Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Grove Retirement Home during CMS and state inspections, most recent first.
Failure to maintain proper positioning and ROM services for two residents. One resident was repeatedly observed leaning to the right in a wheelchair without the required armrest, despite staff confirming the armrest was needed for positioning and trunk control. Another resident with a right-hand contracture was observed without any positioning device or ROM intervention, and staff and the ADM could not find documentation of ongoing ROM services after OT discharge.
Missing pre-employment background checks for two newly hired direct care staff. Facility policy and the employee handbook required criminal background checks for all new hires, but a CNA and an LPN were allowed to work without completed checks in their files. The ADM confirmed the missing documentation, and the BOM stated she failed to follow up and allowed them to work because staffing shortages influenced the decision.
A resident’s Annual MDS was coded incorrectly in Section A1500t regarding whether the resident was currently considered by the state level II PASRR process to have SMI and/or ID or a related condition. The record showed diagnoses including mood disorder and psychotic disorder with delusions, and the MDS also documented psychotic disorder in Section I. An MDS RN confirmed the item was answered incorrectly and stated the inaccurate coding could prevent the resident from receiving needed services.
The facility failed to develop a care plan for a resident with a right-hand contracture and failed to follow a care plan for another resident’s nail care. One resident with right-sided hemiplegia and contractures had no care plan addressing the contracture or ROM needs, while another resident with a self-care deficit was observed with long, dirty fingernails and a CNA confirmed the nail care should have been completed during shower time. The MDS nurse confirmed the care plan was not followed.
Failure to provide ADL care related to fingernail hygiene was identified for one resident with a self-care deficit, PVD, and severe cognitive impairment. Observations showed the resident had long, dirty fingernails with brown substance underneath, and a CNA and LPN confirmed the nails should have been cleaned and clipped during shower time but were not. The resident required assistance with all ADLs, including personal hygiene.
A resident with multiple diagnoses, including polyosteoarthritis and polyneuropathy, had a care plan that was not updated to include a Stage IV pressure ulcer identified on the right hip. During wound care, the resident showed signs of pain, but the care plan had not been revised to address this new condition. The Administrator confirmed the oversight, highlighting the care plan's role in guiding staff on resident care issues.
A resident with a Stage IV pressure ulcer exhibited signs of pain during wound care, but the IDON continued the procedure without providing immediate pain relief. The resident, who had a history of hemiplegia and other conditions, had last received pain medication earlier that morning. The IDON acknowledged the oversight, and the facility's administrator confirmed that the resident should have been assessed and medicated for pain before treatment.
The facility failed to provide adequate weekend staffing during the second quarter of 2024, as reported in the PBJ Staffing Data. Interviews with staff revealed significant turnover and frequent call-ins, making it difficult to maintain sufficient staffing levels. Despite attempts to overstaff and implement a Baylor shift, the facility continued to face challenges in finding replacements for call-ins, with the DON often covering shifts.
A resident with Parkinson's Disease and Type 2 Diabetes reported a loose toilet in their bathroom during multiple resident council meetings, but the grievance was not documented or resolved by the facility. Social Services failed to fill out a grievance form, and Maintenance was not informed of the issue, leading to a prolonged unresolved complaint.
A facility failed to provide written notification to a resident's representative upon the resident's transfer to the hospital, as required by policy. The Social Services staff member responsible only made phone calls and did not send written notices, which was confirmed during an interview. The resident, with severe cognitive deficits and a history of cerebrovascular disease and schizophrenia, was transferred for a hip fracture and later discharged to a behavioral facility, with no written notice documented.
The facility failed to develop and implement comprehensive care plans for two residents, resulting in deficiencies in pressure ulcer care and the use of a splinting device. One resident lacked a care plan for a reopened Stage IV pressure ulcer and did not have the prescribed palm guard in place for a hand contracture. Another resident's care plan for a Stage III pressure ulcer was mistakenly resolved, leaving them without a current plan. These issues were confirmed by facility staff.
A resident with a Stage 3 pressure ulcer on the left lateral ankle did not receive the prescribed wound care treatment. The physician's order required specific wound care steps, including the use of Mepilex AG, which was not followed. Instead, the IDON used derma blue foam due to a lack of Mepilex AG, without notifying the physician. This deviation from the prescribed treatment was confirmed by the IDON and the Administrator, who acknowledged the potential for the wound to worsen.
A resident with a right-hand contracture did not receive appropriate care to maintain range of motion due to the facility's failure to apply a prescribed palm guard. Despite an order for the palm guard's use, it was not applied, and staff interviews confirmed the oversight. The Occupational Therapist noted the issue and provided training, but the problem persisted, contributing to a decline in the resident's passive range of motion. The resident had a history of hemiplegia and hemiparesis following a cerebral infarction.
