Oak Grove Retirement Home

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF688Nov 13, 2025

  Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure proper positioning for (Resident #14) and failed to provide range of motion (ROM) services for Resident #25 to prevent further decline in physical functioning. This deficient practice was identified for two (2) of three (3) residents reviewed for ROM and positioning. Findings include: Review of the facility policy titled, Mobility and Range of Motion, last reviewed January 2024, revealed: Policy Statement: Residents with limited range of motion (ROM) will receive treatment and services to increase and/or prevent further decrease in ROM. […]

• No harm, potential for more than minimal, isolatedF606Nov 13, 2025

  Based on staff interviews, record review, and facility policy review, the facility failed to ensure that pre-employment background checks were completed prior to allowing newly hired direct care staff to work for two (2) of five (5) employee files reviewed, Certified Nurse Assistant (CNA) #3 and Licensed Practical Nurse (LPN) #4 Findings include: Review of the facility policy titled, Abuse, Neglect, and Exploitation, last reviewed 1/2024, revealed: The facility has developed policies and procedures which provide essential components to an abuse prevention and intervention program. […]

• No harm, potential for more than minimal, isolatedF641Nov 13, 2025

  Based on staff interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS)Assessment related to coding a resident as having a serious mental illness for one (1) of 17 resident MDS assessments reviewed. Resident #3.Findings Include: Review of the Facility Policy titled, Coordination/Certification of Assessments with reviewed date of 01/2024 revealed, Each resident's assessment will be coordinated by and certified as complete by a Registered Nurse, and all individuals who complete a portion of the assessment will sign and certify the accuracy of the portion of the assessment he or she completed Record review of Resident #3's admission Record revealed an initial admission date of 01/11/2019 with medical diagnoses that included Unspecified Mood (Affective)… […]

• No harm, potential for more than minimal, isolatedF656Nov 13, 2025

  Based on observations, staff interviews, and record review the facility failed to develop a care plan related to contractures for Resident #25 and failed to implement a care plan related to nail care for Resident #29 for (2) two of 23 sampled resident care plans reviewed. Resident #25 and 29Findings include: Review of typed statement on facility letterhead revealed Proper Name retirement home follows the RAI (Resident Assessment Instrument) manual as a policy for initiating, completing, and updating of the care plan. Resident #25 An observation of Resident #25 on 11/11/25 at 12:00 PM and again on 11/12/25 at 9:00AM and 1:00PM revealed a right-hand contracture with no device in place for positioning or protection. […]

• No harm, potential for more than minimal, isolatedF677Nov 13, 2025

  Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care related to fingernail hygiene for 1 (one) of 56 residents residing in the facility. Resident #29.Findings Include: Review of the typed statement on facility letterhead by the Administrator (ADM)revealed, Proper Name (facility) follows the RAI (Resident Assessment Instrument) manual for the Activities of Daily Living policy. Observations on 11/11/25 at 1:00 PM and on 11/12/25 at 1:50 PM revealed Resident #29 with long, dirty fingernails. His fingernails on both hands were approximately one-fourth to one-half an inch long and they had brown substance underneath. […]