Oak Grove Nursing Home

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF880Sep 10, 2025

  Based on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #4, Resident #74, and Resident #71) of 20 residents reviewed for infection control. 1. The facility failed to ensure LVN A sanitized the bottle of wound cleanser after using it in Resident #4 room and before it was placed in the medication cart. 2. The facility failed to ensure CNA C sanitized her hands and changed gloves before performing incontinent and catheter care for Resident #74. 3. […]

• No harm, potential for more than minimal, patternF805Jul 11, 2023

  Based on observation, interview and record review, the facility failed to provide food in a form designed to meet individual needs for 1 of 2 meals reviewed for food form. The facility failed to ensure the residents who required a pureed textured diet, received the appropriate food form to meet their needs on 07/10/23 for the noon meal. The pureed food had lumps of food, not fully pureed and was thick and dry in consistency. This failure could affect the 9 residents, who received a pureed diet, at risk of aspiration and choking. Findings included: 1. […]

• No harm, potential for more than minimal, patternF580May 25, 2022

  Based on observation, interview and record review, the facility failed to ensure the physician was consulted regarding a need to alter treatment for 1 of 18 residents reviewed for notification of changes. (Resident #55) The facility did not consult with Resident #55's physician about her pattern of low blood pressure and/or heart rate over consecutive days and of her blood pressure medication being held for multiple doses. This failure could place residents at risk for complications due to delayed or failed physician intervention. Findings included: A record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet PO (by mouth) every 6 hours. Hold if SBP <100 Pulse <60. […]

• No harm, potential for more than minimal, patternF842May 25, 2022

  Based on observation, interview, and record review, the facility failed to ensure the medical record of each resident was accurately documented in accordance with accepted professional standards and practices, for 1 of 18 residents reviewed for medical records. (Resident #55). The facility failed to document Resident #55's B/P (blood pressure) and HR (heart rate) for 17 days the MAR. This failure could place residents at risk of not having accurate documentation to prevent inappropriate dosing and assist in monitoring the effectiveness of medications. Findings Included: A record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1 tablet PO (by mouth) every 6 hours. Hold if SBP <100 Pulse <60. […]

• No harm, potential for more than minimal, isolatedF655Sep 10, 2025

  Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 of 20 residents reviewed for new admissions. (Resident #51)The facility failed to develop and accurately complete a baseline care plan within 48 hours of admission for Resident #51.This failure could lead to residents not receiving necessary care and decreased quality of life.Findings include:Record review of Resident #51's face sheet, dated 09/10/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. […]