Oak Grove Christian Retirement Village: Med Failures - IN
The resident, identified only as Resident C in the report, had a physician's order dating to April 1 that was precise about when the medication should be held and when it should not. Metoprolol tartrate, a drug used to manage blood pressure and protect the heart, was to be given twice daily. Staff were to check blood pressure first and hold the dose only if the reading fell below 100/50 or the heart rate dropped below 60.
The records told a different story.
In June, the morning dose was held on June 13 when the resident's blood pressure was 101/55, a reading above the threshold that would have required withholding it. The bedtime dose was held on June 14 when the reading was 104/50, again above the cutoff. Then on June 19, the morning dose was held with no vital signs recorded at all. There was no documented blood pressure. No heart rate. Nothing.
July brought two more holds. The bedtime dose was withheld on July 2 when the blood pressure was 108/58, and again on July 31 when it was 106/68. Both readings cleared the physician's threshold.
August continued the pattern. On August 2, the bedtime dose was held when the blood pressure was 117/50. On August 5, the morning dose was held again with no vital signs on record.
Six instances. Two of them with no documented vital signs at all. Four of them with readings that, by the physician's own written order, should have resulted in the medication being given.
Metoprolol is not a drug with a wide margin for inconsistency. It is prescribed to manage blood pressure and reduce the workload on the heart, particularly in patients with heart failure. The resident's care plan, last updated in March, listed an altered cardiovascular status related to congestive heart failure and hypertension among the primary concerns. Administering medications as ordered was listed as an intervention.
When inspectors interviewed the Director of Nursing on the afternoon of August 13, she said she had no further information to provide about why the medication had been held when the vital signs were within the parameters to give it.
That was the full explanation.
The resident's cognitive status adds another layer to what the records describe. The Annual Minimum Data Set assessment from July 18 rated the resident as moderately impaired for daily decision making. Someone with moderate cognitive impairment and Alzheimer's disease cannot flag a missed dose, cannot tell a family member the medication wasn't given, cannot ask why the nurse didn't come back. The care plan's job is to be the safeguard. The physician's order is supposed to be the safeguard. Neither one functioned as one here.
The inspection was triggered by a complaint, filed under complaint number 2587154, and completed on August 13. Inspectors classified the level of harm as minimal harm or potential for actual harm, the lower end of the federal scale, and noted that few residents were affected.
The report does not say whether anyone reviewed the medication administration records before the complaint was filed. It does not say whether the resident's physician was notified that doses had been held outside the parameters of the order. It does not say whether the family was told.
What it says is that a resident with a failing heart had a heart medication withheld six times, and when asked about it, the Director of Nursing had nothing to add.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
OAK GROVE CHRISTIAN RETIREMENT VILLAGE in DEMOTTE, IN was cited for violations during a health inspection on August 13, 2025.
Metoprolol tartrate, a drug used to manage blood pressure and protect the heart, was to be given twice daily.
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.