manager and Registered Dietitian confirmed these discrepancies, highlighting a failure to adhere to the menu spreadsheet.
The facility failed to follow infection control practices in three instances: uncovered meal trays were transported, a shared glucometer was not sanitized between uses on two residents with diabetes, and a foley catheter collection bag was found on the floor instead of being hooked onto the bed rail. These actions were against the facility's policies and posed potential infection risks.
A resident with intact cognition and multiple health conditions experienced disrespect and rough handling during a blood draw by an LN, who refused to perform a central venous access device blood draw and was rude to both the resident and a phlebotomy technician. The facility's policy on dignity was not upheld, as confirmed by the DON and the LN's performance review.
The facility failed to follow its medication self-administration policies for two residents, lacking assessments and physician's orders for safe self-administration and bedside storage. One resident stored calcium carbonate without proper labeling or documentation, while another kept an inhaler at the bedside without informing staff. Staff interviews confirmed the absence of necessary orders and assessments, contrary to facility policies.
A resident's medication administration was not accurately documented in the MAR, leading to potential risks of overmedication. The facility's policy requires immediate documentation after administration, but discrepancies were found in the records for Vancomycin and Oxycodone. Interviews with the DON and ADON confirmed the medications were given but not recorded, highlighting a risk of miscommunication and unsafe practices.
The facility failed to offer activities that met the interests and preferences of two residents, as outlined in their care plans. One resident with a femur fracture received only one activity visit in five weeks, while another resident with Alzheimer's and depression was not engaged in group or 1:1 activities. The Activities Director and DON acknowledged the insufficiency of activity visits, which did not meet the residents' needs.
Call Light Not Kept Within Reach for Resident on Bedside Commode
Penalty
Summary
The facility failed to ensure a resident’s call light was within reach as required by the resident’s care plan and facility policy. The resident had diagnoses including a fall, a healing left femur fracture, difficulty walking, and a communication deficit, with a BIMS score of 11 indicating moderate cognitive impairment. The resident’s care plan for fall risk, dated 10/18/25, specified that the call light should be within reach when the resident was in the room. During an observation in the resident’s room, the resident was seated on a bedside commode on the right side of the bed and stated a need for help, while the call light was positioned on the left side of the bed, out of the resident’s reach. In interviews, the CNA who had transferred the resident to the bedside commode acknowledged that the call light was out of reach and stated that the call light should always be within reach, and that the resident should have been able to press it after finishing on the commode. The resident stated that the call light should be within reach and that if it was not, it would take a while for someone to help. A licensed nurse confirmed that the call light should be within the resident’s reach and that otherwise the resident would wait longer. The DON stated that residents should be able to reach their call lights at all times and that without this it would be impossible for residents to ask for help. The facility’s “Answering the Call Light” policy required that the call light be accessible to residents when in bed, on the toilet, in the shower or bathing facility, and from the floor.
Failure to Implement Enhanced Barrier Precautions for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident who had an indwelling urinary catheter, a condition that requires Enhanced Barrier Precautions (EBP) according to facility policy. During an observation, a Physical Therapy Assistant (PTA) transferred the resident without wearing a gown, despite being in close contact and being aware that EBP was required for residents with indwelling catheters. The PTA confirmed during an interview that a gown should have been worn during the care activity. Additionally, there was no signage outside the resident's room to indicate that EBP was in place, as required by the facility's policy. The Infection Preventionist Nurse confirmed the absence of signage and acknowledged that residents with indwelling catheters should have EBP signage to inform staff of the necessary precautions. The Director of Nursing also stated that EBP was expected for residents with indwelling catheters to prevent the spread of infection.
