Oak Grove Nursing Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The facility failed to ensure MA A sanitized her hands after touching a dirty medication cup and before administering eyedrops into Resident #71 eyes. These failures…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:Record review of Resident #51's face sheet, dated 09/10/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included displaced fracture of right tibial tuberosity (shinbone), cellulitis (bacterial infection of skin and underlying tissues), diabetes, and chronic kidney disease. Resident #51 had a history of a kidney transplant and was prescribed immunosuppression therapy (a medical treatment that aims to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: Resident #71 Record review of Resident #71's clinical record revealed a [AGE] year-old female, admitted to the facility initially on 12/10/2023 with re-admit 08/31/2024, with pertinent diagnoses: other seasonal allergic rhinitis (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: Resident #71 Record review of Resident #71's clinical record revealed a [AGE] year-old female, admitted to the facility initially on 12/10/2023 with re-admit 08/31/2024, with pertinent diagnoses: other seasonal allergic rhinitis (a condition that causes inflammation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: Record review of Resident #71's face sheet dated [DATE] indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with other seasonal allergic rhinitis (a condition that causes inflammation of the nasal passages in response to airborne allergens, such as pollen from trees, grasses, and weeds), cognitive communication deficit (a difficulty with effective verbal and nonverbal communication),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review of physician orders dated August 2024 indicated Resident #11, re-admitted [DATE], was a [AGE] year-old male with diagnoses of kidney stones and retroperitoneal abscess (an unusual type of abscess [a confined pocket of pus] that occurs in the retroperitoneal space [the tissue that lines the abdominal wall and covers the abdominal organs]).The consolidated orders indicated The drain sites were to be cleaned with normal saline, pat dry, apply topical antibiotic ointment and cover every day until drains are removed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review of a face sheet dated 07/10/2024 indicated Resident #1 was 68-years-old female, initially admitted to the facility on [DATE] with readmission date of 06/26/2024. Her diagnoses included schizoaffective disorder, bipolar type (mental health condition with a combination of symptoms of schizophrenia and mood disorder), vitamin deficiency (condition of a long-term…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review of Resident #3's face sheet dated 12/21/23 indicated she was a [AGE] year old female admitted on [DATE] and her diagnoses included Alzheimer's (brain disorder), anxiety (feeling of fear, dread, and uneasiness), unspecified mood disorder, and aphasia (loss of ability to understand or express speech, caused by brain damage). Record review of Resident #3's MDS dated [DATE] indicated she was not able to make herself…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review of the facility's undated Reporting Abuse and Neglect Policy indicated Any facility staff member who has cause to believe that the physical or mental health of a resident has been, or may be adversely affect(ed) by abuse, neglect, or exploitation case(ed) by another person, is to report the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The facility failed to report resident to resident 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.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: 1. Record review of an admission face sheet indicated Resident #36, admitted [DATE], was [AGE] years old and included diagnoses of dysphagia (difficulty in swallowing). Record review of the physician orders dated July 2023 indicated Resident #36 orders included a puree diet with start date of 05/16/23. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #36 was severely impaired with cognition, swallow disorder and required extensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings included: During an observation on 07/09/23 at 8:42 a.m. the Hall G medication room door was not shut well and there were no staff present in the hall. This surveyor pulled on the door, and it opened. There were no nursing staff inside the medication room. Located in the medication room was an open shelf of facility stock medications. In a cubby on the side wall were prescription medication cards labeled with a resident's name, and in the small refrigerator were prescription suppositories labeled with another resident's name. No medication carts were in the med room. During an interview on 07/09/23 at 8:45 a.m., LVN C said she was not aware the medication door was not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.