Oak Grove Christian Retirement Village
Inspection Findings
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
Based on record review and interview, the facility failed to ensure medications were administered as ordered for 1 of 3 residents reviewed for medication administration. (Resident C) Finding includes: Resident C's record was reviewed on 8/13/25 at 9:04 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, heart failure, and hypertensive chronic kidney disease. The Annual Minimum Data Set assessment, dated 7/18/25, indicated the resident was moderately impaired for daily decision making. A Care Plan, dated 3/31/25, indicated the resident had an altered cardiovascular status related to congestive heart failure, hypertension (high blood pressure), and hyperlipidemia (high levels of fat/lipids in the blood).
Interventions included, but were not limited to, administer medications as ordered. A Physician's Order, dated 4/1/25, indicated metoprolol tartrate (blood pressure medication) 25 milligrams, 1 tablet by mouth twice a day. Check blood pressure (bp) prior to administering the medication. Hold the medication if bp is less than 100/50 or heart rate is less than 60. The June 2025 Medication Administration Record (MAR) indicated the medication was held on the following dates and times: - Morning dose: 6/13/25 bp 101/55 and 6/19/25 no vital signs recorded - Bedtime dose: 6/14/25 bp 104/50 The July 2025 Medication Administration
Record (MAR) indicated the medication was held on the following dates and times: - Bedtime dose: 7/2/25 bp 108/58 and 7/31/25 bp 106/68 The August 2025 Medication Administration Record (MAR) indicated the medication was held on the following dates and times: - Morning dose: 8/5/25 no vital signs recorded Bedtime dose: 8/2/25 bp 117/50 During an interview on 8/13/25 at 2:15 p.m., the Director of Nursing indicated she had no further information to provide related to the medications being held when the vital signs were within the parameters to administer. This citation relates to Complaint 2587154. 3.1-37(a)
Residents Affected - Few
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
Event ID:
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Grove Christian Retirement Village
221 W Division St Demotte, IN 46310
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)
F-Tag F0695
F 0695
This citation relates to Complaint 2567618.
Level of Harm - Minimal harm or potential for actual harm
3.1-47(a)(6)
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Oak Grove Christian Retirement Village
221 W Division St Demotte, IN 46310
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)
F-Tag F0842
F 0842 Level of Harm - Minimal harm or potential for actual harm
The Annual Minimum Data Set assessment, dated 7/18/25, indicated the resident was moderately cognitively impaired and required oxygen therapy.
A Care Plan, dated 3/31/25, indicated the resident had COPD and chronic respiratory failure with hypoxia.
Interventions included, but were not limited to, administer aerosol or bronchodilators (inhalers) as ordered.
Residents Affected - Few
The current August Physician’s Order Summary indicated ipratropium/albuterol solution 1 vial inhale orally four times a day, Anoro Ellipta aerosol inhaler 62.5-25 1 puff inhale orally once daily, and budesonide suspension 1 milligram/2 milliliter 1 inhalation orally four times a day via nebulizer.
The June 2025 Medication Administration Record indicated the Anoro Ellipta inhaler was not administered as ordered on 6/19/25 and 6/25/25 at 12:00 p.m., and the budesonide suspension inhaler was not administered as ordered on 6/1/25, 6/19/25, and 6/25/25 at 12:00 p.m.
The July 2025 Medication Administration Record indicated the ipratropium/albuterol inhaler was not administered as ordered on 7/26/25 at 6:00 a.m.
During an interview on 8/13/25 at 2:15 p.m., the Director of Nursing indicated she had no further information to provide.
This citation relates to Complaint 2587154. 3.1-50(a)(1) 3.1-50(a)(2)
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
OAK GROVE CHRISTIAN RETIREMENT VILLAGE in DEMOTTE, IN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DEMOTTE, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from OAK GROVE CHRISTIAN RETIREMENT VILLAGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.