Oak Grove Healthcare

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF602Sep 6, 2024

  Based on record reviews and interviews with staff, residents, responsible parties, and the Medical Director (MD), the facility failed to protect resident's rights to be free of misappropriation of controlled substances for 2 of 2 residents reviewed for misappropriation of resident property (Resident #212 and Resident #49). The findings included: The facility's Abuse, Neglect, Exploitation, and Misappropriation policy, last revised on 11/16/2022, revealed in part the facility would ensure all residents were free from misappropriation of property. a. Resident #212 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, osteomyelitis of right ankle and foot, and protein-calorie malnutrition. […]

• No harm, potential for more than minimal, isolatedF641Sep 6, 2024

  Based on record reviews and staff interviews the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of Level II Pre-Admission Screening and Resident Review (PASRR) (Resident #17 and Resident #27), and anticoagulants (Resident #23). This deficient practice was identified for 3 of 3 residents reviewed for MDS accuracy. The findings included: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder and bipolar disorder. Resident #17's most recent comprehensive Minimum Data Set (MDS) was an annual assessment dated [DATE]. […]

• No harm, potential for more than minimal, isolatedF578Jul 13, 2022

  Based on record review and staff interviews, the facility failed to maintain accurate advance directives throughout the medical record for 1 of 18 residents reviewed for advance directives (Resident #204). The findings included: Resident #204 was admitted to the facility on [DATE]. A review of Resident #204's Electronic Medical Record (EMR) indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A document entitled, Advance Directives Discussion Document, dated [DATE] in Resident #204's paper chart indicated to withhold cardiopulmonary resuscitation (CPR) and that Resident #204 had a living will. […]

• No harm, potential for more than minimal, isolatedF657Jul 13, 2022

  Based on record review and staff interviews, the facility failed to update care plans to reflect weight loss for 1 of 2 residents reviewed for nutrition (Resident #39) and failed to update care plans for 1 of 1 resident reviewed for pressure ulcers (Resident #17). The findings included: 1. Resident #39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #39 was cognitively intact and weighed 97 pounds. Review of the facility's care plan meeting minutes dated 3/9/2022 revealed the facility was aware of Resident #39's history of permanent loss of taste and smell. Review of Resident #39's care plan dated 3/16/2022 revealed a focus area for potential for nutritional problem. […]

• No harm, potential for minimal, widespreadF732Dec 3, 2025

  Based on observations, record review and staff interviews, the facility failed to post the daily nurse staffing data for 1 of 4 days of the survey (11/30/25) and maintain posted daily nurse staffing data sheets for 83 of 169 days reviewed from June 2025 through December 2025.The findings included:Observation of the daily nurse staffing sheet on 11/30/2025 at 10:30 AM, and 12:46 PM revealed a daily nurse staffing sheet dated 11/25/2025.Review of the daily nurse staffing sheets from 6/18/2025 through 12/3/2025 revealed there were 83 days of daily nurse staffing sheets missing: 6/21/25, 6/22/25, 6/28/25, 7/4/25 through 7/8/25, 7/12/25, 7/13/25, 7/16/25, 7/19/25 through 7/21/25, 7/26/25 through 7/28/25, 8/2/25, 8/3/25, 8/9/25, 8/10/25, 8/16/25, 8/17/25, 8/23/25 through 8/26/25, 8/29/25 through… […]