The 75-bed facility failed to schedule the consultation despite repeated physician orders and the resident's deteriorating cardiovascular condition, according to a September inspection report.
Resident #36 arrived at Oak Grove Manor with chronic ischemic heart disease and acute diastolic congestive heart failure. Her care plan required staff to monitor and report chest pain, shortness of breath, excessive sweating, and changes in circulation to medical providers.
On May 26, the resident experienced shortness of breath and chest pain. Staff called a triage nurse practitioner who spoke with the resident via video call and determined she didn't need emergency room treatment.
The next day, the nurse practitioner examined the resident in person for chest pain and dizziness. An electrocardiogram was ordered along with follow-up with a cardiologist based on the findings.
On May 28, new orders specified an EKG due to orthostatic blood pressure problems and consultation with cardiology.
The facility faxed the consultation request to cardiology on July 8 and again on July 28. Then nothing happened.
Medical records show no evidence that a cardiology appointment was scheduled or that the resident saw a cardiologist between May 28 and September 23, when inspectors arrived.
During the inspection, the resident told investigators she was still waiting to see a cardiologist because of her congestive heart failure. She said the Director of Nursing had told her months earlier that she needed to see a cardiologist, but no appointment had been made.
Transportation Aide #304, who started handling appointments and transportation in June, told inspectors the facility had ongoing problems with residents missing appointments before her arrival. She confirmed that Resident #36 had a referral to cardiology but there were issues with the cardiology office receiving the referral from the facility.
The transportation aide acknowledged that since July 28, no further attempts were made to schedule the appointment.
The Director of Nursing confirmed during the inspection that Resident #36 should have had a cardiology consultation scheduled due to her chest pain, shortness of breath, and congestive heart failure diagnosis.
Oak Grove Manor's own transportation policy, dated April 28, requires facility staff to receive appointments from residents, families, transportation companies, or doctors' offices and schedule transportation to and from appointments as needed.
The inspection was conducted in response to a complaint filed with state regulators.
Congestive heart failure occurs when the heart cannot pump blood effectively throughout the body. Symptoms include shortness of breath, chest pain, and fluid retention. The condition requires ongoing monitoring and specialized cardiac care to prevent complications and hospitalization.
The resident remained cognitively intact throughout her stay, according to her quarterly assessment, meaning she was aware of the delays in her medical care.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to residents. The deficiency affected one of two residents reviewed for appointment scheduling issues during the inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Grove Manor from 2025-09-25 including all violations, facility responses, and corrective action plans.