Oak Grove Manor

Inspectors wroteBased on record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to ensure food was palatable and appropriate temperature. This had the potential to affect all 75 residents residing in the facility who receive food from the kitchen.

Inspectors wroteBased on medical record review, resident and staff interviews, and review of the facility policy, the facility failed to ensure medical appointments were timely scheduled as physician ordered. This affected one (Resident #36) of two residents reviewed for appointments. The facility census was 75.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure a kitchen did not have expired food, kitchen was clean and sanitary, and opened food items were not labeled or dated. This had the potential to affect all 73 residents residing in the facility who receive food from the kitchen.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure they implemented their smoking policy by ensuring the facilities grounds were free from discarded cigarette butts. This finding had the potential to affect all 73 residents residing in the facility.

Inspectors wrote2. Observation on 06/29/25 at 11:16 A.M. revealed Registered Nurse (RN) #383 obtained a blood sugar using a blood glucose testing (BGT) machine for Resident #66. RN #383 then walked back down the hall and placed the contaminated BGT machine on top of the medication cart before placing the contaminated BGT machine in the top drawer of the medication cart without disinfecting the device. Interview on 06/30/25 at 11:51 A.M. with RN #383 with the Director of Nursing (DON) present revealed RN #383 obtained Resident #12's blood sugar just prior to obtaining Resident #66's blood sugar using the same BGT machine. [...]

Inspectors wroteBased on medical record review, facility policy review, and staff interview, the facility failed to ensure residents had accurate advance directive orders and consistent information in place throughout the medical record for Resident #121. This affected one (#121) of 23 residents reviewed for advanced directives. The facility census was 73.

Inspectors wroteBased on observation, record review and resident and staff interviews, the facility failed to complete a treatment for Resident #12. This affected one of one resident reviewed for wound treatments. The facility census was 73.

Inspectors wroteBased on record review, review of the Ohio Board of Nursing Administrative Code, and staff interview, the facility failed to ensure they had sufficient nursing staff with the appropriate skills to complete the resident's central venous line therapy procedures. This affected one (Resident #122) of one resident reviewed for intravenous (IV) access.

Inspectors wroteBased on observation, record review, facility policy review, and staff interview, the facility failed to ensure the medication error rate did not exceed medication error rate of five percent (%) or greater. Two errors occurred within 28 opportunities for an error rate of 7.14%. This affected two (Residents #35 and #41) of four residents observed for medication administration.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure the residents received the correct texture of diet and adaptive equipment as ordered by the physician. This affected one (Resident #53) of three residents reviewed for nutrition. The facility identified 18 residents on a mechanically altered diet. The facility census was 73.

Inspectors wroteBased on review of personnel files and staff interview the facility failed to ensure certified nursing assistants (CNA) received regular performance reviews as required. This had the potential to affect all 73 residents residing in the facility.

Inspectors wroteBased on review of personnel files and staff interviews, the facility failed to ensure certified nursing assistants (CNA), who were hired for more than one year, had 12 hours of in-services annually. This had the potential to affect all 73 residents residing in the facility.

Inspectors wroteBased on record review and staff interview. the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) in a timely manner to the residents. This affected two (Residents #1 and #17) of three residents reviewed for NOMNC. The facility census was 73.

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents had water at the appropriate temperature in their bathrooms. This affected three (Residents #3, #4, and #6) out of three reviewed for water temperatures. Facility census was 59.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure treatments were put in place in a timely manner. This affected three (Residents #3, #6, and #7) of three residents reviewed for wounds. Facility census was 59.

Inspectors wroteBased on observation, staff interview, review of a cleaning task list, and policy review, the facility failed to store food in a safe and sanitary manner and failed to ensure food service equipment, storage areas, and kitchen floor were properly cleaned. This had the potential to affect all 67 residents. The facility census was 67.

Inspectors wroteBased on observation, staff interview, and review of a facility policy, the facility failed to maintain a pest free environment. This had the potential to affect all 67 residents. The census was 67.

Inspectors wroteBased on medical record review, resident family interview, staff interview, orthopedic staff interview, review of hand written statements, review of the facility incident and accident log, and policy review, the facility failed to investigate an injury of unknown origin as required. This affected one (#24) of three residents reviewed for abuse, neglect, mistreatment, exploitation, and misappropriation. The facility census was 67.

