Oak Grove Center

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 units ([NAME] Unit, [NAME] Unit and [NAME] Unit) for 2 of 2 facility tours.

Inspectors wroteBased on Payroll Based Journal staffing (PBJ) report, record reviews and interviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility for weekends of the first quarter 2026 (October 1 - December 31, 2025). This has the potential to affect all residents needing assistance with Activities of Daily Living (ADL's).

Inspectors wroteBased on observations, record reviews, interviews, and facility policy, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and ensure that two people who are authorized to administer medications signed the Shift Count page of the Controlled Substances book [a logbook used to record and inventory controlled medications], indicating that they counted all controlled substances at the change of shift for multiple shifts, for 3 of 4 medication carts observed on 2 of 3 units ([NAME] Unit Cart A, [NAME] Unit Cart B, [NAME] Unit Cart).

Inspectors wroteBased on record review, interview, and facility policy, the facility failed to obtain informed consent for the use of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (Resident #36).

Inspectors wroteBased on interview and clinical record review, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay, a final summary of the resident's status, and reconciliation of all the resident's pre- and post-discharge medications for 1 of 2 residents reviewed for discharge to the community (Resident #98).

Inspectors wroteBased on interviews, document review, the facility's Suicide Precautions policy and the facility's Person Centered Care Plan policy review, the facility failed to ensure that a resident who had signs of self-harm and suicidal ideation received the care and services necessary to reach and maintain the highest level of mental and psychosocial functioning for 1 of 1 residents reviewed for mood/behavior (Resident #92).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 1 of 3 residents reviewed for Activities of Daily Living (Resident #14).

Inspectors wroteBased on observations, interviews, record review, and facility policy, the facility failed to maintain an Infection Control Program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to hand hygiene and the use of appropriate Personal Protective Equipment (PPE) while providing care for a resident on Enhanced Barrier Precautions (EBP) for 1 of 4 days of survey (6/3/26).

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the current resident representative was notified of a change in the resident's medication regimen for 1 of 3 residents having court appointed guardianship (Resident #1 [R1]).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 units ([NAME] Unit, [NAME] Unit and [NAME] Unit) and the laundry room for 1 of 1 facility tour.

Inspectors wroteBased on record review, observations, interviews, and facility policy, the facility failed to implement a care plan for 3 of 4 sampled residents (Resident (R20, R21, and R66).

Inspectors wroteBased on observations, record reviews, interviews and facility policy, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care for 4 of 5 residents reviewed for respiratory care (Resident [R] R13, R21, R46 and R65).

Inspectors wroteBased on record review and interview, the facility failed to identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 3 of 3 sampled resident reviewed with a current diagnosis of PTSD (Resident #(R)15, R27 and R35).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside on 3 of 3 units.

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation by failing to ensure that two people who are authorized to administer medications signed the Shift Count page indicating that they counted all controlled substances at the change of shift for multiple shifts, on 1 of 3 units reviewed ([NAME]).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure medications and treatments were stored properly, including removal of expired medications from available supply, on 3 of 5 days of survey (3/18/25, 3/19/25, 3/20/25). Additionally, the facility failed to obtain physician orders for medications located at a resident's bedside, for 2 of 2 sampled resident (Resident #65 and #79).

Inspectors wroteBased on observations and interviews, the facility failed to maintain garbage storage areas in a sanitary condition to prevent the harborage and feeding of pests for 1 of 3 dumpsters for 1 of 4 days(3/18/24) and 1 of 3 dumpsters for 3 of 4 days of survey. (3/18/25, 3/19/25, and 3/20/25)

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that clinical records were complete and contained accurate information for 5 of 7 sampled residents reviewed for respiratory (Resident #[R] R15, R20, R21, R41 and R44).

Inspectors wroteBased on record review and interview, the facility's Quality Assurance Committee failed to ensure that the Plan of Correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification dated 2/1/24, were effective. The Federal citations F584, F625, F656, F689, F725, F842 and F880 were cited again during the annual Long Term Care Recertification Survey dated 3/24/25.

Inspectors wroteBased on observations, interviews, clinical record review, and facility policy review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases for residents requiring Enhanced Barrier Precautions (Resident #33) on 1 of 3 facility units.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that the resident and/or resident representative were provided with written information concerning the right to accept or refuse medical or surgical treatment and/or formulate an advanced directive, was completed for 2 of 22 residents reviewed for advanced directives. (Residents #27, and #79)

Inspectors wroteBased on record review and interview, the facility failed to ensure that the State mental health authority for Pre-admission Screening and Resident Review (PASRR) Level II was implemented for 1 of 6 sampled residents reviewed for PASRR (Resident #20, (R20).

