Oak Grove Christian: Blood Pressure Med Errors - IN
The resident, identified only as Resident C, has Alzheimer's disease, heart failure, and chronic kidney disease. Their care plan specifically noted cardiovascular problems including congestive heart failure and high blood pressure.
A doctor's order from April required staff to give the patient metoprolol tartrate twice daily — a blood pressure medication critical for heart failure management. The order included clear safety parameters: hold the medication only if blood pressure dropped below 100/50 or heart rate fell under 60 beats per minute.
Staff ignored those instructions repeatedly over three months.
In June, nurses held the morning dose on June 13 when the patient's blood pressure measured 101/55 — above the minimum threshold for giving the medication. They held another dose on June 19 without recording any vital signs at all.
The pattern continued through July. Staff withheld the bedtime dose on July 2 when blood pressure read 108/58, well within safe parameters. On July 31, they held it again with a reading of 106/68.
August brought more of the same. Nurses skipped the morning dose on August 5 without taking vital signs. They held the bedtime dose on August 2 when blood pressure measured 117/50 — nearly 20 points above the minimum threshold.
The medication errors occurred despite the resident's moderate cognitive impairment from Alzheimer's disease, which made them unable to advocate for proper treatment. Their July assessment confirmed they had limited ability to make daily decisions about their care.
When inspectors interviewed the Director of Nursing about the medication holds, she provided no explanation. She told investigators she had "no further information to provide" about why staff withheld medications when the patient's vital signs were within acceptable ranges.
The violations stemmed from a complaint filed against the facility. Federal inspectors classified the deficiency as causing minimal harm but noted it had potential for actual harm to residents.
Metoprolol tartrate is a beta-blocker commonly prescribed for heart failure patients to reduce strain on the heart and control blood pressure. Skipping doses can worsen heart failure symptoms and increase risks of cardiovascular complications.
The facility's own care plan emphasized the importance of administering medications as ordered for the resident's cardiovascular conditions. Staff failed to follow both the physician's specific instructions and their own documented care approach.
Oak Grove Christian Retirement Village operates as a 120-bed facility in Jasper County. The August inspection focused on medication administration practices after the complaint was filed.
The inspection report shows a systematic failure to follow medication orders over multiple months, with staff making decisions that contradicted clear medical parameters. The resident's complex medical conditions — including heart failure requiring careful medication management — made proper adherence to orders particularly critical.
No other residents were cited for similar medication administration failures during this inspection, though investigators reviewed medication practices for three residents total.
The facility must submit a plan of correction to continue participating in Medicare and Medicaid programs. The deficiency findings become public 14 days after the nursing home receives the inspection report.
For Resident C, the medication holds meant missing doses of heart medication during a three-month period when their cardiovascular system needed consistent treatment. Each skipped dose represented a missed opportunity to properly manage their heart failure and blood pressure conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Grove Christian Retirement Village from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
OAK GROVE CHRISTIAN RETIREMENT VILLAGE in DEMOTTE, IN was cited for violations during a health inspection on August 13, 2025.
The resident, identified only as Resident C, has Alzheimer's disease, heart failure, and chronic kidney disease.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.