Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Grove Nursing Home during CMS and state inspections, most recent first.
A facility failed to maintain infection control during wound care, incontinent/catheter care, and medication administration. An LVN returned a wound cleanser bottle to the med cart without sanitizing it after use on a resident with a stage IV pressure ulcer. A CNA performed incontinent and catheter care for a resident with an indwelling catheter without hand hygiene or glove changes after initial contact. A medication aide also handled pills and a dirty medication cup without hand hygiene before giving eyedrops to a resident with glaucoma.
Incomplete Baseline Care Plan for New Admission: A resident admitted with a post-surgical tibia fracture, cellulitis, DM, CKD, and a kidney transplant history had an incomplete baseline care plan that omitted the admitting diagnosis, language/communication needs, PRN opioid and routine meds, enhanced barrier precautions, dietary preferences, and therapy frequency. The MDS nurse and DON both acknowledged the baseline care plan was not fully completed and should have included these instructions.
Improper Administration of Flonase Nasal Spray: Two residents with seasonal allergic rhinitis received Flonase during observed med passes without the bottle being gently shaken first, despite the manufacturer’s instructions. The MAs said they checked the expiration date and knew the spray should be shaken, while the DON, ADON, and LVN stated staff were expected to follow MD orders, facility policy, and manufacturer directions when administering meds.
Medication error rate exceeded the allowed threshold when two MAs administered Flonase to two residents without gently shaking the bottle as required by the manufacturer. One resident had seasonal allergic rhinitis, dementia, and glaucoma, and the other had seasonal allergic rhinitis, low back pain, weakness, and coordination deficits. Both MAs acknowledged the errors, and nursing leadership stated staff were expected to follow MD orders and manufacturer instructions during med administration.
A resident with dementia and glaucoma had 13 expired Systane Ultra PF artificial tear vials stored in her bedside drawer without supervision and without a physician order. During observation, the resident said she used the drops sometimes and demonstrated that she could open the vials herself. LVN staff, the DON, and the ADON stated residents were not supposed to have medications in their possession or in bedside drawers unless ordered and approved, and the resident’s RP expressed concern because of the resident’s confusion and glaucoma.
A resident with kidney stones and a retroperitoneal abscess did not receive daily dressing changes for drain sites as ordered by the physician. Nursing staff admitted to not changing the dressings due to being busy and forgetting, which could lead to infection. Despite this, there were no signs of infection, and the resident reported no pain.
A resident with a history of mental health issues reported an alleged inappropriate touching incident, but the facility failed to report it to the State Agency within the required 2-hour timeframe. Despite staff notifying the DON and Administrator immediately and reviewing surveillance footage, the report was delayed by 9 hours. The facility's policy mandates immediate reporting of abuse allegations, which was not adhered to in this case.
Infection Control Lapses During Wound Care, Catheter Care, and Medication Pass
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 3 residents reviewed for infection control. One event involved a LVN providing wound care to a resident with a stage IV sacral pressure ulcer. The resident’s record showed she was admitted with diagnoses including a stage 4 pressure ulcer, and her treatment orders directed daily cleansing of the sacral wound with wound cleanser, medi-honey, alginate, and a dry dressing. During observation, the LVN removed the soiled dressing, sanitized her hands, donned new gloves, sprayed gauze with NS/wound cleanser, and placed the bottle on the table next to the bed while performing care. After completing the dressing change, she returned the bottle of NS/wound cleanser to the medication cart without sanitizing it first. A second event involved incontinent care and catheter care for a resident with an indwelling urinary catheter. The resident’s record showed diagnoses including type 2 diabetes mellitus and neuromuscular dysfunction of the bladder, and her care plan identified her as at risk for infection related to the catheter. During observation, the CNA washed hands and donned gown and gloves, then uncovered the resident, opened the brief, and tucked it under the resident. Without performing hand hygiene or changing gloves, the CNA began incontinent and catheter care, wiping the outer folds of the vagina and labia, performing catheter care around the insertion site and tubing, and continuing care after repositioning the resident. Hand hygiene and glove changes were performed later during the care process. A third event involved medication administration for a resident with glaucoma and cognitive communication deficit/dementia. The resident’s orders included Timolol Maleate ophthalmic solution twice daily. During observation, the medication aide removed pill cards from the medication cart and placed pills into a medication cup without performing hand hygiene. After the resident took the medication, the aide grabbed the dirty medication cup and discarded it, then administered the eyedrops without sanitizing her hands after touching the cup. The aide stated she should have slowed down and sanitized her hands before administering the eyedrops, and the DON and Infection Control Nurse stated staff were expected to perform hand hygiene to prevent the spread of infection.
