Inspection Reports for
Oak Grove Christian Retirement Village

Complaint IN00455274 was substantiated with federal and state deficiencies cited at tags F684 and F689 related to quality of care and accident prevention.

The facility failed to ensure proper assessments were completed for a resident with new fractures following a facility incident, failed to prevent injury during resident transfers by agency staff, and failed to adequately supervise a high-risk resident resulting in a fall with head injury. Multiple deficiencies related to quality of care and accident prevention were cited.

The facility was found in compliance with NFPA 101A Chapter 4 and Life Safety Code requirements, achieving a passing score on the FSES survey. However, a deficiency was noted regarding the lack of a 2-hour fire resistive separation between the first floor Healthcare Occupancy and the second floor Assisted Living areas, which was acknowledged by the Plant Manager and subsequently corrected.

Complaint IN00442131 was investigated and corrected as of this revisit.

The facility had deficiencies related to infection prevention and control, failure to complete semi-annual evaluations, failure to update service plans for urinary catheter management and glucose monitoring, incomplete medical diagnoses in resident records, and incomplete resident emergency binders. The facility implemented plans of correction including re-education of staff and auditing procedures to prevent recurrence.

The facility was found not in compliance with Life Safety Code requirements, including inadequate fire separation between healthcare and assisted living areas, obstructions in corridors, improperly secured egress doors, and lack of self-closing devices on hazardous area doors.

Complaint IN00442131 - Federal/State deficiencies related to the allegations are cited at F695.

The facility was found deficient in multiple areas including failure to provide required transfer/discharge notices, incomplete and inaccurate Minimum Data Set (MDS) assessments, failure to update care plans, inadequate physician notification parameters, improper wound care and infection control practices, improper catheter care, oxygen equipment maintenance, medication management including psychotropic medication monitoring, and sanitary issues in the kitchen related to dishwasher temperatures.

Complaint IN00439002 was substantiated with federal/state deficiencies cited at F842 related to resident records and oxygen documentation.

The facility failed to ensure medical records were complete and accurately documented related to oxygen administration and saturation levels for 2 of 3 residents reviewed. Specific documentation gaps were found for Residents B and C regarding oxygen therapy and saturation monitoring.

Complaint IN00434136 was substantiated with federal/state deficiencies cited. Complaints IN00433724 and IN00433725 had no deficiencies related to the allegations.

The facility failed to report an allegation of abuse/neglect for one resident and failed to ensure adequate supervision and care plan adherence to prevent accidents for two residents. Deficiencies were cited related to reporting alleged violations and accident prevention.

Complaint IN00431990 was substantiated with federal/state deficiencies cited at F684 related to inadequate post-fall assessment. Complaint IN00430687 had no deficiencies related to the allegations.

The facility failed to ensure a resident (Resident B) received a thorough and timely assessment after a fall on 3/29/2024, resulting in delayed identification of a right tibia/fibula fracture. The facility's post-fall assessment policy was not followed, and corrective actions were implemented including staff education and monitoring.

The facility was found in compliance with the Fire Safety Evaluation System (FSES) Survey conducted on 01/04/2024, achieving a passing score. However, a deficiency was noted regarding the construction type and fire separation between the first floor Healthcare Occupancy and the second floor Assisted Living areas, which lacked a 2-hour fire resistive barrier as required.

The facility was found not in compliance with Life Safety Code requirements including issues with construction type separation, sprinkler system maintenance, smoke barrier doors, electrical room access, and oxygen storage safety. Corrective actions and systemic changes were planned to address these deficiencies.

The facility was found out of compliance in multiple areas including resident dignity, care planning, medication management, infection control, staff licensure, and food safety. Specific deficiencies included uncovered urinary catheter bags, failure to honor resident preferences, incomplete transfer notifications, inaccurate assessments, incomplete care plans, improper medication monitoring, unsanitary kitchen conditions, expired nurse license, improper disposal of lancets, and incomplete clinical records.

Complaint IN00413465 had no deficiencies related to the allegations. Complaint IN00414951 was substantiated with federal/state deficiencies cited at F806 and F808 related to medication self-administration, dietary preferences, and therapeutic diet compliance.

The facility was found deficient in determining the appropriateness of resident self-administration of medications, failing to ensure dietary preferences were followed, and not providing therapeutic diets as ordered by the physician. Specific issues included medications left with residents without proper assessment, failure to provide preferred dietary items, and failure to serve therapeutic diets including extra protein supplements and health shakes.

This visit was triggered by multiple complaints including IN00400228, IN00403128, IN00406313, IN00408550, IN00411197, and IN00412035. Several complaints were substantiated with deficiencies cited, including issues with call light accessibility, bowel management, pressure ulcer care, catheter care, medication management, food service, staff education, and resident property protection. Some complaints had no deficiencies cited.

The facility was found to have multiple deficiencies including failure to accommodate resident needs related to call light accessibility, inadequate bowel management, failure to provide pressure ulcer treatments and nutritional supplements as ordered, improper urinary catheter care, failure to ensure unnecessary medications were avoided, improper food service practices, and failure to protect residents' property from theft with inadequate investigations.

The facility was found in compliance with NFPA 101A Chapter 4 based on the Fire Safety Evaluation System Survey. However, a deficiency was noted regarding the building construction type and fire resistance rating between healthcare and assisted living areas, specifically the lack of a 2-hour fire resistive barrier separating these occupancies.

The facility was found not in compliance with several Life Safety Code requirements including construction type separation, sprinkler system maintenance, portable fire extinguisher installation height, smoke barrier penetrations, and improper use of extension cords in the laundry room. The Emergency Preparedness survey found the facility in compliance with requirements.

Complaint IN00386370 was substantiated. The complaint involved failure to conduct a thorough investigation of missing narcotics and related deficiencies cited at F689.

The facility was found to have multiple deficiencies including failure to conduct a thorough investigation of missing narcotics, inaccurate Minimum Data Set discharge assessments, incomplete medication-related care plans, inadequate care related to diarrhea management, improper supervision during showering leading to a fall, failure to properly screen visitors for COVID-19, incomplete annual abuse and dementia training for staff, and missing resident emergency information in the Emergency Binder.