Failure to Maintain Proper Positioning and ROM Services
Penalty
Summary
The facility failed to ensure proper positioning for one resident who was observed sitting in a wheelchair leaning to the right with the right arm resting on the wheel and no right-side armrest in place. The resident was seen in this position multiple times, including while being assisted with a meal at the dining table. Interviews with the Therapy Director, PTA, CNA, LPN, Administrator, and PT confirmed that the resident leaned to the right, required the right armrest for positioning and trunk control, and that the armrest was missing from the wheelchair. The resident’s record showed diagnoses including lack of coordination and abnormal posture. The facility also failed to provide ROM services for another resident with a right-hand contracture. The resident was observed with the right hand contracted and no device in place for positioning or protection on multiple occasions. CNA staff stated they were unaware of any interventions or charting tasks for ROM or positioning, and an LPN confirmed the fingers were tightly contracted into the palm with no device or intervention in place. The Administrator could not find documentation showing ROM or positioning services for the resident’s right-hand contracture. The OT confirmed the resident had been discharged from OT services, but maintenance ROM and positioning should have continued with nursing staff. The resident’s record showed diagnoses including right-sided hemiplegia and contractures, and the MDS indicated impairment on both sides of the upper extremities.
Missing Pre-Employment Background Checks for New Hires
Penalty
Summary
The facility failed to ensure that pre-employment background checks were completed before allowing newly hired direct care staff to work for two of five employee files reviewed. Review of the facility policy and employee handbook showed that criminal background checks were required for all new hires as part of the facility’s abuse prevention program. However, CNA #3 was hired on 10/6/25 with no background check in the personnel record and was allowed to work 21 days between 10/7/25 and 11/12/25. LPN #4 was hired on 10/12/25 with no background check in the personnel record and was allowed to work 12 days between 10/13/25 and 11/12/25. During interview, LPN #4 confirmed she had not completed a background check and said she missed her first appointment and never rescheduled it. The Administrator confirmed the staff did not have background checks in their files and stated it was the Business Office Manager’s responsibility to ensure completion. The Business Office Manager confirmed she was responsible for the background checks, said both staff told her they had completed prior checks and would bring documentation, and acknowledged she never received the records or followed up, allowing them to work because staffing shortages influenced the decision.
Inaccurate MDS Coding for Serious Mental Illness
Penalty
Summary
The facility failed to accurately complete a Minimum Data Set (MDS) assessment for one resident by incorrectly coding Section A1500t on the Annual MDS with an ARD of 02/20/25. The resident’s record showed an admission date of 01/11/2019 and diagnoses that included Unspecified Mood (Affective) Disorder and Psychotic Disorder with Delusions Due To Known Physiological Condition. The Annual MDS indicated the resident was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, even though Section I documented Psychotic Disorder (other than schizophrenia). During interview, the MDS Nurse stated that the A1500 question was answered incorrectly, confirmed the resident had a diagnosis of Psychotic Disorder with Delusions due to known Physiological Condition, and stated that inaccurate coding could prevent the resident from receiving services he may need.
Failure to Develop and Follow Resident Care Plans
Penalty
Summary
The facility failed to develop a care plan related to contractures for Resident #25 and failed to implement a care plan related to nail care for Resident #29. Resident #25 was admitted with diagnoses including right-sided hemiplegia and contractures, and an observation on 11/11/25 and again on 11/12/25 showed a right-hand contracture with no device in place for positioning or protection. The MDS Nurse confirmed on 11/13/25 that there was no care plan addressing the resident’s right-hand contracture or ROM needs, and stated the care plan should identify resident-specific needs and guide staff on required interventions. Resident #29 was observed on 11/11/25 and again on 11/12/25 with long, dirty fingernails on both hands, approximately one-fourth to one-half inch long, with a brown substance underneath. During the observation, CNA #1 confirmed the fingernails were long and dirty and stated they should have been taken care of during the resident’s shower time the day before. The MDS Nurse later confirmed that the resident’s care plan was not followed because fingernail care had not been completed. Record review showed the resident had a self-care deficit and required assistance with ADLs including bathing, dressing, and personal hygiene, and had diagnoses including Peripheral Vascular Disease and acquired absence of the left leg below knee.
