Groves Center

Inspectors wroteBased on observations, interviews, record reviews, the facility failed to implement and maintain an infection prevention and control program to mitigate and prevent the spread of infection related to: 1) not ensuring staff were donning appropriate Personal Protective Equipment (PPE) when entering a resident room under transmission based precautions, 2) not ensure residents were offered handy hygiene prior to meal service for one of four halls observed and 3) did not ensure the laundry area was kept in a manner to prevent the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to maintain an ongoing antibiotic stewardship program for 11 of 12 months reviewed.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure an assessment of self-administration of medications for one resident (#16) of one resident reviewed.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to obtain a blood test to monitor the therapeutic level of a medication used as a psychotropic, for one (#118) of five residents sampled for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with a serious mental disorder(s)/diagnoses were referred to the State's Mental Health authority for a Level II Preadmission Screening and Resident Review (PASRR) review for two residents (#9 and #10) out of five residents sampled.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) screenings were completed accurately at the time of admission for two (#42 and #118) of six residents sampled for the accuracy of PASRRs.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to update and revise the person-centered comprehensive care plan for one resident (#50) of six residents sampled.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide one resident (#42) of two residents an environment that was free from avoidable accidents and hazards related to implementation of adequate non-slip material under moveable floor mats.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to implement pharmacy recommendations for one resident (#118) of five residents sampled for unnecessary medications.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a medication error rate of less than 5.00%. Thirty-nine medication administration opportunities were observed, and four errors were identified for one resident (#31) of five residents observed. These errors constituted a 10.26% medication error rate.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure two residents (#36 and #11) of five observed residents received medications within the scheduled time frame and failed to ensure the physician was notified prior to the administration of late medications.

Inspectors wroteBased on interviews, and record review, the facility failed to provide necessary care and services to prevent Urinary Tract Infections (UTIs) from developing or worsening by 1.) Failing to follow physician's orders for a silver coated foley catheter, failed to order labs, and change the foley catheter per orders for one resident (#2) out of four residents reviewed, resulting in Resident #2 developing a urinary tract infection that progressed to Fournier's gangrene and sepsis. 2.) Failed to give antibiotics for UTI as ordered for one resident (#13) out of four residents reviewed with catheters. This failure placed Resident #13 at risk for worsening infection or delayed recovery.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure 1.) necessary care and services were to prevent Urinary Tract Infections (UTIs) from developing or worsening by, failing to follow physician's orders for a silver coated foley catheter, failed to order labs, and change the foley catheter per orders for one resident (#2) out of four residents reviewed, resulting in Resident #2 developing a urinary tract infection that progressed to Fournier's gangrene and sepsis. Failed to give antibiotics for UTI as ordered for one resident (#13) out of four residents reviewed with catheters. This failure placed Resident #13 at risk for worsening infection or delayed recovery. [...]

Inspectors wroteBased on observation, record review, and policy review, the facility failed to ensure a grievance was filed and investigated and resolved for one resident (#9) of seven sampled residents.

Inspectors wroteBased on interviews and record reviews the facility did not ensure reporting of an allegation of neglect for one resident (#1) out of three residents reviewed. Findings Included: A facility policy titled Abuse Prevention Program, reviewed September 2025, showed: Policy: - The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. [...]

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an allegation of neglect, by failing to conduct interviews with all relevant staff related to a reportable event for one resident (#2) of five sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper catheter care was provided to include securing and changing catheter bags per physician orders, for four residents ( #15, #16, #4 and #2) of four residents sampled for catheter care.

Inspectors wroteBased on record review and interviews, the facility failed to ensure pain was managed for one resident (#12), out of three residents sampled.

