Grove Health & Rehab Ctr, the

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a newly identified injury was fully assessed, documented, and investigated for one of three residents (R2) reviewed for injuries in the sample list of 20. R2's Face Sheet documented a re-admission date of 4/30/26 with diagnoses that included Alzheimer's Disease, Neurocognitive Disorder with Lewy Bodies, Type 2 Diabetes Mellitus, Aphagia and Unspecified Protein Calorie Malnutrition. R2's Minimum Data Set (MDS) dated [DATE] does not document a Brief Interview for Mental Status (BIMS) score due to R2 being rarely/never understood. On 4/3/2026 at 2:00PM, Nursing progress note documents R2 being sent to the local emergency department for evaluation related to foul smelling and dark colored gastric residual. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent an accident during a full mechanical lift transfer in 1 of 5 residents (R3) reviewed for accident hazards in the sample of 9. This failure resulted in R3 sustaining fractures to the left distal fibula, right distal tibia, and right distal fibula. Findings Include:On 4/1/26 at 9:45 AM, R3 was observed in her wheelchair with bilateral ankle contractures and a right knee contracture. A full mechanical lift transfer was observed with V16, CNA (Certified Nursing Assistant), and V17, CNA, without incident. R3's Face Sheet, undated, documents R3 has the following diagnoses, in part: Dementia, Contractures of the Right Knee, Left Knee, Right Ankle and Left Ankle, Fracture of the Right Tibia and Left Fibula, History of Falling, and Disorders of Bone Density and Structure. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure CPR (cardiopulmonary resuscitation) was initiated per physician's orders and resident's wishes for 1 of 3 (R16) residents reviewed for death. This failure resulted in an Immediate Jeopardy on [DATE] at 8:20 AM when R16 was found without a pulse nor respirations by a CNA (Certified Nurse Assistant). CPR was not attempted per R16's wishes. This failure has the potential to affect all 138 residents of the facility. The Immediate Jeopardy began on [DATE] at 8:20 AM when R16 was found without a pulse or respirations by V30 CNA. V30 notified R16's nurse V19 LPN (Licensed Practical Nurse) of R16's condition and V19 failed to initiate CPR per R16's wishes. R16 expired at the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent misappropriation of resident's medication for 5 of 8 residents (R4, R5, R6, R7, and R13) reviewed for misappropriation of personal property in the sample of 19.

Inspectors wroteBased on interview and record review the facility failed to prepare food at an appetizing temperature. This failure affects 2 of 2 (R1 and R3) residents reviewed for dietary services.

Inspectors wroteBased on interview and record review the Facility failed to provide a safe transfer for 1 of 3 residents (R1) reviewed for transfers in the sample of 10. This failure resulted in R1 being left unattended as staff left the room and R1 fell out of the bed and sustained an Intracranial hemorrhage (head injury).

Inspectors wroteBased on interview and record review, the facility failed to answer call lights in a timely manner in 2 of 3 residents (R109, R131) when reviewed for accommodation of needs in the sample of 32. Findings Include:On 08/26/2025 at 10:50 AM, R109 was observed in her room, in the wheelchair, clean, dry, without odors, and call light within reach. R109 stated sometimes she will have to press her call light 2-4 times to get someone to come in. R109 stated it has taken over 2 hours for the staff to provide care. R109 stated she has a bed sore on her bottom from not being cleaned up timely. R109 stated she goes to dialysis 3 days per week and has to sit up for the 3 hours she is there, so when she gets back to the facility, she's ready to lay down and it takes a long time. R109's Face Sheet, undated, documents R109 has the following diagnoses: [...]

Inspectors wroteBased on Interview, and Record Review the facility failed to ensure physical abuse did not occur for 1 of 2 (R88) residents reviewed for abuse in the sample of 32. Findings Include: R112's Face sheet documents an admission date of 10/10/2023. Diagnosis include Heart failure, Dementia, Anemia, Dysphagia, and Hypertension. R112's Minimum Data Set, MDS, updated 6/25/2025 documents R112 is moderately cognitively impaired. R112's Care Plan updated 7/10/2025 documents R112 has a behavior problem of hitting others related to: Cognitive Impairment/Dementia. Interventions include: If reasonable/appropriate, discuss R112's behavior. Explain/reinforce why behavior is inappropriate and or unacceptable to R112. Monitor for behavior of hitting. Praise R112 for appropriate behavior. R88's Face sheet documents an admission date of 5/12/2023. [...]

Inspectors wroteBased on interview, observation, record review, the facility failed to attach mechanical lift sling in the appropriate manner to prevent 1 resident (R12) of 8 residents from experiencing a fall from the mechanical lift out of a sample of 32.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse for 2 of 7 residents (R1, R2) reviewed for abuse in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's guardian of a change in medications in 1 of 5 residents (R2) reviewed for notification of changes in the sample of 6.

