Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Health & Rehab Center, Llc during CMS and state inspections, most recent first.
Failure to Apply Care-Planned Splint: A resident with a history of stroke and reduced mobility had a care plan directing a right upper extremity splint/brace for 3 hours daily to improve ROM, but the record had no documentation that it was being applied. Staff observed the resident without the brace on multiple occasions, and the DON and an LPN/UM confirmed it was not being worn and could not be located. The DON stated the brace application had not been added to daily care documentation and therefore had never been applied.
A resident with a history of stroke, RA, malnutrition, dysphagia, and dementia had a significant weight loss documented, but the record did not show a re-weight or the ordered weekly weights. Although the resident received a mech soft diet with nectar thick liquids, fortified foods, and a 2-Cal supplement, the RD and DON confirmed the missed weight monitoring and that the nutritional recommendations were not followed.
Medication administration errors exceeded the allowed rate when an RN gave a resident MiraLAX in too little fluid and administered a multivitamin with minerals instead of the ordered multivitamin without minerals. The resident had CHF, malnutrition, and severe cognitive impairment. The RN said the mineral-containing vitamin was the only form available and that she misjudged the amount of fluid used for MiraLAX; the DON stated medications were expected to be given in the correct form and dose, and facility policy required MiraLAX to be mixed in 4 to 8 ounces of liquid.
Failure to Apply Care-Planned Splint
Penalty
Summary
The facility failed to ensure that a splint was routinely applied for one resident with a history of stroke and reduced mobility. Review of the resident’s record showed that occupational therapy had trained staff to apply the resident’s right upper extremity splint/brace for three hours daily, and the care plan directed that it be applied every day from 8:00 AM until 11:00 AM to improve ROM. The resident’s quarterly MDS indicated limited ROM to the upper and lower extremities bilaterally and noted that a brace/splint was not being applied. The physician’s order report contained no order for the splint/brace, and the record had no documentation showing that the splint/brace was being applied as planned. Observations on multiple occasions showed the resident in bed or in a wheelchair without the care-planned brace on the right upper extremity. When the resident was observed with the LPN/UM and DON, both confirmed the brace was not being worn and could not be located. During follow-up interview, the DON stated that although the resident was expected to have the brace applied daily, the application had not been added to the daily care documentation and so had never been applied. The facility policy stated that splints are to be issued or fabricated with a provider’s order, evaluated by therapy, and the splint schedule communicated to the multidisciplinary team and documented in the care plan.
Failure to Monitor Weight and Follow Nutritional Orders
Penalty
Summary
The facility failed to ensure consistent and comprehensive nutritional management for one resident who had diagnoses including rheumatoid arthritis, history of stroke, malnutrition, dysphagia, protein-calorie malnutrition, dementia, and other chronic conditions. The resident was ordered a regular mechanical soft diet with nectar thick liquids, fortified foods, and a 2-Cal nutritional supplement twice daily. The record showed a weight of 102.4 pounds in early December and 81.0 pounds in early February, reflecting a significant weight loss of 20.9% in two months. The record did not show that a re-weight had been obtained after the significant loss was recorded. The quarterly MDS indicated the resident could not complete the BIMS due to poor cognition, had short- and long-term memory deficits, had not experienced significant weight loss or gain during the assessment period, and was dependent on staff to eat meals. A nutrition note documented that the resident remained at increased nutritional risk and noted significant weight loss over the prior 3 and 6 months. The note also stated the resident had not yet had a monthly weight, recommended a re-check of weight, increasing fortified foods to all meals, and weekly weights for four weeks. The resident's care plan identified risk for significant weight loss and included interventions such as providing the ordered diet, supplements, and weighing per facility protocol. Review of MARs/TARs and meal cards showed the resident received the supplement twice daily and fortified foods at meals, with meal cards indicating fortified foods at all three meals. However, the record did not show that the resident was re-weighed or that weekly weights were obtained as recommended in the nutrition note. During interviews, the RD stated the resident should have been weighed in January and re-weighed after the significant loss was identified, and the DON confirmed the January weight was missed and weekly weights were not implemented. The facility policy stated weights would be obtained routinely to monitor nutritional health over time.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than five percent after two medication administration errors were identified during one resident’s medication pass, resulting in an error rate of 6.67 percent. During observation of RN1 administering medications to a resident with congestive heart failure, malnutrition, and severe cognitive impairment (BIMS score of 3 out of 15), the resident’s MiraLAX was mixed with approximately two to three ounces of water rather than the required four to eight ounces of fluid, and a multivitamin with minerals was given instead of the ordered multivitamin without added minerals. RN1 stated she gave the multivitamin with minerals because it was the only form available in the facility and said she believed MiraLAX should be administered in about eight ounces of water, but she did not realize the cup used was only a four-ounce cup. The DON stated medication was expected to be administered in the correct form and dose, and MiraLAX was expected to be administered in at least four to eight ounces of fluid. The facility policy for bowel tracking directed staff to give Miralax 17 grams in 4 to 8 ounces of liquid, and the medication administration policy required verification of the correct medication, dose, route, rate, time, and resident.
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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 Chesapeake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chesapeake Health And Rehabilitation Center | 0.8 mi | ★★★★★ | 3 | 0 |
| Autumn Care Of Chesapeake | 2.1 mi | ★★★★★ | 0 | 0 |
| Maimonides Health Center Of Virginia Beach | 4.1 mi | ★★★★★ | 5 | 0 |
| Kempsville Health & Rehab Center | 4.7 mi | ★★★★★ | 9 | 0 |
| Deep Creek Health & Rehabilitation | 5.9 mi | ★★★★★ | 13 | 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 July 2026) and official state health department websites.