Inspectors wroteBased on review of the facility menu, resident interview, staff interview, observation, review of the facility food temperature logs, and review of the facility policy the facility failed to ensure food temperatures were assessed to ensure safe ranges prior to resident consumption. This had the potential to affect all 64 residents in the facility who were identified by the facility to receive food from the facility kitchen. The facility census was 64 residents.

Inspectors wroteBased on medical record review, resident interview, observation, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Residents #39) of three residents reviewed for medication administration. The facility census was 64 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to serve residents with orders for mechanically altered diets the proper textured diet as ordered by the physician. This affected three (Residents #11, #16, and #18) of 14 residents on a mechanically altered diets. The facility census was 64 residents.

Inspectors wroteBased on medical record review, observation, staff interview, resident interview, and review of the facility policy, the facility failed to serve resident meals which honored the resident's preferences and accommodated resident allergies. This affected three (Residents #11, #16, and #18) of 14 residents on a mechanically altered diets. The facility census was 64 residents.

Inspectors wroteBased on resident interview and staff interview, the facility failed to ensure mail was delivered to residents on Saturdays. This affected nine (#3, #7, #17, #27, #33, #41, #52, #53, and #56) of nine residents interviewed regarding mail delivery and had the potential to affect all 70 residents residing in the facility. The census was 70.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure garbage and refuse was disposed of properly. This had the potential to affect all 70 residents residing in the facility. The census was 70.

Inspectors wroteBased on observation, resident and staff interviews, and review of a concern log, the facility failed to maintain comfortable sounds levels in the facility. This has the potential to affect nine (#3, #7, #17, #27, #33, #41, #52, #53, and #56) of nine residents who voiced concerns regarding the sound levels in the facility. The facility census was 70.

Inspectors wroteBased on observation, medical record review, resident representative interview, staff interview, and review of scheduled activities, the facility failed to ensure residents were offered or assisted in attending activities and failed to provide activities as scheduled. This affected six (#3, #17, #27, #41, #46, and #53) of nine residents reviewed for participation in activities. The facility census was 70.

Inspectors wroteBased on personnel file review, staff interview, and review of a job description, the facility failed to ensure the activities program was directed by a qualified individual as required. This had the potential to affect all residents who resided in the facility with the exception of two (#32 and #60) residents who the facility identified as not participating in activities. The facility census was 70.

Inspectors wroteBased on observation, medical record review, and resident and staff interviews, the facility failed to provide one (#71) of 17 sampled residents reasonable accommodations of needs and preferences to enhance the ability to perform self-mobility. The facility census was 70.

Inspectors wroteBased on medical record review and resident and staff interview, the facility failed to ensure one (#38) of five residents reviewed for advanced directives were consistent throughout the medical record. The facility census was 70.

Inspectors wroteBased on medical record review, resident and staff interview, review of self-reported incidents (SRIs), and policy review, the facility failed to ensure alleged perpetrators were identified in reports of abuse allegations submitted to the State Survey Agency. This affected one (#30) of two residents reviewed for abuse. The facility census was 70.

Inspectors wroteBased on medical record review, resident and staff interview, review of emergency medication availability lists, and review of an emergency medication policy, the facility failed to provide an as needed medication from the emergency supply for one (#3) of five residents reviewed for medications. The facility census was 70.

Inspectors wroteBased on medical record review and resident and staff interview, the facility failed to ensure residents were free from significant medication errors. This affected one (#59) of five residents reviewed for medications. The facility census was 70.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure accurate documentation in the medical record when wound care treatments, prevention devices, and supplement orders were administered. This affected one (#66) of two residents reviewed for wounds. The facility census was 70.

Inspectors wroteBased on observation, record review, review of the facility Elopement/Unauthorized Absence policy and procedure and interviews with staff and the transportation driver, the facility failed to provide adequate supervision and comprehensive individualized interventions to prevent Resident #14, who was identified at risk for elopement, from leaving the building when on an outside doctor's appointment, unaccompanied by facility staff or family, and prior to the transportation company picking her up and returning her to the facility after the appointment had concluded. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when Resident #14, who was assessed to be at risk for elopement, exited the doctor's office without staff knowledge when the appointment was completed. [...]

