Oak Grove Christian Retirement Village

In the surveyor’s words

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

• Actual harm, isolatedF689May 7, 2025

  Based on observation, record review, and interview, the facility failed to ensure a resident received proper assistance to prevent accidents, related to a CNA (Agency CNA 1) transferring a dependent resident (Resident B) from the bed to a chair without following the plan of care, causing pain and fractures to the resident's right leg and left ribs. The facility also failed to ensure Resident D, who was a high risk for falls and had a history of falls, was adequately supervised to prevent a fall which resulted in a head laceration requiring staples for healing for 2 of 3 residents reviewed for accidents/supervision. Findings include: 1. During an observation on 5/6/25 at 9:25 a.m., Resident B was sitting in a high back reclining chair. A mechanical lift pad was underneath the resident. […]

• Actual harm, isolatedF689Oct 14, 2021

  Based on record review and interview, the facility failed to ensure a resident received adequate assistance to prevent accidents, related to a resident who was dependent on two staff members for transfers, was transferred by one staff member. The resident was lowered to the floor, which resulted in a fracture of the left leg and severe pain for 1 of 3 residents reviewed for accidents. (Resident B) Finding includes: Resident B's record was reviewed on 10/14/21 at 11:55 a.m. The diagnoses included, but were not limited to, stroke, post COVID-19, and polyneuropathy. […]

• No harm, potential for more than minimal, widespreadF812Sep 22, 2025

  Based on observation, record review, and interview, the facility failed to serve food under sanitary conditions related to dishes stored upright above and below the steam table, on a cart across from the 3-compartment sink and transporting uncovered food on room trays down the hallway. This had the potential to affect all 62 residents who received food from the Kitchen and 6 residents who received room trays on Oak Branch 2 unit. (Kitchen, Oak Branch 2) Findings include:1. The initial Kitchen tour was completed on 9/15/25 at 9:12 a.m., with the Dietary Manager (DM). The following was observed.a. Plates and bowls were stored upright above the steam table.b. Pans were stored upright on a shelf below the steam table.c. […]

• No harm, potential for more than minimal, widespreadF812Oct 22, 2024

  Based on observation, record review and interview, the facility failed to ensure a sanitary kitchen related to dishwasher temperatures not reaching the required temperature and lack of temperature monitoring for a high temperature dish machine. This had the potential to affect all 52 residents who received meals from the Main Kitchen. Finding includes: The initial kitchen tour was completed on 10/15/24 at 9:00 a.m. with the Dietary Manager (DM). The DM indicated the dishwasher was a high temperature dish machine. A wash cycle was observed and the wash temperature was 105 degrees (Fahrenheit) and the rinse was 191 degrees. The DM indicated the wash cycle should be 180 degrees and he was unsure about the rinse cycle. The Dish Machine Temperature Log for October 2024 was reviewed. […]

• No harm, potential for more than minimal, widespreadF812Nov 20, 2023

  Based on observation and interview, the facility failed to ensure a sanitary kitchen related to built up burnt food debris and grease in 2 ovens for 1 of 1 kitchens observed (Main Kitchen). This had the potential to affect 54 residents who received food from the kitchen. Finding includes: The initial kitchen tour was completed on 11/13/23 at 9:07 a.m. The inside of 2 ovens had an accumulation of built up burnt food debris and grease. Interview with Cook 1 on 11/13/23 at 9:18 a.m., indicated the ovens were supposed to be cleaned weekly and dig not appear to be cleaned for awhile. Interview with the Dietary Manager on 11/17/23 at 11:09 a.m., indicated the ovens should be cleaned at least weekly. 3.1-21(i)(3)