Incomplete Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and accurately complete a baseline care plan within 48 hours of admission for Resident #51. The resident was admitted on 08/28/2025 with diagnoses including displaced fracture of the right tibial tuberosity, cellulitis, diabetes, and chronic kidney disease, and had a history of kidney transplant with immunosuppression therapy. The admission MDS reflected a BIMS score of 09 and noted a surgical wound requiring nonsurgical dressings. The resident’s orders included Eliquis, escitalopram, hydrocodone-acetaminophen as needed for pain, tacrolimus, temazepam, dialysis three times weekly, dialysis access precautions, enhanced barrier precautions, and therapy services. Review of the baseline care plan showed it did not include several instructions needed for effective and person-centered care, including communication needs related to the resident’s primary language of Spanish, the admitting diagnosis, PRN opioid pain medication, routine medications, enhanced barrier precautions, kidney transplant and immunosuppression therapy, dietary preferences, and therapy service frequency. During interview, the MDS nurse acknowledged the care plan was incomplete and stated the medication list, therapy services, enhanced barrier precautions, and admitting diagnosis should have been included. The DON also stated the baseline care plan should have contained instructions for language barrier, wound treatment, pain medications, dietary preferences, physician treatment orders, therapy services, and enhanced barrier precautions, and that all fields were expected to be completed accurately.
Improper Administration of Flonase Nasal Spray
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate administration of Flonase nasal suspension for two residents reviewed for pharmacy services. Resident #71, a female with diagnoses including seasonal allergic rhinitis, cognitive communication deficit, unspecified dementia with agitation, and unspecified glaucoma, had an active order for Flonase 2 sprays in each nostril daily. During a medication pass observation, MA A removed the medication from the manufacturer’s box and administered it without gently shaking the bottle before use, even though the manufacturer’s instructions required it to be shaken gently before each use. Resident #77, a male with diagnoses including seasonal allergic rhinitis, low back pain, generalized muscle weakness, and lack of coordination, had an active order for Flonase 1 spray in both nostrils twice daily. During a medication pass observation, MA B removed the medication from the manufacturer’s box and administered it without gently shaking the bottle before use, despite the manufacturer’s instructions. Both medication aides stated they checked the expiration date before administration and acknowledged that Flonase needed to be shaken, but neither did so during the observed passes. Interviews with nursing leadership and staff showed that the DON expected staff to follow physician orders and manufacturer instructions, and the ADON and LVN C stated that medication administration should follow MD orders, facility policy, and manufacturer directions. The facility’s medication pass worksheets indicated both MAs had demonstrated proper technique on a prior skills check-off with no errors related to nasal spray administration. The manufacturer’s box for Flonase stated the bottle should be shaken gently before each use, and the facility policy required medications to be administered in accordance with orders and that the administering individual check the label three times before giving the medication.
Medication Error Rate Exceeded Threshold Due to Improper Flonase Administration
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors identified a 7.41% medication error rate, based on 2 errors out of 27 opportunities, involving 2 residents and 2 medication aides. The errors involved administration of Flonase nasal suspension without first gently shaking the bottle, as directed by the manufacturer before use. Resident #71 was a female with diagnoses including seasonal allergic rhinitis, cognitive communication deficit, unspecified dementia with agitation, and unspecified glaucoma. Her physician order for August 2025 directed Flonase nasal suspension, 2 sprays in each nostril once daily, and her care plan identified seasonal allergies with Flonase as treatment. During observation of the medication pass, MA A removed the Flonase from the medication cart, entered the resident’s room, explained the procedure, and administered the medication without shaking the bottle. MA A later stated she made a medication error by not shaking the bottle and acknowledged that the medication should have been shaken to ensure the resident received the full effective dose. Resident #77 was a male with diagnoses including seasonal allergic rhinitis, low back pain, generalized muscle weakness, and lack of coordination. His physician order for August 2025 directed Flonase nasal suspension, 1 spray in both nostrils twice daily, and his care plan identified him as at risk for shortness of breath with Flonase as treatment. During observation of the medication pass, MA B removed the Flonase from the medication cart, entered the resident’s room, explained the procedure, and administered the medication without shaking the bottle. MA B stated she should have shaken the bottle and that not doing so was a medication error. Interviews with nursing leadership and staff indicated that medication administration was expected to follow physician orders and manufacturer instructions, including shaking medications when required.
