Oak Grove Center

In the surveyor’s words

From the most serious findings on record at Oak Grove Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689May 29, 2024

  Based on observations and interviews, the facility failed to ensure a safe environment by allowing access to a potentially unsafe environment on 1 of 3 units observed for ([NAME] House). Findings: On 5/28/24 at 8:21 a.m., During an initial observation of [NAME] small dining room, 2 surveyors observed a large hole in the ceiling with an obvious leak. A yellow plastic wet floor sign was under the hole. A yellow mop bucket was approximately 4 feet away from the sign containing about 4 inches of dirty water. There were no barriers noted to prevent access to this area. Follow-up observations of [NAME] House small dining room on 5/28/24 between 9:45 a.m., and 3:45 p.m. […]

• No harm, potential for more than minimal, widespreadF812Feb 1, 2024

  Based on observations, interviews, the facility's Dish Machine Logs, Food Storage-Cold Goods Policy and Procedure last revised 4/2018, Food Storage-Dry Goods Policy and Procedure last revised 9/2017, and Refrigerated/Frozen Storage Policy and Procedure last revised 6/15/18, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for air conditioning units, vents, a mixer, the ice machine, shelving, a reach-in freezer, a walk-in refrigerator and dry storage for 1 of 1 kitchen tour. In addition, the facility failed to ensure that the dish machine was maintaining proper temperature ranges for proper cleaning and sanitizing. […]

• No harm, potential for more than minimal, patternF584Jun 4, 2026

  Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 units ([NAME] Unit, [NAME] Unit and [NAME] Unit) for 2 of 2 facility tours.Findings:1. On 6/1/26 at 7:04 p.m., a surveyor observed in Resident room [ROOM NUMBER]'s shared bathroom, a bedpan on the floor next to the toilet which was unbagged and unlabeled. At this time, in an interview with a surveyor, the Market Clinical Lead confirmed the finding. On 6/1/26 at 7:35 p.m., a surveyor observed in Resident room [ROOM NUMBER]'s bathroom, a dirty and unlabeled bed pan on the back of the toilet which had dried urine in it. […]

• No harm, potential for more than minimal, patternF725Jun 4, 2026

  Based on Payroll Based Journal staffing (PBJ) report, record reviews and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility for weekends of the first quarter 2026 (October 1 - December 31, 2025). This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's). Findings:1.Review of Payroll Based Journal staffing report revealed the facility triggered for low weekend staffing during the first quarter of 2025 (October 1, 2025 - December 31, 2025).During a review of nursing staffing sheets for certain dates between 6/8/25 and 6/9/25, weekends from 10/1/25 through 12/31/25, and 5/10/26 through 5/29/26. […]

• No harm, potential for more than minimal, patternF755Jun 4, 2026

  Based on observations, record reviews, interviews, and facility policy, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and ensure that two people who are authorized to administer medications signed the Shift Count page of the Controlled Substances book [a logbook used to record and inventory controlled medications], indicating that they counted all controlled substances at the change of shift for multiple shifts, for 3 of 4 medication carts observed on 2 of 3 units ([NAME] Unit Cart A, [NAME] Unit Cart B, [NAME] Unit Cart).Findings:Facility policy NSG300 Controlled Drugs: Management of revised 1/31/25 states, All staff who administer medications will safeguard controlled… […]