Oak Grove Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 6, 2024

  Based on observation, record review, review of the facility Elopement/Unauthorized Absence policy and procedure and interviews with staff and the transportation driver, the facility failed to provide adequate supervision and comprehensive individualized interventions to prevent Resident #14, who was identified at risk for elopement, from leaving the building when on an outside doctor's appointment, unaccompanied by facility staff or family, and prior to the transportation company picking her up and returning her to the facility after the appointment had concluded. […]

• Actual harm, isolatedF686Feb 6, 2024

  Based on observation, staff interviews, resident interview, and record review, the facility failed provide ongoing assessment and monitoring of existing pressure ulcers, failed to complete treatments as ordered by the physician, and failed to notify the physician of the need to alter treatment when pressure ulcers increased in size and when new pressure ulcers developed. This affected two (Resident #63 and #69) of three residents reviewed for skin breakdown. Actual harm occurred when Resident #69 did not have any ongoing assessments of existing pressure ulcers and did not have treatments applied as ordered which resulted in the Stage 3 pressure to the resident's right buttock increasing in size from 7 centimeters (cm) by 5 cm to 12.1 cm by 8 cm by 2 cm. […]

• Actual harm, isolatedF689Nov 17, 2021

  Based on observations, medical record review, review of manufacture's instructions for passenger and wheelchair security and staff interviews, the facility failed to provide adequate supervision and security to a resident during a transport in the facility van. Actual harm occurred when Resident #80 and the wheelchair were not properly secured with safety straps in the facility van. This resulted in Resident #80's wheelchair tipping over in transport and Resident #80 suffering a fractured humerus. This affected one (#80) of three residents reviewed for accident/hazardous. The facility census was 56. Findings include: Review of Resident #80's medical record revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF804Sep 25, 2025

  Based on record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to ensure food was palatable and appropriate temperature. This had the potential to affect all 75 residents residing in the facility who receive food from the kitchen. Findings include:Review of the resident council meeting for 09/08/25 revealed residents did not like most of the food due to having the same food, dry meat, and food not being seasoned. Under the area that reads status update on the resident council minutes revealed the concern was not resolved. Interview on 09/24/25 at 1:39 P.M. with Resident #53 revealed breakfast was always cold so he no longer eats breakfast. […]

• No harm, potential for more than minimal, widespreadF812Jul 1, 2025

  Based on observation, staff interview, and policy review, the facility failed to ensure a kitchen did not have expired food, kitchen was clean and sanitary, and opened food items were not labeled or dated. This had the potential to affect all 73 residents residing in the facility who receive food from the kitchen. Findings include: A tour of the kitchen on 06/29/25 from 8:10 A.M. through 8:33 A.M. revealed in the dry storage room, there were 12 bags of raisins that had a best buy date of 07/14/24, red wine vinegar was opened and had a best if used 03/13/24, molasses was opened and had a best if used by date of 11/15/24, and ziti, penne and elbow pasta bags were opened with no label or date. […]