Oak Grove Health & Rehab Center, LLC

In the surveyor’s words

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

• Actual harm, isolatedF580Aug 9, 2023

  Based on a family interview, staff interviews, clinical record review, and review of facility documents, the facility staff failed to notify the Physician and/or Practitioner of an abnormally elevated blood pressure reading, the inability to procure a newly ordered blood pressure medication and of identified changes in mentation which progressed to a serious and life-threatening hypertensive emergency and a large left-brain bleed for 1 of 5 residents (Resident #1), in the survey sample, which constituted harm. Past Non-Compliance was given to this citation. The Findings Included: Resident #1 was no longer a resident of the facility; therefore, a closed record review was conducted. […]

• No harm, potential for more than minimal, patternF658Jan 28, 2022

  Based on compliant investigation, staff interviews, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing for 1 of 34 residents (Resident #47) in a survey sample. The findings included: The facility staff failed to ensure blood pressures were taken prior to the administration of medication ([MEDICATION(S)]) as ordered by the physician Resident #47 was admitted to the nursing facility on 06/03/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #47's Minimum Data Set (an assessment protocol) a quarterly assessment with an Assessment Reference Date (ARD) of 12/10/21 coded the resident's Brief Interview for Mental Status (BIMS) score 08 of a possible 15 with moderate impairment for daily decision-making. […]

• No harm, potential for more than minimal, patternF726Jan 28, 2022

  Based on information gleamed during a complaint investigation, staff interviews, and review of facility documents, the facility staff failed to have a procedure in place to ensure that a presumed Graduate Nurse (GN) had a license or authorization to practice in the state prior to hiring, starting orientation and rendering care to residents in the facility. The findings included: An interview was conducted with the Director of Nursing and Administrator on 1/28/21 at approximately 5:45 p.m. regarding the complaint that they had nurses right out of school without proper credentials working in the facility. The Director of Nursing stated they didn't have anyone working as a nurse who didn't meet the requirements to work as a graduate Nurse. […]

• No harm, potential for more than minimal, patternF742Jan 28, 2022

  Based on observations, resident interview, family interview, staff interviews, and clinical record review, the facility staff failed to to ensure a resident exhibiting resistive behaviors secondary to a history of pain related trauma received person-centered services to support and promote mental and physical well-being which resulted escalated behaviors and a significant decline in mental and physical functioning for 1 of 34 residents (Resident #36), in the survey sample. The findings included: Resident #36 was originally admitted to the facility 10/11/21, and readmitted [DATE], after an acute care hospital stay. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF756Jan 28, 2022

  Based on observation, clinical record review, staff interview the facility, the failed to ensure 1 of 34 Residents (#92) in the survey sample was seen by the pharmacist for Medication Regimen Review (MRR) on a monthly basis. The findings included: The facility staff failed to review Resident #92's medication regimen for the month of August 2021. Resident #92 was admitted to the facility on [DATE]. Diagnosis for Resident #92 included but not limited to Major Depressive disorder and Anxiety disorder. Resident #92's Minimum Data Set (MDS), a quarterly Assessment Reference Date (ARD) of 01/09/22 coded the resident with a 09 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. […]