Oak Grove Health & Rehab Center, LLC

Inspectors wroteBased on review of facility policy, record review, observations, and interviews, the facility failed to ensure a splint was applied routinely for one out of one resident (Resident (R) 11) reviewed for position and mobility. The facility's failure to ensure R11's splint was routinely applied created the potential for this and other residents to experience avoidable decline in range of motion (ROM). A total of 31 residents were reviewed in the sample. Review of R11's Resident Face Sheet, dated 02/19/26 and found in the electronic medical record (EMR) under the Admissions tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included history of stroke and reduced mobility. [...]

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure consistent and comprehensive management of nutritional services for one out of 11 residents (Resident (R) 67) reviewed for nutrition. The facility's failure to ensure consistent nutritional interventions were provided for R67 created the potential for this and other residents to experience significant/unanticipated weight loss or nutritional deficits. A total of 31 residents were reviewed in the sample. Review of the Resident Face Sheet, dated 02/19/26 and found in the electronic medical record (EMR) under the Profile tab, revealed R67 was admitted to the facility on [DATE]. The resident's diagnoses included rheumatoid arthritis, history of stroke, and malnutrition. [...]

Inspectors wroteBased on record review, observations, interviews, and review of facility policy, the facility failed to ensure a medication error rate of less than five percent. Two errors occurred during the administration of one Resident's (Resident (R) 134) medications out of 30 observed opportunities, resulting in an error rate was 6.67 percent. The facility's failure created the potential for R134 and other residents to experience negative physical and/or psychosocial effects related to improper medication administration. A total of 31 residents were reviewed in the sampleReview of R134's Resident Face Sheet, dated 02/19/26 and found in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included congestive heart failure and malnutrition. [...]

Inspectors wroteBased on compliant investigation, staff interviews, clinical record review and facility documentation review, the facility staff failed to follow professional standards of nursing for 1 of 34 residents (Resident #47) in a survey sample.

Inspectors wroteBased on information gleamed during a complaint investigation, staff interviews, and review of facility documents, the facility staff failed to have a procedure in place to ensure that a presumed Graduate Nurse (GN) had a license or authorization to practice in the state prior to hiring, starting orientation and rendering care to residents in the facility.

Inspectors wroteBased on observations, resident interview, family interview, staff interviews, and clinical record review, the facility staff failed to to ensure a resident exhibiting resistive behaviors secondary to a history of pain related trauma received person-centered services to support and promote mental and physical well-being which resulted escalated behaviors and a significant decline in mental and physical functioning for 1 of 34 residents (Resident #36), in the survey sample.

Inspectors wroteBased on observation, clinical record review, staff interview the facility, the failed to ensure 1 of 34 Residents (#92) in the survey sample was seen by the pharmacist for Medication Regimen Review (MRR) on a monthly basis.

Inspectors wroteBased on observation, staff interviews and clinical record review the facility staff failed to ensure 1 resident (Resident #35), in the survey sample of 34 Residents who was unable to carry out activities of daily living receives the necessary services to maintain toenail care.

Inspectors wroteBased on observations, record review and staff interviews, the facility staff failed to ensure one Resident (Resident #45) in the survey sample of 28 residents did not smoke inside the facility.

Inspectors wroteBased on observation, resident and staff interviews, clinical record review and during the course of a complaint investigation the facility staff failed to follow the physician order for the oxygen flow rate, monitor the flow rate and failed to label and date the oxygen tubing for 1 of 34 residents (Resident #23) in the survey sample.

Inspectors wroteBased on staff interview, clinical record review and in the course of a complaint investigation, it was determined that facility staff failed to maintain a complete record for one of 34 residents in the survey sample; Resident #298. During the course of the survey from 1/25/22 through 1/28/22 a surveyor was not able to retrieve records for one closed record resident through the facility's current eMAR (Electronic Medication Administration Records) system called My Unity. The administrator assured the surveyor that she would be able to get the requested records for Resident #298. The records were received upon request. However, when requesting wound care information the records provided by the facility did not contain adequate information. [...]

Inspectors wroteBased on observation, staff interviews, clinical record review and review of the facility's policy, the facility staff failed to ensure the necessary treatment, care and services were provided to promote healing, prevent infection and to prevent development of new foot ulcer for 1 of 39 residents (Resident #75) in the survey sample.

Inspectors wroteBased on staff interviews, resident interview, and clinical record review, and in the course of a complaint investigation, the facility staff failed to provide pain management consistent with professional standards of practice for one (Resident #84) of 39 residents in the survey sample, resulting in harm. The resident was not assessed for pain from the time of admission until the following day during occupational therapy. There was no evidence that once pain was identified that it was treated timely.