Unqualified Dietary Manager Leads to Food Service Deficiencies
Penalty
Summary
The facility failed to ensure that the full-time Director of Food and Nutrition Services (Dietary Manager) met the state's educational qualification requirements as mandated by federal regulation. The Dietary Manager, who had been employed for three months, did not possess the necessary credentials such as Certified Dietary Manager (CDM) or Dietary Services Supervisor (DSS) certification. This lack of qualification led to lapses in the delivery of food and nutrition services, including inaccuracies in meal distribution and issues with safe food handling and sanitation. The Registered Dietitian (RD) was only available on a part-time consulting basis, which further contributed to insufficient oversight of the dietary department. During the survey, several deficiencies were identified, including incorrect serving sizes, failure to provide fortified food as ordered, and various sanitation issues such as an unclean ice machine and improper handwashing practices. The facility's Administrator was aware of the Dietary Manager's lack of certification but relied on his previous experience and ServSafe certification, which did not meet state requirements. The RD, who worked part-time at the facility, was also unaware of the Dietary Manager's lack of qualifications. The facility's failure to employ a qualified Dietary Manager resulted in compromised food service operations for all 60 residents receiving meals from the facility kitchen.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain food service safety standards, as evidenced by several deficiencies observed during a survey. The ice machine was found to be unclean, with significant black substances on the evaporator unit, indicating a lack of proper cleaning and maintenance. The Dietary Manager (DM) and Maintenance Supervisor (MS) confirmed the ice machine's condition, acknowledging that the deep cleaning process was not adequately verified. The facility's policy required regular cleaning of the ice machine, but the last recorded cleaning was not effective, leading to potential contamination risks. In the kitchen, various kitchenware items were improperly stored, with some stacked while still wet and others having brown sticky liquid residues. The DM confirmed these findings, stating that the staff responsible for storing the dishes failed to ensure they were clean and dry, which could promote bacterial growth. Additionally, two boxes of sliced turkey deli meat, which required freezing, were improperly stored in the walk-in refrigerator instead of the freezer, as per the storage instructions. This oversight was attributed to the staff responsible for receiving deliveries not following the proper storage procedures. Further deficiencies were noted in handwashing practices and dishwashing procedures. The handwashing sink's location led to water splashing onto clean dishes, causing potential cross-contamination. A cook was observed washing hands at a prep sink without proper facilities for handwashing, and a dietary aide was unable to correctly verbalize the manual dishwashing process. These practices were contrary to the facility's policies and the FDA Food Code, highlighting a lack of adherence to proper sanitation and hygiene protocols.
Failure to Replace Emergency Medications in E-kit
Penalty
Summary
The facility failed to maintain adequate pharmacy services for its residents, as evidenced by the improper management of emergency medications in the E-kit. During an observation and interview, it was found that the E-kit had a broken seal and contained medications that had been removed but not replaced in a timely manner. Specifically, Vancomycin tablets were removed on two separate occasions for one resident, while Potassium KCL and Levofloxacin tablets were removed for another resident, and Doxycycline was removed for a third resident. The Licensed Nurse confirmed that the process required notifying the pharmacy for replacement, which should occur the next day. Further investigation with the Director of Nursing revealed that the medications had been removed several days prior and had not been replaced, either due to a failure to notify the pharmacy or the pharmacy's failure to replace them. The facility's policy stated that replacement doses should be added to the kit within 72 hours, but this was not adhered to, potentially leaving residents without necessary emergency medications.
Failure to Follow Prescribed Therapeutic Diets
Penalty
Summary
The facility failed to adhere to prescribed therapeutic diets during lunch meals on two consecutive days, affecting 19 residents. On the first day, two residents on a Consistent Carbohydrate (CCHO) diet received a full slice of garlic bread instead of the prescribed half slice. The Registered Dietitian confirmed that the menu was not followed as per the facility's spreadsheet. On the second day, six residents on a fortified diet did not receive the additional one ounce of shredded cheese required for their meal. Additionally, five residents on a 2-gram sodium diet received a full serving of dessert instead of the prescribed half serving. Furthermore, five residents on a mechanical soft diet were given regular dessert instead of the modified version, while four residents on a regular diet received the mechanical soft dessert instead of the regular one. The Dietary Manager acknowledged these discrepancies during an interview, confirming that the staff did not follow the menu spreadsheet, which led to the incorrect meal distributions. The Registered Dietitian also acknowledged the findings and emphasized the importance of following the menu to meet the residents' nutritional needs. The facility's job description for the Director of Food and Nutrition and the menu planning document both highlight the necessity of adhering to prescribed diets, which was not done in these instances, potentially compromising the medical and nutritional status of the affected residents.
Infection Control Lapses in Food Transport, Glucometer Use, and Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices in three distinct instances. First, four meal trays with uncovered desserts were transported from the dining room to resident rooms using a utility cart, contrary to the facility's policy that requires food items to be covered during transport to prevent contamination. This was confirmed by both the Certified Nursing Assistant and the Dietary Manager, who acknowledged the risk of foodborne illness due to uncovered food. Second, a shared glucometer was not sanitized between uses on two residents with type 2 diabetes mellitus, as observed with a Licensed Nurse. The nurse admitted to not cleaning the glucometer between uses, which was against the facility's policy and posed a potential infection control issue. Lastly, a foley catheter collection bag for a resident with a lumbar vertebrae fracture was found on the floor, which was acknowledged by a Certified Nursing Assistant and the Director of Nursing as a breach of infection control procedures, as the bag should have been hooked onto the bed rail to prevent contamination.