Inspectors wroteBased on interviews and record review, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), that included, to the extent possible, participation of the resident and/or his/her representative after each Minimum Data Set (MDS) assessment for 1 of 4 residents reviewed for care planning (Resident #41).

Inspectors wroteBased on observations, interviews, and a review of Safety Data Sheets (SDS), the facility failed to ensure that the resident's environment was free of accident hazards relating to the storage of an unlabeled medicated cream and chemicals being properly secured for 2 of 2 observations for 1 of 4 days of survey. (3/18/25)

Inspectors wroteBased on clinical record review and interview, the facility failed to demonstrate evidence of monitoring for mood, behavior, and side effects of psychotropic medications for 1 of 5 residents reviewed for unnecessary medications (#10).

Inspectors wroteBased on record reviews, and interviews, the facility failed to issue a written transfer/discharge notice to a resident or their legal representative for a facility-initiated transfer/discharge for 2 of 6 Resident's reviewed for hospitalization (Resident # [R66] and [R10]).

Inspectors wroteBased on record review and interview, the facility failed to issue written bed hold notices to include cost of care to the resident and /or legal representative for 2 of 5 sampled residents reviewed for transfer to an acute care hospital. (Resident #10[R10] and #66[R66]).

Inspectors wroteBased on observations and interviews, the facility failed to ensure a safe environment by allowing access to a potentially unsafe environment on 1 of 3 units observed for ([NAME] House).

Inspectors wroteBased on observations, review of the plan of correction, and interviews, the facility's Quality Assurance Committee failed to ensure that the plan of correction for identified deficiencies from the Annual Long Term Care Survey Process for Federal Recertification on 2/1/24 was effective. The deficiencies, F689 (Free of Accident Hazards/ Supervision/Devices) was again identified during the 8/14/24 and 8/15/24 Revisit Survey.

Inspectors wroteBased on review of the quarterly Quality Assurance Performance Improvement/Quality Assurance Assessment (QAPI/QAA) Committee meeting attendance sheets and interview, the facility failed to ensure that the Medical Director attended 3 of 4 quarterly meetings.

Inspectors wroteBased on observations and interviews the facility failed to provide a safe, comfortable homelike environment on 2 of 3 units observed during complaint investigations ([NAME] and [NAME] House).

Inspectors wroteBased on record reviews and interview, the facility failed to ensure that all direct care staff received training in effective communication skills reflecting the needs of the resident population served, for 2 of 5 employee education records reviewed (#2, #5)

Inspectors wroteBased on record review and interview, the facility failed to ensure staff received mandatory training on it's Quality Assurance and Performance Improvement Program (QAPI), which included the staff's role and communication with the program, for 2 of 5 employee files reviewed (#2, #5).

Inspectors wroteBased on record reviews and interview, the facility failed to ensure it's standards, policies and procedures for it's Compliance and Ethics program were communicated to all staff, for 2 of 5 employee files reviewed (#2, #4).

Inspectors wroteBased on interviews and record review, the facility failed to protect and promote a resident's dignity for 1 of 4 resident sampled for hygiene (Resident #1).

Inspectors wroteBased on interviews and observations, the facility failed to ensure that accommodations were made for residents that included call bell and telephone being within reach for a resident that is capable of using a call bell and telephone for 1 of 1 resident observed for accommodations (Resident #2).

Inspectors wroteBased on record review, and interview, the facility failed to ensure provider documentation of resident needs that cannot be met and facility attempts to meet those needs during a facility initiated discharge for 1 of 2 residents reviewed for discharge (Resident #4).

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of significant change in condition for 2 of 2 residents reviewed for significan change in condition (Residents #2 and #3).

Inspectors wroteBased on record reviews, interviews the facility failed to update/implement a care plan in the area of constipation for 1 of 1 care plan reviewed (Resident #2).

Inspectors wroteBased on record reviews, interviews, and facility policy, the facility failed to ensure that clinical records were complete and contained accurate information for 4 of 5 residents reviewed for documentation (Resident's #1 and #2, #3 & #5).

Inspectors wroteBased on interview, the facility failed to demonstrate a good faith effort to secure a written transfer agreement with a local hospital to ensure the safe and orderly transfer of residents for care and treatment.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a sanitary environment related to the storage of personal toiletries, and urine collection devices for 1 of 3 units observed ([NAME] House).

