Inspection Reports for
Oak Grove Center

The facility was found not in substantial compliance with Medicare and Medicaid certification requirements. Deficiencies were identified in housekeeping and maintenance, sufficient nursing staff, pharmacy services, informed consent for psychotropic medications, discharge process, treatment of residents with mental health concerns, resident records, and infection prevention and control.

Oak Grove Center was found to be in substantial compliance with 42 CFR 483, Subpart B-Requirements for Long Term Care Facilities during an off-site desk audit on 4/8/26.

The facility was found not in compliance with several federal regulations related to comprehensive care plans, psychotropic medication use, drug labeling and storage, resident records, quality assurance, and infection prevention and control. Deficiencies were identified in monitoring residents' care plans, medication management, record keeping, and infection control practices.

The facility was found not in compliance with multiple federal requirements including failure to implement comprehensive care plans, failure to monitor side effects of psychotropic medications, improper medication storage including expired medications, incomplete clinical records, ineffective quality assurance follow-up, and inadequate infection prevention and control practices.

This document is the facility's plan of correction for the survey completed on 03/24/2025. It addresses deficiencies related to advance directives, safe and clean environment, notice before transfer, bed hold policy, PASRR assessments, comprehensive care plans, trauma informed care, sufficient staffing, pharmacy services, labeling and storage of drugs, garbage and refuse, resident records, and infection prevention and control.

The facility was found not in compliance with fire safety requirements including unsealed penetrations in fire barriers, improperly maintained smoke partitions, and lack of a remote emergency stop station outside the generator enclosure. These deficiencies affect the safety of hazardous areas and smoke compartments.

Oak Grove Center is in substantial compliance with 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities. No deficiencies were cited during this revisit.

The facility failed to ensure a safe environment free from accident hazards related to loose, unsecured laminate plank type flooring that moved out of place, posing a risk of falls for residents, staff, and visitors. Additionally, the facility failed to demonstrate a good faith effort to secure a written transfer agreement with a local hospital and failed to maintain compliance with quality assurance, communication training, compliance and ethics training, and behavioral health training requirements.

The facility was found not in substantial compliance with multiple requirements related to resident dignity, reasonable accommodations, permitting residents to return to the facility, significant change notifications, comprehensive care plans, free of accident hazards, resident records, and infection control. Several residents were affected by these deficiencies.

Oak Grove Center was found to be in substantial compliance with 42 CFR 483, Subpart B-Requirements for Long Term Care Facilities.

Oak Grove Center was determined to be in compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities, with no deficiencies cited.

The facility was found not in substantial compliance with infection prevention and control requirements, specifically regarding linen handling, sharps disposal, and staff adherence to safety protocols. The plan of correction outlines education and re-education efforts, audits, and policy reviews to address these issues.

This document is the facility's plan of correction for the survey completed on 02/01/2024. It addresses deficiencies related to safe environment, bed hold policy, baseline care plans, activities, accident prevention, nutrition/hydration, nursing staff sufficiency, food procurement and storage, resident records, infection prevention, and staff training.

The facility was found not in substantial compliance with the National Fire Protection Association 101 Life Safety Code, 2012 Edition, due to deficiencies in hazardous area enclosures, fire door maintenance and testing, electrical systems, and portable fire extinguishers.

Oak Grove Center was found not in compliance with 9.A.4. Minimum Staffing Rules, as the facility failed to meet required direct care staffing levels on multiple days between 09/16/23 and 01/01/24.

Oak Grove Center was found to be in substantial compliance with 42 CFR 481, Sub-part B-Requirements for Long Term Care Facilities. No deficiencies were cited.

Oak Grove Center is in substantial compliance with 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities. No deficiencies were cited.

The facility is in substantial compliance with emergency preparedness regulations but is not in substantial compliance with NFPA 101 Life Safety Code 2012 edition requirements. Deficiencies include unsealed penetrations in fire barriers, resident room doors that do not latch, smoke barrier penetrations, and lack of a remote emergency stop device for the generator.

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The facility failed to notify the resident's court-appointed guardian of a medication change involving an increased Lithium dose for one resident, violating the resident's rights.

The facility failed to implement comprehensive care plans for three sampled residents, lacking goals and interventions for dental care, medication self-administration, and management of medications and stage II pressure sores.

The facility was found deficient in multiple areas including medication management, care planning, infection control, staffing, and environmental safety. Several residents lacked appropriate care plans, medication orders, or monitoring. Infection control practices for residents on Enhanced Barrier Precautions were not consistently followed. Medication storage and labeling were inadequate, with expired and undated medications found. Staffing shortages impacted timely care delivery.

The facility was found to have multiple deficiencies including failure to protect resident dignity, inadequate accommodations, incomplete clinical documentation, unsafe environment hazards, lack of proper transfer agreements, ineffective quality assurance processes, unsanitary conditions, unpleasant odors, and insufficient staff training in communication, QAPI, compliance, and behavioral health.

The facility failed to maintain an infection control program related to linen handling, urinary collection devices, and sharps safety as evidenced by uncovered clean linens, a Foley catheter bag lying on the floor, and unsafe needle handling by staff.

The facility failed to provide sufficient nursing staff to meet resident needs, resulting in missed showers and delayed responses to call bells. Additionally, clinical records for multiple residents were incomplete, with numerous days lacking documentation of activities of daily living and treatment administration.

The facility was found deficient in multiple areas including environmental cleanliness, care planning, infection control, staffing adequacy, and equipment maintenance. Several residents lacked proper care plan documentation and CNA documentation was frequently incomplete. The dishwashing machine failed to reach required sanitizing temperatures. Infection control practices for residents on transmission-based precautions were inconsistently followed and staff education was insufficient.

The facility failed to provide timely written notification of transfers/discharges to residents or their representatives, failed to issue bed hold notices including daily bed hold costs, and failed to provide discharge notices including appeal rights for residents transferred to acute care hospitals.

The facility failed to ensure that a resident's choice in bathing was followed for 1 of 3 sampled residents, as the resident did not receive showers as ordered.

The facility was cited for multiple deficiencies including inadequate housekeeping and maintenance, failure to complete timely background checks for employees, delayed reporting of suspected abuse, incomplete and untimely care planning, failure to monitor fluid restrictions, lack of adaptive eating utensils for a resident, unsanitary kitchen conditions, and failure to implement infection control contact precautions for a resident with antibiotic resistant bacteria.