OAK GROVE RETIREMENT HOME

Nursing Home Inspector

209 OAK CIRCLE/P. O. BOX 198
DUNCAN, MS 38740
Bolivar County
Phone: 662-395-2577
Provider Number: 25E115
Last Inspection: 12/22/2016

About the Nursing Home

Number of Beds: 60
Number of Residents: 58
Beds Available: 2
Percent Occupancy: 97%
Insurance Accepted: Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

18

Facility
12

County
11

MS
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

18

2016
38

2016
27

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

12/22/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 1/22/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 1/22/2017
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 1/22/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 1/22/2017
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Pattern : Minimal 4 1/22/2017
 

1/9/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 2/9/2016
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 2/9/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Widespread : Minimal 5 2/9/2016
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Pattern : Minimal 4 2/9/2016
 
Failed To: Provide or obtain laboratory services only when ordered by the attending physician. Isolated : Minimal 3 2/9/2016
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 2/9/2016
 
Failed To: Assure that each resident’s assessment is updated at least once every 3 months. Isolated : Minimal 3 2/9/2016
 
Failed To: Provide activities to meet the interests and needs of each resident. Pattern : Minimal 4 2/9/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 2/9/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 2/9/2016
 

3/14/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 4/28/2015
 
Failed To: Provide housekeeping and maintenance services. Widespread : Minimal 5 4/28/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 4/28/2015
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Pattern : Minimal 4 4/28/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 4/28/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Immediate 5 4/28/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

3/22/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 4/22/2017
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MS State Avg
Number of Residents 58 65.60 77.87
Registered Nurses 0.29 0.57 0.78
Licensed Practical / Vocational Nurses 0.65 0.81 0.98
Certified Nursing Assistants 2.35 2.21 2.33
Total Staff Hours 3.28 3.59 4.09

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MS State Avg%
of high risk long-stay residents with pressure ulcers 2 10 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 90 96 97
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 93 95 96
of long-stay residents experiencing one or more falls with major injury 1 2 3
of long-stay residents who have depressive symptoms 0 0 1
of long-stay residents who lose too much weight 3 8 7
of long-stay residents who received an antianxiety or hypnotic medication 37 31 26
of long-stay residents who received an antipsychotic medication 53 31 19
of long-stay residents who self-report moderate to severe pain 0 5 8
of long-stay residents who were physically restrained 1 4 1
of long-stay residents whose ability to move independently worsened 13 20 18
of long-stay residents whose need for help with daily activities has increased 15 16 16
of long-stay residents with a catheter inserted and left in their bladder 0 2 2
of long-stay residents with a urinary tract infection 1 3 4
of low risk long-stay residents who lose control of their bowels or bladder 26 38 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 20 64 87
of short-stay residents who self-report moderate to severe pain 0 20 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 20 55 62
of short-stay residents with pressure ulcers that are new or worsened 0 3 2