Inspectors wroteBased on interview and record review the facility failed to verify medications for accuracy and number of dose of each medication being sent home on discharge for 1 of 3 residents (R4) reviewed for discharge medications in the sample of 10.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure personal use items were within reach and provide an environment free of clutter to prevent falls and injury for 1 of 6 residents (R12) reviewed for accidents in the sample of 61. This failure resulted in R12 sustaining a cervical fracture, wearing a neck brace from 4/8/24 until 6/18/24, and requiring 9 sutures to his forehead.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to assess, monitor, and implement interventions to prevent weight loss in 1 out of 5 residents, R323, reviewed for nutrition in a sample of 61. This failure resulted in R323 acquiring a 9.09% weight loss in less than 3 months.

Inspectors wroteBased on interview and record review, the facility failed to provide Physician prescribed medication for 1 of 4 residents (R223) reviewed for medication. This failure resulted in R223 missing 28 doses of oxcarbazepine (seizure medication) and having 10 seizures between 8/2/24 and discharge to the hospital on 8/11/24.

Inspectors wroteBased on observation, interview and record review the facility failed to provided assistance during feeding in a dignified manner for 5 of 32 residents (R26, R39. R50, R54 and R91) reviewed for dignity in the sample of 61.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform complete incontinent and peri care for 4 of 4, (R4, R29, R232, R273) residents, reviewed for incontinence, in a sample of 61.

Inspectors wroteBased on interview, observation, and record review, the facility failed to discard expired blood glucose monitor control solutions for 4 of 4 (R10, R14, R48, R84) reviewed for medication storage in the sample of 61.

Inspectors wroteBased on observation interview and record review, the facility failed to perform hand hygiene before donning and after doffing gloves, prior to donning personal protective equipment (PPE), failing to prevent cross contamination during care and donning PPE prior to entering a enhance barrier precaution labeled resident room, for 4 of 4 (R29, R58, R273 and R323) residents reviewed for infection control, in a sample of 61.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to provide eating assistance for 1 out of 8 residents (R323), reviewed for feeding assistance in a sample of 61.

Inspectors wroteBased on interview and record reviews the facility failed to promote residents' dignity by answering call lights and addressing residents' needs for 4 of 11 residents (R1, R5, R6 and R7) reviewed for dignity in the sample of 22.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staff to provide care in a timely manner for 5 of 22 residents (R6, R7, R10, R1 and R5) reviewed for staffing in the sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide complete incontinent care to prevent urinary tract infections for 2 of 4 residents (R19, R20) reviewed for incontinent care in the sample of 22.

Inspectors wroteBased on observation, interview and record review, the facility failed to get timely treatment for changes in condition to meet the highest practical physical well-being of residents for 2 of 5 residents (R4, R5) reviewed for changes in condition in the sample of 5. Findings Include: 1. On 12/14/23 at 11:45 AM, R4 was observed in her room in wheelchair R4 appeared ill. R4 stated she has pneumonia and still isn't feeling well. R4 was observed with a dry, tight cough and appears to be short of breath. R4's oxygen was on at 3L (liters)/minute. Oxygen not on R4, nasal cannula on bedside table in front of resident. When asked why she didn't have her oxygen on, R4 stated Oh I thought I did. R4 stated the oxygen does help some. R4 stated she does not feel like the facility acted quickly to get her treatment for the pneumonia and she isn't getting any better. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide supervision and assistance, do a thorough fall investigation including a root cause analysis, and implement progressive intervention to prevent falls for 3 of 4 residents (R1, R4, R5) reviewed for falls. This failure resulted in R4 falling and sustaining a left sided subdural hematoma, subarachnoid hemorrhage with intraventricular hemorrhage which was the cause of her death.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement proper infection prevention and control practices to prevent the transmission spread of COVID-19 infections for 4 of 4 residents, (R1, R2, R3, R4) reviewed for infection control in the sample of 5.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide pain medication to control pain for 1 of 2 residents (R202) reviewed for pain control in the sample of 43. The failure resulted in R202 being in severe pain from 8:00 AM until 4:40 PM on 8/8/23.

Inspectors wroteBased on interview and record review the facility failed to answer call lights timely for 4 of 32 residents (R6, R32, R57 and R80) reviewed for call lights in the sample of 43.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide, complete incontinent care to prevent Urinary Tract Infections for 4 of 5 residents (R10, R14, R91, R62) in the sample of 43.

Inspectors wroteBased on interview and record review the facility failed to offer hour of sleep snacks to 4 of 32 residents (R6, R57, R67 and R73) reviewed for snacks in the sample of 43.

Inspectors wroteBased on observation, interview and record review the facility failed to perform proper handwashing and failed to wear Personal Protective Equipment, (PPE), to prevent the transmission of pathogens and cross contamination for 4 of 8 residents (R3, R14, R40, R152) reviewed for infection control practices in a sample of 43.

Inspectors wroteBased on record review and interview facility failed to notify Physician of blood sugar results, of greater than 300 and failed to send biweekly blood sugar logs to Physician per Doctors Orders for 1 of 20 residents (R6) reviewed for Physician Notification in the sample of 43.