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

Staffing

Hours and turnover

RN hours / resident day

0.34

Registered nurse staffing

LPN hours / resident day

0.91

Licensed practical nurse staffing

Aide hours / resident day

1.86

Nurse aide staffing

Weekend hours

3.03

Weekend nurse staffing

RN turnover

80%

Annual RN turnover

Total nurse turnover

67%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

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