Resident Dignity Compromised During Blood Draw
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect during a blood draw procedure. The resident, who had intact cognition and was admitted with conditions including infection due to a knee prosthesis and chronic systolic heart failure, reported that a Licensed Nurse (LN 3) was disrespectful and rough during the procedure. The resident stated that LN 3 refused to perform a central venous access device blood draw, citing other tasks, and was rough during the lab draw. Despite the resident's request to try the other lumen of the central line after an unsuccessful attempt, LN 3 refused. Further investigation revealed that LN 3 was rude to both the resident and the phlebotomy technician, blaming the resident for the timing of the blood draw and causing the resident distress. The Director of Nursing (DON) confirmed that only registered nurses are permitted to draw blood from a CVAD/PICC line and emphasized the expectation for staff to be kind and respectful. LN 3's performance review indicated a need for improvement in communication, as she could be punitive. The facility's policy on dignity requires that residents are treated with respect at all times, which was not upheld in this instance.
Failure to Follow Medication Self-Administration Policies
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding medication self-administration for two residents, Resident 29 and Resident 43. There were no assessments conducted to determine the safety of self-administration and storage of medications at the bedside for these residents. Additionally, the facility did not obtain physician's orders for the self-administration and bedside storage of medications for both residents. This lack of documentation and assessment led to potential risks associated with unsafe medication administration. Resident 29, who was admitted with diagnoses including Parkinson's disease and sepsis, was observed with an unlabeled bottle of tablets on the bedside table. The resident confirmed storing calcium carbonate at the bedside for acid reflux, but there was no documented evidence of an assessment for self-administration or safe storage, nor a physician's order for such practices. Similarly, Resident 43, admitted with asthma and chronic respiratory failure, had an inhaler stored in a bag at the bedside without original packaging or labeling. The resident admitted to not always informing staff about self-administration, and there was no documented evidence of assessment or progress notes confirming self-administration. Interviews with staff, including a Licensed Nurse and the Pharmacist Consultant, confirmed the absence of necessary orders and assessments. The Director of Nursing acknowledged the expectation for evaluations and orders for bedside medication storage and self-administration, which were not consistently followed. The facility's policies required assessments and documentation for self-administration and safe storage, which were not adhered to, leading to potential risks of medication misuse and access by other residents.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to follow physician orders for a resident, identified as Resident 35, by not accurately documenting medications administered on the Medication Administration Records (MAR). This deficiency was identified during a review of Resident 35's records, which showed discrepancies in the documentation of medication administration. Specifically, the MAR for a particular date indicated that the 8:00 p.m. dose of Vancomycin was not documented as administered, although the Director of Nursing (DON) confirmed that the dose was given. Additionally, the MAR for another date showed that no doses of Oxycodone were documented as administered, despite the Assistant Director of Nursing (ADON) stating that the medication was given. The facility's policy and procedure for medication administration, dated March 2018, requires that the individual administering the medication records the administration on the MAR immediately after giving the medication. The failure to document the administration of medications as per the facility's policy posed a risk of miscommunication among nursing staff and the potential for the resident to receive more medication than ordered, which could lead to adverse side effects. Interviews with the DON and ADON highlighted the expectation for licensed staff to accurately document medication administration to prevent inaccurate and unsafe medication practices.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide activities that met the interests and preferences of two residents, Resident 39 and Resident 33, as outlined in their care plans and assessments. Resident 39, admitted with a fracture of the right femur, was not offered activities in her room despite her care plan indicating the need for encouragement in activities of interest and socialization. The Activities Director confirmed that Resident 39 received only one activity visit in five weeks, which was insufficient to meet her needs. The lack of documented activity notes or logs further highlighted the deficiency in providing adequate activities for Resident 39. Similarly, Resident 33, who has Alzheimer's Disease and major depressive disorder, was not engaged in activities as per her care plan, which included group activities and 1:1 visits. Observations showed Resident 33 frequently asleep in her room, with no evidence of 1:1 activities being provided. The Activities Director acknowledged that staff did not get Resident 33 up for group activities and confirmed that the few documented visits were inadequate. The Director of Nursing also recognized that the frequency of activity visits did not meet the residents' physical, mental, and psychosocial needs, as required by the facility's policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Roseville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Roseville Point Health & Wellness Center | 0.3 mi | — | 3 | 0 |
| Roseville Care Center | 0.9 mi | — | 2 | 0 |
| Pine Creek Care Center | 0.9 mi | — | 1 | 0 |
| Citrus Heights Post Acute | 5.3 mi | — | 1 | 0 |
| Fair Oaks Healthcare Center | 6 mi | — | 22 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.