Failure to Provide Fingernail Hygiene
Penalty
Summary
Failure to provide ADL care related to fingernail hygiene was identified for one resident. Observations on 11/11/25 at 1:00 PM and 11/12/25 at 1:50 PM showed the resident with long, dirty fingernails on both hands, approximately one-fourth to one-half inch long, with a brown substance underneath. During an observation and interview on 11/12/25 at 1:55 PM, a CNA confirmed the fingernails were long and dirty and stated that unkept fingernails could spread germs and infection if the resident scratched himself. The resident’s scheduled shower days were Tuesdays, Thursdays, and Saturdays, and the CNA stated the nails should have been taken care of the day before. An LPN later confirmed the fingernails were long and dirty and stated CNAs were responsible for fingernail care during shower or bath time, adding that the resident had a shower the previous day and his fingernails should have been cleaned and clipped then. Record review showed the resident had a self-care deficit requiring assistance with all ADLs, including bathing, dressing, and personal hygiene. The resident was admitted on 02/25/25 with diagnoses including Peripheral Vascular Disease and acquired absence of the left leg below knee, and the MDS dated 10/10/25 showed a BIMS score of 06, indicating severe cognitive deficit.
Failure to Revise Care Plan for Resident with Stage IV Pressure Ulcer
Penalty
Summary
The facility failed to revise the care plan for a resident who was at risk for pain due to multiple diagnoses, including polyosteoarthritis, polyneuropathy, and arthritis of the right knee. The care plan, last revised on June 3, 2024, did not include a Stage IV pressure ulcer on the resident's right hip, which was identified on July 6, 2024. This omission was discovered during an observation of wound care on July 29, 2024, when the resident exhibited signs of pain, such as flinching, moaning, and grimacing, while the Interim Director of Nursing (IDON) performed wound care. The IDON acknowledged the resident's pain and indicated she would inform the nurse to provide pain relief. However, the care plan had not been updated to reflect the new condition of the reopened Stage IV pressure ulcer. During an interview, the Administrator confirmed that the care plan had not been revised to include the pressure ulcer and emphasized that the purpose of the care plan is to inform staff about the resident's problems and how to address them. The resident had been admitted to the facility in 2018 with a history of hemiplegia and hemiparesis following a cerebral infarction, polyneuropathy, and contractures in the right and lower leg muscles.
Failure to Provide Pain Management During Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for a resident during wound care. During an observation, the Interim Director of Nursing (IDON) performed wound care on a resident with a Stage IV pressure ulcer on the right hip. The resident exhibited both verbal and nonverbal signs of pain, including flinching, moaning, and stating, "Yes, my butt hurts." Despite these clear indications of pain, the IDON continued with the wound care procedure, only stating that she would inform the nurse to provide pain relief after completing the treatment. The resident had a history of hemiplegia, hemiparesis, polyneuropathy, and muscle contractures, and had been admitted to the facility in 2018. The resident's medication record indicated that the last pain medication, Tramadol 50 mg, was administered earlier that morning. The IDON admitted to being unaware of the resident's pain medication orders and acknowledged that she should have paused the treatment to address the resident's pain. The facility's administrator confirmed that the IDON's actions were inconsistent with the facility's practice of assessing and medicating residents for pain before wound treatment.
Insufficient Weekend Staffing in LTC Facility
Penalty
Summary
The facility failed to provide sufficient weekend staffing to meet the individualized needs of residents during the second quarter of 2024. The facility's policy on staffing hours, which is monitored by the Director of Nursing (DON) or a designee, was not adhered to, as evidenced by excessively low weekend staffing reported in the Payroll-Based Journal (PBJ) Staffing Data Report. Interviews with staff, including a Registered Nurse (RN) and a Certified Nurse Aide (CNA), revealed that the facility experienced significant staff turnover and frequent call-ins, making it challenging to maintain adequate staffing levels. The CNA reported that working with only three or four aides on the day shift made assignments difficult, although they tried to manage by working together. The Administrator confirmed the staffing challenges, noting that the acuity of residents determined staffing needs and that call-ins were a significant issue. Despite attempts to overstaff and have extra personnel, the facility struggled to find replacements when staff called in. The DON often had to work shifts due to these shortages. The facility introduced a Baylor (weekend) shift to accommodate employees' preferences for working either during the week or on weekends, but call-ins persisted, exacerbating the staffing issues.
Failure to Document and Resolve Resident Grievance
Penalty
Summary
The facility failed to document and resolve a grievance reported by a resident during multiple resident council meetings. The resident, who has Parkinson's Disease with Dyskinesia and Type 2 Diabetes Mellitus, reported that the toilet in his bathroom was loose and rocked back and forth when used. Despite bringing up this issue in at least two or three resident council meetings, the grievance was not documented or addressed by the facility's Social Services, who was responsible for recording and resolving such issues. Interviews with various staff members, including the Activities Director, Social Services, and Maintenance, revealed a breakdown in communication and procedure. Social Services admitted to not filling out a grievance form for the resident's complaint, and Maintenance confirmed that the issue was never reported to them. The Administrator also verified that the grievance was not documented in the maintenance log book. This oversight resulted in the resident's complaint going unresolved for an extended period, highlighting a failure in the facility's grievance handling process.
