Health inspection·August 21, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **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) Residents Affected - Few 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. Record review of the most recent significant change MDS assessment dated [DATE] indicated Resident #11 was recently re-admitted to the facility on [DATE] and had a BIMS score of 15 (cognitively intact). The resident had an impairment in range of motion to the upper and lower extremities bilaterally, had an indwelling catheter/nephrostomy (surgery to make an opening from the outside of the body to the renal pelvis used to drain urine) and a diagnosis of retroperitoneal abscess. Record review of a care plan updated 08/20/24 indicated Resident #11 had drains to the left lower back. The goal was for the resident to have no complications. The interventions indicated to perform treatment to drain sites as ordered. During observation and interview on 08/19/24 at 9:14 a.m., Resident #11 said he had been in and out of the hospital for kidney stones and an abscess to his kidney. The resident had 2 long slender white tubes with a drainage bag attached to each tube. One drainage bag had a clear yellow fluid, and one drainage bag had a scant amount of dark yellow fluid. During an interview on 08/19/24 at 9:26 a.m., LVN A said Resident #11 had kidney stones and went in the hospital for removal of the stones with a stint put in. The resident then went back in the hospital for pain and the surgeon removed more stones and replaced the stints. The resident returned and after several days he began having pain and a knot appeared on his left lower back, so he was sent back out to the hospital. He said they learned the surgeon had cut his kidney during the procedure (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676122 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676122 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/21/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Grove Nursing Home 6230 Warren St Groves, TX 77619 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)