Inspectors wroteBased on observation, staff interviews, resident interview, and record review, the facility failed provide ongoing assessment and monitoring of existing pressure ulcers, failed to complete treatments as ordered by the physician, and failed to notify the physician of the need to alter treatment when pressure ulcers increased in size and when new pressure ulcers developed. This affected two (Resident #63 and #69) of three residents reviewed for skin breakdown. Actual harm occurred when Resident #69 did not have any ongoing assessments of existing pressure ulcers and did not have treatments applied as ordered which resulted in the Stage 3 pressure to the resident's right buttock increasing in size from 7 centimeters (cm) by 5 cm to 12.1 cm by 8 cm by 2 cm. The facility census was 75.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the medical director was an active participant of the Quality Assurance (QA) Committee. This had the potential to affect all residents. The facility census was 74.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the facility provided a sanitary environment. This affected seven residents (Resident #3, #9, #43, #46, #54, #69 and #80) and had the potential to affect all residents residing in the facility. The facility census was 74.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure the physician was notified when residents had a change of condition. This affected three residents (Resident #14, #49 and #69) out of three reviewed for change of condition. The facility census was 74.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its smoking policy was followed as written. This affected three (#2, #45, and #56) of three residents interviewed for smoking. The facility identified 14 residents who were smokers. The facility census was 74.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to maintain a system to preventing the spread of infections and communicable diseases for nine residents (Resident #5, #6, #12, #27, #59, #60, #67, #70 and #74) identifed as being on isolation precautions. This has the potential to affect all residents. The facility census was 74.

Inspectors wroteBased on observation, resident and staff interview, record review, and policy review, the facility failed to provide routine bathing and grooming services for Resident #65 and routine bathing services for Resident #63. This affected two residents (#65 and #63) of three residents reviewed for provision of Activities of Daily Living (ADLs). The facility census was 74.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a comprehensive plan of care was developed to address a resident's communication barriers. This affected one (#15) of three residents reviewed for communication. The facility census was 73.

Inspectors wroteBased on medical record review, review of a fall investigation, staff interview, and review of facility policy, the facility failed to implement fall interventions for a resident identified at risk for falls. This affected one (#74) of three residents reviewed for falls. The facility census was 73.

Inspectors wroteBased on record review, staff interview, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidance, the facility failed to ensure a resident was placed on contact isolation and contact isolation precautions were followed when the resident tested positive for a drug resistant organism. This affected one (#8) of three residents reviewed for infection control. The facility census was 71.

Inspectors wroteBased on review of staffing schedules, review of Benefits Improvement and Protection Act (BIPA) daily staff postings, and staff interview, the facility failed to maintain the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 61 residents currently residing in the facility.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure expired refrigerated medications were discarded, monitor temperatures in the medication refrigerators, and ensure foods and drinks were not stored in the medication refrigerator. This had the potential to affect all 61 residents receiving medications stored in the medication refrigerator. The facility census was 61.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure a clean and sanitary kitchen area. This had the potential to affect all residents who resided in the facility and received meals from the facility kitchen. The facility identified no residents who did not eat from the facility kitchen. The facility census was 61.

Inspectors wroteBased on review of the facility provided Quality Assessment and Assurance (QAA) quarterly meeting attendance sheets and staff interview, the facility failed to ensure the Infection Preventionist attended QAA meetings at least quarterly. This had the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on medical record review, observation, resident and staff interview, policy review, and review of the Centers for Disease Control and Prevention guidance, the facility failed to ensure infection control measures were followed related to hand hygiene and personal protective equipment (PPE). This had the potential to affect all residents residing in the facility. The facility census was 61.

Inspectors wrote3. Review of Resident #54's medical record revealed an admission date of 09/16/22 and discharged on 09/18/22. Diagnoses included COVID-19, atrial fibrillation, vascular dementia, epileptic seizures, wedge compression fracture of thoracic vertebra, and intracerebral hemorrhage. Record review of the nursing progress note dated 09/18/22 at 2:26 P.M., revealed Resident #54 was having seizures. Resident #54's physician was made aware and gave orders to send Resident #54 to the hospital. Resident #54 was transported to the emergency room. Interview on 11/08/22 at 5:01 P.M.,with Business office Manager (BOM) #302 confirmed Resident #54 nor her Representative received a written notice of discharge. Interview on 11/09/22 at 10:19 A.M., with Social Services Designee (SSD) #353 confirmed Resident #54 nor her Representative or the Ombudsman received a written notice of discharge for Resident #54. [...]

Inspectors wroteBased on medical record review, observations, resident interview, and staff interview, the facility failed to ensure residents who were required staff assistance with activities of daily living were provided assistance with grooming. This affected one (Resident #45) out of four residents reviewed for activities of daily living. Additionally, the facility failed to ensure residents received showers as scheduled. This affected five (Residents #9, #18, #28, #44, and #49) out of five residents reviewed for showers. The census was 61 residents.