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 of 5 employee files reviewed (#2) contained evidence of training to meet the residents' behavioral health care needs.

Inspectors wroteBased on record review, observations and interviews the facility failed to maintain an Infection Control Program designed to help prevent cross contamination and/or development of infection by maintaining a safe and sanitary environment related linen handling, urinary collection devices and sharps/needle safety for 1 of 1 days of survey on 1 of 3 units ([NAME] House).

Inspectors wroteBased on observations, interviews, the facility's Dish Machine Logs, Food Storage-Cold Goods Policy and Procedure last revised 4/2018, Food Storage-Dry Goods Policy and Procedure last revised 9/2017, and Refrigerated/Frozen Storage Policy and Procedure last revised 6/15/18, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for air conditioning units, vents, a mixer, the ice machine, shelving, a reach-in freezer, a walk-in refrigerator and dry storage for 1 of 1 kitchen tour. In addition, the facility failed to ensure that the dish machine was maintaining proper temperature ranges for proper cleaning and sanitizing. This has the potential to effect all residents.

Inspectors wroteBased on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 3 of 3 Units ([NAME] House, [NAME] House & [NAME] House) and the Laundry

Inspectors wroteBased on interview's and record review's, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 2 of 39 sampled residents (#22, #52).

Inspectors wroteBased on interviews and record review, the facility failed to provide residents with a continuous resident centered activities program. This failure has the potential to affect all residents that would normally participate in activities.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside on 3 of 3 units. (#3, #7, #14, #27, #29, #52, #55, #69, #79 & #291)

Inspectors wroteBased on performance evaluations and interview, the facility failed to complete annual performance evaluations at least every 12 months for 3 of 5 sampled Certified Nursing Assistants (CNA #1, CNA #3, and CNA #5).

Inspectors wroteBased on record reviews and interview, the facility failed to ensure that clinical records were complete and contained accurate information for 12 of 39 residents reviewed for activities of daily living (#7, #14, #22, #27, #28, #29, #30, #32, #43, #52 & #69), and for 2 of 39 residents reviewed for medication and treatment administration (#14, #22).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement appropriate infection control standards for residents requiring transmission-based precautions (TBPs) for 3 of 3 residents reviewed (#31, #35, #198), and failed to ensure staff received appropriate education regarding TBPs. 1. 0n 1/30/24, a review of the clinical record revealed Resident #31 had a current physician order that noted: contact precautions for urine only. staff should wear gloves with attends changes and goggles should splash from a bed pan or commode be possible. ESBL[Extended Spectrum Beta-Lactamase] in urine. Other Active 10/30/2023 0n 1/30/24 at 2:00 p.m., a surveyor observed Resident #31's room and there was no personal protective equipment (PPE) station and no sign informing those entering the room that enhanced barrier precautions were required. [...]

Inspectors wroteBased on observations, interviews and he facility's Dish Machine Logs, the facility failed to ensure that the kitchen high temperature dish washing machine was maintained in good repair and in safe operating condition for 1 of 1 kitchen tours (1/29/24). From October 2023 to February 2024, the kitchen high temperature dish washing machine was no consistently reaching proper wash and rinse/sanitizing temperatures.

Inspectors wroteBased on record review, observation and interviews, the facility failed to develop or implement the care plan interventions for the residents' current needs for residents requiring transmission-based precautions (TBPs) for 1 of 3 residents reviewed (#31).

Inspectors wroteBased on observations and interviews, the facility failed to ensure that the residents environment was free from the potential risk of accidents relating to faux wood flooring for 1 of 3 units([NAME]) for 1 of 1 observations.

Inspectors wroteBased on record review and interview, the facility failed to recognize and address a potential significant weight change for 1 of 8 sampled residents reviewed for nutritional status (#52).

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who requires dialysis receive such services, consistent with the professional standards of practice in the area of monitoring a dialysis catheter site from 10/4/2023 to 2/1/24, for 1 of 1 resident receiving dialysis (#69).

Inspectors wroteBased on record review and interview, the facility failed to implement and maintain an effective training program which includes, at a minimum, training on abuse, resident rights and dementia management by failing to ensure that 1 of 5 Certified Nursing Assistant's (CNA) employed, completed the required annual training (CNA #1).

Inspectors wroteBased on record review and interviews, the facility failed to issue a bed hold notice for a facility initiated transfer/discharge to a resident, or his/her legal representative, for 2 of 6 sampled residents transferred to an acute care facility (#7, #191).