Oak Grove Nursing Home

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #4, Resident #74, and Resident #71) of 20 residents reviewed for infection control. 1. The facility failed to ensure LVN A sanitized the bottle of wound cleanser after using it in Resident #4 room and before it was placed in the medication cart. 2. The facility failed to ensure CNA C sanitized her hands and changed gloves before performing incontinent and catheter care for Resident #74. 3. The facility failed to ensure MA A sanitized her hands before placing Resident #71 pills into medication cup without using any hand hygiene. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for 1 of 20 residents reviewed for new admissions. (Resident #51)The facility failed to develop and accurately complete a baseline care plan within 48 hours of admission for Resident #51. This failure could lead to residents not receiving necessary care and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate administering of all drugs and biologicals to meet the needs of each resident for 2 of 5 residents (Residents #71 and #77) reviewed for Pharmacy Services. MA A failed to shake the bottle of Flonase [Fluticasone Propionate Suspension] Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) before administering it to Resident #71. MA B failed to shake the bottle of Flonase [Fluticasone Propionate Suspension] Nasal Suspension 50 MCG/ACT (Fluticasone Propionate (Nasal)) before administering it to Resident #77. This failure could cause residents to experience cough, congestion, sneezing or shortness of breath. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7.41%, based on two errors out of 27 opportunities, which involved 2 of 5 residents (Resident #71, and #77) and 2 of 3 staff (MA A, and MA B) reviewed for medication error, in that: MA A failed to shake the bottle of Flonase [Fluticasone Propionate Suspension] Nasal Suspension 50 MCG/ACT before administering it to Resident #71. MA B failed to shake the bottle of Flonase [Fluticasone Propionate Suspension] Nasal Suspension 50 MCG/ACT before administering it to Resident #77. This failure could affect the Residents health, safety and quality of life. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for 1 of 4 residents (Resident #71) reviewed for storage of medications. -Resident #71 had 13 liquid plastic single vials of Systane Ultra PF 0.7 ml (Artificial tears- eyedrops) with an expiration date of [DATE] inside her bed side drawer unsupervised. This failure could cause harm to Resident #71 eyes by causing infection, increasing her eye pressure, thus leading to blindness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the services provided or arranged by the facility, as outlined by the comprehensive care plan, meet professional standards of quality for 1 of 18 residents reviewed for following physician orders. (Resident #11) The facility did not change the dressings to Resident #11's drains every day as ordered. This failure could place the residents at risk of infection and the drain sites not healing.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse of residents are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to HHSC for 1 of 9 residents (Resident #1) reviewed for abuse. The facility failed to report an allegation of sexual abuse within 2 hours to the State Agency when Resident #1 alleged that she had been touched inappropriately. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prompt efforts were made to resolve resident grievances for 1 of 8 residents (Resident #3) reviewed for grievances. There was no grievance available or evidence of resolution when a family member advised the administrator that CNA C went into Resident #3's room and covered up the video camera on 11/18/2023 or that the family member did not want CNA C to provide care to Resident #3. This failure could place all residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 8 residents (Resident #s 1 and 2) reviewed for abuse. The facility failed to ensure the abuse coordinator and/or designee implemented the facility policy to report immediately to HHSC within two hours of an allegation or incident of alleged abuse after Resident #2 threatened to choke Resident #1 and punched Resident #1 in the left eye on 12/08/23. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (which included to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 8 residents (Resident #s 1 and 2) reviewed for abuse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food in a form designed to meet individual needs for 1 of 2 meals reviewed for food form. The facility failed to ensure the residents who required a pureed textured diet, received the appropriate food form to meet their needs on 07/10/23 for the noon meal. The pureed food had lumps of food, not fully pureed and was thick and dry in consistency. This failure could affect the 9 residents, who received a pureed diet, at risk of aspiration and choking.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for 1 of 2 medication rooms (Hall G) reviewed for drug storage. The facility failed to ensure Hall G medication room was secured when not in use or unattended. This failure could place residents who reside in the facility at risk of possible drug diversion.

Inspectors wroteBased on interview and record review the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 4 of 5 quarters reviewed for payroll data information. *The facility failed to submit staffing information to CMS for the 3rd and 4th quarter of the fiscal year 2022. *The facility failed to submit staffing information to CMS for the 1st and 2nd quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.