Agave Grove Post Acute

Inspectors wroteBased on staff and resident interviews, review of records, and review of facility policy and procedure, the facility failed to report an allegation of abuse within the required timeframe to the state agency for one (#5) out of three sampled residents. The Universe was 118. The deficient practice could lead to ongoing abuse leading to harm of a resident.-

Inspectors wroteBased on observation, clinical record review, facility documentation, and staff interviews, the facility failed to ensure that medication was not left unattended in the one Resident's (#10) room. The sample size was 3. The deficient practice potential for overdose, and other residents accessing medication not prescribed for them.

Inspectors wroteBased on observations, staff interviews, policy review, and observation of current practice, the facility failed to ensure that resident drinks were transported from the kitchen to the residents' rooms in accordance with professional standards. The sample size was 22. The deficient practice could result in contamination of the resident's drinks.

Inspectors wroteBased on clinical record review, interviews, facility documents, and policy review, the facility failed to ensure 2 residents (#458 and #16) were free from abuse. The deficient practice resulted in residents being abused.

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to ensure that one of three sampled residents (#20) had a PASARR (preadmission Screening and Resident Review) completed . The deficient practice could result in specialized services not being provided for residents who need it. Regarding Resident #20 Resident #20 was re-admitted to the facility on [DATE] with diagnoses that included bipolar disorder, anxiety, and heart failure. A care plan revised on May 04, 2025 revealed that the resident is being considered for a Level II PASARR, and that the paperwork has been submitted for review/determination. Further review revealed an approach dated February 10, 2023 for social services to review the PASARR as needed and during the annual review and recommendation of the level II will be followed- E.G routine psychological counseling. [...]

Inspectors wroteBased on clinical record review, interviews, facility documentation, and policy review, the facility failed to ensure one resident (#465) received lab services as ordered by a physician. The deficient practice could lead to delayed diagnosis or treatment or potential deterioration in the resident's condition placing the resident at risk for harm.

Inspectors wroteBased on observations, interviews, and facility documentation and policy, the facility failed to ensure one shower room was kept in clean and sanitary conditions. The deificient practice could result in the spread of disease and infection. On March 6, 2024 observed with Certified Nurse Assistants # 7 and 12, feces in the shower stall next to the shower chair and near the drain. During initial pool screeing, on March 6, 2025 at 10:27 a.m. a resdient revealed that receiving showers at the facility are hit and miss. The resident recalled wanting a shower the other night, but was tired of seeing feces on the floor, so she elected to have bed baths instead. An interview was conducted with Certified Nurse Assistants # 7 and # 12 on March 6, 2025 at 11:22 revealed that both parties were in agreement that the feces present on the floor is not a facility expectation. [...]

Inspectors wroteBased on documentation, staff interviews, and the facility policy and reviews, the facility failed to revise the care plan after one resident (#33) fell and had a change of condition. The deficient practice could result in residents not being provided the sufficient level of care needed for safety.

Inspectors wroteBased on clinical record review, interviews, review of facility policies and the State Agency (SA) complaint tracking system, the facility failed to ensure residents do not sustain injuries with falls. Having mattresses that fit resident's beds properly will reduce the risk of possible slipping off the bed.

Inspectors wroteBased on documentation, staff interviews, and the facility policy and process, the facility failed to ensure that resident (#1) was not abused by a staff (#42). The deficient practice could result in residents being abused by staff.

Inspectors wroteBased on clinical record reviews and staff interviews, the facility failed to ensure two residents (#33 and #97) were administered medications as ordered. The deficient practice could result in the underlying condition not being treated and the condition could worsen or persist.

Inspectors wroteBased on clinical record review, staff interviews, and facility policies and procedures, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRR) Level I screening was completed for one resident (#7). The deficient practice could result in residents not receiving the appropriate service they need.

Inspectors wroteBased on observations, staff interviews and policy review, the facility failed to ensure that all the required information was documented on the daily staff posting. The deficient practice could result in residents and visitors not being made aware of the current staffing information.

Inspectors wroteBased on clinical record review, staff interview and review of facility policy review, the facility failed to ensure that a pharmacy recommendation for one resident (#7) was implemented as agreed to by the physician. The facility census was 134 residents, and the sample was 26. The deficient practice would result in medication irregularities that go unnoticed or are not acted upon.

Inspectors wroteBased on clinical record review, staff interviews, and the facility policy and procedure, the facility failed to ensure rehabilitation services was provided as ordered by the physician for one resident (#480). The deficient practice could result in residents not receiving rehabilitation needed to maintain or improve their physical health.

Inspectors wroteBased on clinical record review, observation, staff interviews and policy and procedure, the facility failed to maintain infection prevention and control during catheter care for one resident (#7). The census was 134 residents, and the sample was 26. The deficient practice could result in transmission of infection.

Inspectors wroteBased on review of employee trainings, staff interviews and policy review, the facility failed to ensure that two staff members (#150, #116) were provided training on resident rights. The deficient practice could result in residents not being afforded their rights.

Inspectors wroteBased on review of employee trainings, staff interviews and policy review, the facility failed to ensure that two staff members (#150, #116) were provided training on dementia care. The deficient practice could result in residents not being afforded their rights.

Inspectors wroteBased on resident and staff interviews, observation, facility documents, clinical record review, and policy review, the facility failed to ensure two sampled residents (#91 and #121) had the right to access their personal funds on the weekend. The deficient practice could result in residents not being able to access their personal funds on the weekends. Findings Include: -Resident #91 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE], with diagnoses that included functional quadriplegia, alcoholic cirrhosis of the liver without ascites, recurrent depressive disorders, and neuromuscular dysfunction of the bladder, unspecified. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. [...]

Inspectors wroteBased on clinical record review, resident and staff interviews, facility documentation, and policy and procedures, the facility failed to ensure that one of three sampled residents (#225) received good personal hygiene. The deficient practice could result in grooming and hygiene needs of residents not being met.