Oak Grove Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF600Aug 1, 2025

  Based on observation, interview and record review the facility failed to provide one to one supervision (a designated staff to provide constant monitoring to prevent or redirect resident from engage in harmful act) to one of three sampled residents (Resident 2, with known behavioral issues), to prevent the physical altercation between Resident 1 and Resident 2 on 6/7/25.This failure resulted in Resident 2 suffering multiple bruises and a laceration to the right side of his face and Resident 1 suffering two fractures in his left hand.Findings:Review of Resident 1's admission RECORD indicated that Resident 1 was admitted to the facility with diagnoses that included but were not limited to unspecified mental disorder to known physiologic condition (a clear link between a physical condition… […]

• Actual harm, isolatedF686Jul 6, 2023

  Based on interview and record review, the facility failed to provide necessary care and services to prevent a pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with friction) from developing and/or worsening for one of two sampled residents (Resident 2) when: 1. Resident 2 developed a wound on the lower back/coccyx (tail bone) on 4/25/23, and the wound nurse was not notified per Resident 2's care planned interventions; and, 2. Licensed nurses did not monitor Resident 2's lower back/tailbone wound according to physician orders, facility policy, and per standard of nursing practice. These failures resulted in delayed identification and treatment of a pressure ulcer for Resident 2. […]

• Actual harm, isolatedF600Oct 11, 2022

  Based on interview and record review, the facility failed to provide services that are necessary to avoid physical harm and pain when one of three sampled residents (Resident 1) demonstrated bruising, persistent pain in her left hip and leg, and a left hip fracture which limited her mobility and activity. This failure resulted in Resident 1 not receiving necessary nursing and medical treatment including positioning, pain management, surgical intervention and treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's Face sheet indicated Resident 1 was admitted into the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Aug 4, 2021

  Based on observations, interviews and record review, the facility failed to provide monitoring and supervision to ensure safety of six residents (Resident 1, Resident 2, Resident 3, Resident 5, Resident 6, Resident 8) in a sample of 8 residents identified at risk for elopement (an act or instance when a cognitively impaired person leaves a safe area or premises unsupervised) when: 1.Resident 1 eloped and was found in a homeless shelter with altered mental status, dehydrated and with urinary tract infection ([CONDITION(S)]) 3 days later. 2. Staff failed to monitor the application and functioning of wanderguard (a monitoring device which beeps when residents go out of the building) bracelets for Resident 5, Resident 6, and Resident 8. 3. […]

• No harm, potential for more than minimal, widespreadF921Aug 13, 2026

  Based on observation, interview, and record review, the facility failed to maintain one of three shower stations in good working order for a total of 105 residents when, the North shower station remained nonfunctional despite documented maintenance requests, resulting in residents being transported to other shower areas, waiting for available showers, and having showers delayed or postponed. This failure had the potential to affect residents' dignity and timely access to scheduled showers.Findings:During a concurrent observation and interview on 8/10/26 at 2:46 PM with Certified Nursing Assistant (CNA) 1, the North shower station was observed with no water coming from the shower fixture. CNA 1 stated that the North shower station had been broken for approximately three months. […]