Inspectors wrote5. Review of the medical record for Resident #312 revealed Resident #312 was admitted to the facility on [DATE] with diagnoses which included heart failure, hypertension, long-term use of anticoagulants, anxiety disorder, neuropathy, peripheral vascular disease, open wound of right foot and left elbow, and muscle weakness. Review of Resident #312's MDS 5-day assessment, dated 10/05/22, revealed the resident had mild cognitive impairment. Review of the pharmacy Medication Regimen Review (MRR) for Resident #312, dated 10/08/22, revealed a pharmacy recommendation regarding a contraindication in administration of the resident's prescribed Plavix and Omeprazole medications. [...]

Inspectors wroteBased on medical record reviews, pharmacy regiment reviews, policy review, family and staff interviews, the facility failed to ensure residents were free from unnecessary psychotropic medications . This affected four (#04, #9, #11, and #18) of four residents reviewed for psychotropic medications. The facility census was 61.

Inspectors wroteBased on observation, staff, physician and pharmacy interview, and medical record review, the facility failed to ensure a medication error rate of less than 5 percent. There were four observed errors out of 31 opportunities this resulted in a medication error rate of 12.9 percent. This affected two resident's (#01 and #310) out of three residents observed for medication administration. The facility census was 61.

Inspectors wroteBased on medical record reviews and staff interviews, the facility failed to provide bed hold notification, at the time of transfer. This affected two (#21 and #54) of five residents reviewed for bed hold notice. The facility census was 61.

Inspectors wroteBased on record review and staff interview, the facility failed to develop a baseline care plan which included the minimum healthcare information necessary to properly care for a resident. This affected two (#49 and #54) of 17 residents reviewed for baseline care plans. The facility census was 61.

Inspectors wroteBased on record review, resident and staff interview, the facility failed to complete a comprehensive care plan and include residents in care planning process. This affected two (#34 and #36) of 20 residents reviewed. The facility census was 61.

Inspectors wroteBased on medical record review, resident and staff interviews, the facility failed to ensure discharge planning for a resident was initiated. This affected one (#110) of two residents reviewed for discharge. The facility census was 61.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure physician ordered skin assessments were completed. This affected on (#49) of one residents sampled for skin integrity. The census was 61 residents.

Inspectors wroteBased on observation, medical record review, resident and staff interview, the facility failed to assess a resident after an accident, complete fall risk assessments after falls and ensure physician orders for were followed to not provide straws to a resident at risk for aspiration. This affected three (#18, #45, and #49) of four residents reviewed for accidents/ hazards. The facility census was 61.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident meal intakes were consistently recorded/monitored. This affected three (#9, #30, and #38) out of 20 residents reviewed. The census was 61.

Inspectors wroteBased on medical record review, observation, staff interview, and facility policy review, the facility failed to ensure oxygen tubing and humidification was changed in accordance with the physician order. This affected one (Resident #36) of six residents reviewed for oxygen services. The facility census was 61.

Inspectors wroteBased on medical record review, review of narcotic records, review of facility medication policies, and resident and staff interviews, the facility failed to ensure pain medications were available and administered as ordered by the physician. This affected one (Resident #36) of two residents reviewed for pain. The facility census was 61.

Inspectors wroteBased on medical record review and staff interview, the facility failed to monitor a resident before and after dialysis treatments. This affected one (Resident #30) of one resident reviewed for dialysis services. The facility's census was 61.

Inspectors wroteBased on medical record review, resident interview, staff interviews, and review of facility policy, the facility failed to ensure medications were available for administration, leading to missed medication. This affected two (Residents #21 and #9) of five residents reviewed for medication availability. The facility's census was 61.

Inspectors wroteBased on record review and staff interview, the facility administered an unnecessary medication to a resident, This affected one (#34) of five residents reviewed for unnecessary medications. The facility census was 61.

Inspectors wroteBased on observation, staff and resident interview, and medical record review, the facility failed to ensure residents were free from significant medication errors and insulin as well as piperacillin - tazobectam was administered without error. This affected two residents (#14 and #310) out of three residents reviewed during medication administration. The facility census was 61.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure medication therapeutic levels were monitored. This affected one resident (#09) out of 20 residents sampled. The facility census was 61.

Inspectors wroteBased on medical record review and staff interview, the facility failed to timely notify the physician of laboratory results. This affected one resident (#34) out of five residents reviewed for physician notification. The facility census was 61.