Inspectors wroteBased on staff interview, facility document review, and clinical record review, it was determined that facility staff failed to maintain an effective antibiotic stewardship program.

Inspectors wroteBased on observation and staff interview, the facility staff failed to enhance and promote dignity during medication administration for one resident, Resident #57 in a survey sample of 39 residents.

Inspectors wroteBased on clinical record review, staff interviews and facility documentation, the facility staff failed to ensure Medicare Beneficiary Notices were issued to 1 of 39 residents (Resident #43) in the survey sample. The facility staff failed to issue an Advanced Beneficiary Notice (ABN) and Notice of Medicare Provider Non-Coverage (NOMNC) letter to Resident #43. Resident #43 was discharged from skilled services who remained in the facility with Medicare days remaining.

Inspectors wroteBased on staff interviews, clinical record review and facility documentation review the facility staff failed to send a copy of the resident's care plan to include their goals for 3 of 39 residents in the survey sample (Residents #85, #16 and #75) upon transfer to the hospital. This deficiency is cited as past non-compliance.

Inspectors wroteBased on staff interviews, facility documentation review and clinical record review the facility staff failed to provide the resident or resident's representative a copy of the bed hold policy upon discharge/transfer to the hospital for 3 of 39 residents (Resident #85, #16 and #75 after being transferred to the hospital. This deficiency is cited as past non-compliance.

Inspectors wroteBased on observation, staff interview and clinical review, the facility failed to complete a significant change assessment for 1 of 39 residents (Resident #39), in the survey sample, after being discharged from Hospice services.

Inspectors wroteBased on medical record review, facility document review and staff interviews the facility staff failed to ensure that the discharge Minimum Data Set Assessment was accurate for 1 of 39 resident in the survey sample, Resident #84.

Inspectors wroteBased on medical record review, facility document review and staff interviews the facility staff failed to ensure a Baseline Care Plan addressed hemo-dialysis for 1 of 39 residents in the survey sample, Resident #237.

Inspectors wroteBased on observations, resident interview, staff interview and clinical record review the facility staff failed to include pain management in the comprehensive care plan, for 1 of 39 resident's in the survey sample (Resident #77).

Inspectors wrote#3. The facility staff failed to revise the comprehensive care plan for Resident #5 to include an indwelling Foley catheter. Resident #5 was admitted to the facility on [DATE] with diagnoses to include, but not limited to cervical spine (neck) surgery, and generalized weakness. The current MDS (Minimum Data Set) a 5 day admit with an assessment reference date of 7/7/19, coded the resident as scoring a 14 out of a 15, indicating the residents cognition was intact. The resident was coded as always incontinent under section H. Bowel and Bladder and required extensive assistance of two staff for toileting. Review of the clinical notes entered 7/12/19 at 12:15 a.m. evidenced the following, Distended pelvis region reported by CNA (certified nurse assistant), bladder scan completed and reading was 787 ml (milliliters). Pt straight cath and 800 cc was collected. [...]

Inspectors wroteBased on observation, staff interviews, clinical record review and review of the facility's policy, the facility staff failed to ensure the necessary treatment, care and services were provided to prevent further development or worsening of, a facility acquired *pressure ulcer for 1 of 39 residents (Resident #75) in the survey sample. The facility staff failed to notify the physician of the podiatrist's recommendation written on 07/01/19 for the use of prevalon boots for a resident with an *unstageable left heel pressure ulcer.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to provide one resident, Resident #13, in the survey sample of 39 residents with an assistive device to help prevent further contractures and/or decline in range of motion of hands.

Inspectors wroteBased on observation, staff interviews, medical record review, and facility document review the facility staff failed to ensure ongoing communication and coordination between the nursing home and the dialysis facility on 7/13/19 and 7/16/19 for 1 of 39 residents in the survey sample, Resident #237.

Inspectors wroteBased on staff interview, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to ensure medications were provided per physician orders for 1 resident (Resident #84) of 39 residents in the survey sample.

Inspectors wroteBased on observation and staff interview of 8 medication carts and 5 medication rooms, the facility staff failed to dispose of expired medications, biologicals and nutritional supplements; and failed to secure a medication cart.

Inspectors wroteBased on observation, staff interview, and facility documentation review, the facility staff failed to follow hand hygiene practices consistent with accepted standards of practice while performing wound care for 1 of 39 residents in the survey sample, Resident #6.