Duncan, MS

Oak Grove Retirement Home

2-star overall rating with 3-star inspections with $16,195 in total fines with 5 recent health deficiencies

209 Oak Circle, Duncan, MS

(662) 395-2577

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1975-11-24

CMS approved date

Coverage

Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.34

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.91

Licensed practical nurse staffing · state 1.10 · national 0.87

Aide hours / resident day

1.86

Nurse aide staffing · state 2.48 · national 2.35

Total nurse hours

3.11

All reported nurse hours · state 4.21 · national 3.89

Licensed hours

1.25

RN + LPN hours · state 1.73 · national 1.54

Weekend hours

3.03

Weekend nurse staffing · state 3.51 · national 3.43

Weekend RN hours

0.40

Weekend registered nurse coverage · state 0.37 · national 0.47

Physical therapist

0.00

Reported PT staffing

Adjusted RN hours

0.43

CMS adjusted RN staffing hours

Adjusted total hours

3.91

CMS adjusted total nurse staffing hours

Case-mix index

1.09

Higher values indicate more complex resident acuity

RN turnover

80%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

67%

Annual nurse turnover · state 48% · national 46%

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Medicare spending per beneficiary	Not Available	1.02	This provider is not required to submit SNF QRP data.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · This provider is not required to submit SNF QRP data.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · This provider is not required to submit SNF QRP data.
Staff COVID-19 vaccination coverage	Not Available	8.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator Not Available · This provider is not required to submit SNF QRP data.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.9	2.4 0.5 pts worse	1.9 1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.5 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.7	2.9 0.8 pts worse	1.8 1.9 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.7 · Observed 3.6 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	93.3%	95.7% 2.4 pts worse	93.4% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 94.6% · Q3 86.0% · Q4 96.4% · 4Q avg 93.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.3%	97.0% 1.3 pts better	95.5% 2.8 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3%
Percentage of long-stay residents experiencing one or more falls with major injury	6.2%	3.2% 3 pts worse	3.3% 2.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.4% · Q3 7.0% · Q4 7.1% · 4Q avg 6.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.6%	1.6% 1 pts better	11.4% 10.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6%
Percentage of long-stay residents who lose too much weight	9.5%	6.1% 3.4 pts worse	5.4% 4.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.7% · Q3 12.3% · Q4 14.3% · 4Q avg 9.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	31.7%	24.4% 7.3 pts worse	19.6% 12.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.5% · Q2 31.5% · Q3 33.3% · Q4 30.4% · 4Q avg 31.7%
Percentage of long-stay residents who received an antipsychotic medication	64.4%	23.4% 41 pts worse	16.7% 47.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 65.4% · Q2 64.0% · Q3 69.6% · Q4 60.0% · 4Q avg 64.4% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.2% 0.2 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	18.7%	22.8% 4.1 pts better	16.3% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 45.8% · Q3 0.0% · Q4 8.2% · 4Q avg 18.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.8%	20.6% 2.2 pts worse	14.9% 7.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 41.7% · Q3 5.6% · Q4 20.4% · 4Q avg 22.8% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	1.5% 1.1 pts better	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	2.5% 2.5 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	25.2%	21.4% 3.8 pts worse	19.8% 5.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 50.5% · Q2 28.6% · Q3 8.3% · Q4 14.3% · 4Q avg 25.2%
Percentage of long-stay residents with pressure ulcers	6.5%	6.9% 0.4 pts better	5.1% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 10.1% · Q3 2.5% · Q4 4.9% · 4Q avg 6.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-11-13 · Fire 2025-11-13

5 health deficiencies

Top issue: Quality of Life and Care (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 2 Health 2024-07-30 · Fire 2024-07-30

8 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2023-04-13 · Fire 2023-04-13

10 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-07-30

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-08-27

F · Potential for more than minimal harm 2023-04-13

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2023-05-25

D · Potential for more than minimal harm 2023-04-13

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2023-05-25

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-11-13

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-12-08

D · Potential for more than minimal harm 2025-11-13

F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Not hire anyone with a finding of abuse, neglect, exploitation, or theft.

Corrected 2025-12-08

D · Potential for more than minimal harm 2025-11-13

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-12-08

D · Potential for more than minimal harm 2025-11-13

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-12-08

D · Potential for more than minimal harm 2025-11-13

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-12-08

G · Actual harm 2024-07-30

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-08-26

G · Actual harm 2024-07-30

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-08-26

F · Potential for more than minimal harm 2024-07-30

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-30

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-30

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-30

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-30

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-08-26

D · Potential for more than minimal harm 2024-07-30

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-08-26

E · Potential for more than minimal harm 2023-06-01

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-06-16

E · Potential for more than minimal harm 2023-06-01

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2023-06-16

E · Potential for more than minimal harm 2023-04-13

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-05-25

D · Potential for more than minimal harm 2023-04-13

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-05-25

D · Potential for more than minimal harm 2023-04-13

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2023-05-25

D · Potential for more than minimal harm 2023-04-13

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2023-05-25

D · Potential for more than minimal harm 2023-04-13

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-05-25

D · Potential for more than minimal harm 2023-04-13

F678 · Quality of Life and Care Deficiencies

Health

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Corrected 2023-05-25

D · Potential for more than minimal harm 2023-04-13

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-05-25

D · Potential for more than minimal harm 2023-04-13