Failure to Provide Written Notification of Transfer
Penalty
Summary
The facility failed to provide written notification to a resident's representative upon the resident's transfer to the hospital, as required by their policy. The policy mandates that a discharge or transfer form be completed and given to the resident or their representative. However, the Social Services staff member responsible for notifying the resident representative admitted to only making phone calls and not sending written notices. This oversight was confirmed during an interview, where the staff member stated she was unaware of the requirement to mail a notice. The deficiency was identified in the case of a resident with severe cognitive deficits, as indicated by a BIMS score of 03, who was transferred to the hospital for a hip fracture and later discharged to a behavioral facility. In both instances, the resident's representative was notified by phone, but there was no documentation of a written notice being mailed. The resident had a history of cerebrovascular disease and schizophrenia, which further underscores the importance of proper communication with their representative.
Deficiencies in Care Plan Development and Implementation
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in pressure ulcer care and the implementation of a splinting device. For one resident, observations revealed a contracture in the right hand without the prescribed palm guard in place, despite the care plan indicating its use. Additionally, there was no care plan developed for a reopened Stage IV pressure ulcer on the resident's right hip, even though treatment orders were in place. The facility's administrator confirmed the absence of a care plan for the pressure ulcer and acknowledged that the intervention for the palm guards was not implemented. Another resident's care plan was found lacking for a Stage III pressure ulcer on the left lateral ankle. Although physician orders were in place for wound care, the care plan had been mistakenly resolved earlier, leaving the resident without a current care plan for the pressure ulcer. The Regional Clinical Director confirmed this oversight. These deficiencies highlight the facility's failure to maintain current and comprehensive care plans that inform staff of residents' needs and required interventions.
Failure to Provide Prescribed Wound Care Treatment
Penalty
Summary
The facility failed to provide the prescribed wound care treatment for a resident with a Stage 3 pressure ulcer on the left lateral ankle. The physician's order, dated 7/19/2024, specified cleaning the wound with a wound cleanser, patting it dry, applying Mepilex AG, covering it with 4x4 gauze, an ABD pad, and Kerlix, and wrapping the wounds above the ankles without tightness. This treatment was to be performed every Monday, Wednesday, and Friday. However, during an observation on 7/29/2024, the Interim Director of Nursing (IDON) applied derma blue foam to the wound bed instead of the prescribed Mepilex AG. The IDON confirmed that the facility was out of Mepilex AG and used derma blue foam as an alternative without notifying the physician of the change in treatment. This deviation from the prescribed treatment was acknowledged by both the IDON and the Administrator, who confirmed that not using the physician-prescribed treatment could potentially worsen the wound. The resident, admitted on 6/10/21, had medical diagnoses including a non-pressure chronic ulcer of the left ankle, cerebrovascular disease, and hemiplegia affecting the left dominant side.
Failure to Apply Palm Guard Leads to Decline in Resident's Range of Motion
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion (ROM) and mobility for a resident, identified as Resident #31, who had a contracture in the right hand. Observations revealed that the resident was not wearing a palm guard, which was ordered to prevent the contracture from worsening. The order for the palm guard, dated 5/31/23, specified its removal at bedtime, but did not indicate when it should be applied or who was responsible for its application. Interviews with staff, including a CNA, the Interim Director of Nursing, and an LPN, confirmed that the palm guard was not applied as required, and the CNA was unable to locate it, suggesting it might be in the laundry. The Occupational Therapist (OT) had previously noticed the issue and provided an in-service training to the nursing staff, but the problem persisted. The OT confirmed that the failure to apply the palm guard contributed to a decline in the resident's passive range of motion (PROM) in the right hand. The resident, admitted to the facility in 2018, had a medical history of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side. The resident's Annual Minimum Data Set (MDS) indicated impairments in both upper extremities, highlighting the need for consistent application of the palm guard to prevent further decline.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Duncan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diversicare Of Shelby | 6.5 mi | ★★★★★ | 0 | 0 |
| Greenbough Health And Rehabilitation Center | 11 mi | ★★★★★ | 11 | 0 |
| Clarksdale Nursing Center | 14.9 mi | ★★★★★ | 0 | 0 |
| Bolivar Medical Center Ltc | 20.4 mi | ★★★★★ | 0 | 0 |
| Cleveland Community Care Center | 20.5 mi | ★★★★★ | 8 | 0 |
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