Unsecured expired eyedrops found in resident bedside drawer
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and accessible only to authorized personnel for one resident reviewed for medication storage. Resident #71, a female re-admitted with seasonal allergic rhinitis, cognitive communication deficit, dementia with agitation, and unspecified glaucoma, had 13 liquid plastic single vials of Systane Ultra PF 0.7 ml artificial tears stored inside her bedside drawer without supervision. The resident’s quarterly MDS indicated a BIMS score of 11, showing moderate cognitive impairment with short-term and long-term memory problems, and her care plan addressed impaired vision related to glaucoma and administration of Timolol maleate as ordered. Record review showed there was no physician order for Systane Ultra PF 0.7 ml. The care plan did not include self-administration of medications. During observation and interview, the resident stated she had drops she used sometimes and pointed to her bedside drawer. LVN B opened the drawer and found the 13 expired artificial tear vials. LVN B and LVN C asked the resident where she got the eyedrops, and she said she had them for a while. Both nurses stated the resident should not have had the eyedrops in her possession and that there was no order for them. The DON stated residents were not expected to have any medications, prescription or over-the-counter, in their possession and said no one knew the resident had the eyedrops until the surveyor interview. The ADON stated the resident could open the eyedrops herself and potentially administer them, and that medications were not supposed to be in a bedside drawer unless ordered and approved by the facility. The resident’s RP stated the resident was very confused because of dementia and was glad the expired eyedrops were found and removed.
Failure to Follow Physician Orders for Dressing Changes
Penalty
Summary
The facility failed to adhere to professional standards of quality by not following physician orders for a resident with kidney stones and a retroperitoneal abscess. The resident, who was cognitively intact, had drains in place to assist with healing after a surgical procedure. The physician's orders required daily dressing changes for the drain sites, which were not performed as prescribed. On observation, the dressings on the resident's drains were found to be dated two days prior, indicating they had not been changed daily as required. Interviews with the nursing staff revealed that the dressings were not changed due to oversight and workload issues. LVN A admitted to not changing the dressings on one occasion because he was busy, and LVN B acknowledged forgetting to change the dressings on another day. The Director of Nursing confirmed that the expectation was for wound care to be performed as ordered, and the failure to do so could lead to infection. Despite the oversight, there were no signs of infection at the time of observation, and the resident did not report any pain at the drain sites.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident within the required 2-hour timeframe to the State Agency. The incident involved a 68-year-old female resident with a history of schizoaffective disorder, bipolar type, and other medical conditions. On the morning of June 8, 2024, the resident approached the nurses' station and reported that she believed someone had entered her room and touched her inappropriately the previous night. Despite the resident's history of delusions and inability to provide specific details, the allegation was not reported to the State Agency until 9 hours later. Interviews with facility staff, including LVN A and LVN B, revealed that the resident was calm and in no distress when she reported the incident. The staff followed protocol by notifying the Director of Nursing (DON) and the Administrator/Abuse Coordinator immediately. Surveillance footage was reviewed, showing no unauthorized individuals entering the resident's room, and the resident was transferred to a hospital for evaluation. However, the DON acknowledged that the allegation should have been reported to the State Agency within the mandated 2-hour window, regardless of the resident's delusional history. The facility's policy on reporting abuse and neglect requires immediate reporting of any allegations, but this protocol was not followed in this case. The DON admitted that the failure to report the allegation promptly was a mistake, as the facility's policy clearly states that all alleged violations involving abuse must be reported immediately, but not later than 2 hours after the allegation is made. This oversight in reporting could potentially place residents at risk of abuse, physical harm, mental anguish, and emotional distress.
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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 Groves
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Magnolia Manor | 1.6 mi | ★★★★★ | 2 | 0 |
| Sabine Heights Nursing And Rehabilitation Center | 3.8 mi | ★★★★★ | 15 | 0 |
| Bonne Vie | 4.3 mi | ★★★★★ | 7 | 0 |
| Port Arthur Nursing And Rehabilitation Center | 5.2 mi | ★★★★★ | 5 | 0 |
| Focused Care At Orange | 13.3 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.