Inspectors wroteBased on record reviews and interviews, the facility did not ensure providers were notified of abnormal lab results for two residents (#1 and #4) out of three residents reviewed for labs.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure appropriate isolation precautions were initiated for two residents ( #10 and #9 ) of three residents sampled and failed to ensure personal protective equipment (PPE) was supplied for residents on isolation precautions for five rooms (101,409, 413, 408 and 305) out of twenty rooms observed. On 5/27/2025 at 8:32 a.m., an observation was made in front of room [ROOM NUMBER] with a blue sign outside the door and Contact Precautions was indicated for resident in bed A. There was no PPE observed outside the door. An interview was conducted with Staff B, Licensed Practical Nurse (LPN). Staff B, LPN stated the resident in bed B was on Contact Isolation for having a peripherally inserted central catheter (PICC) line. Staff B stated the PPE was located behind the door inside the residents' room. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure their pest control program was effective during two (05/27/2025 and 05/28/2025) of two days of survey.

Inspectors wroteBased on interviews, record and policy review, the facility failed to ensure grievances were promptly addressed and resolved to ensure complainant's satisfaction for one (#7) of seven residents reviewed.

Inspectors wroteBased on observation, interviews and record review, the facility failed to have pain medication available per physician orders for one resident (#5) out of three residents sampled. Findings Included: On 5/27/2025 at 1:49 p.m., an interview was conducted with Resident #5 with Staff A, Registered Dietician, for interpretation. Resident #5 stated getting her pain medication was an issue the last month and stated she went without getting her pain medication. A record review of Resident #5's Medication Administration Record (MAR) for the month of April 2025 showed a missed dose of Oxycodone HCL oral tablet 10 milligrams (mg) by mouth one time a day for non- acute pain on 4/26/2025. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide incontinence care for four ( #4, #5 #8 and #11) out of four residents sampled. Findings Included: During an interview on 05/27/2025 at 12:46 p.m., Resident #4 stated a few months ago she put her call light on, and a male staff member came into her room told her that he was not her aide and that he was going to get her aide. She stated he turned off her light and no one ever came back. She stated she had to wait for the next shift to come in and change her wet brief. She spoke with the facility at the time of the incident and told them that staff do not come into her room at night and they do not offer to change her. She reported she was told that this would change, and staff would come and check on her during the night. Resident #4 stated this has not happened. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide privacy and confidentiality for three (#1, #4, #7) of seven sampled residents related to placing items in the trash can with resident identifiable information and leaving the medication cart unattended with resident information present and accessible in paper and electronic format.

Inspectors wroteCross reference F695 and F880 Based on interview and record review the facility failed to provide care consistent with the comprehensive person-centered care plan for two (#1 and #6) of three sampled residents with tracheostomies.

Inspectors wroteCross reference F656 and F880 Based on observation, interview, and record review the facility failed to provide tracheostomy (trach) and suctioning care consistent with professional standards of practice and the resident's comprehensive person-centered care plan for one of three sampled residents (#1).

Inspectors wroteCross reference F656 and F695 Based on observation, interview, and record review the facility failed to follow standard and enhanced barrier precautions when performing resident care for one (#1, #7) of seven sampled residents.

Inspectors wroteA review of the facility's abuse log revealed Resident #164 made an allegation of abuse on 9/19/23. During an interview on 01/10/24 at 12:16 p.m. the Nursing Home Administrator (NHA) confirmed an allegation of abuse was made by Resident #164 on 09/19/23 and a federal report was completed. The resident reported his Certified Nursing Assistant (CNA), Staff R poisoned his coffee. The resident stated he witnessed the CNA remove his coffee and put an unknown substance in his coffee. An investigation was initiated. The NHA stated she could not find the statements she obtained from the CNA. She stated she spoke to the nurse who worked that day as well but could not find that statement either. A follow-up interview with the NHA on 01/10/24 at 12:38 p.m., revealed she misplaced the entire file related to Resident #164's abuse investigation to include witness statements. [...]

Inspectors wroteBased on observation, interviews with residents, facility staff, resident representatives, the Clinical Manager of a dialysis facility, and the Medical Director, and review of policy and procedures, clinical records, training records and incident logs, it was determined the facility failed to identify, investigate, prevent, and take corrective action for the neglect of two (#308 and #106) of 12 residents reviewed for abuse and neglect. The facility failed to ensure wound care orders were implemented for Resident #308 and #106 resulting in the worsening of the wounds, and failed to investigate the cause of a fracture of unknown origin for one (#12) of 12 residents. [...]

Inspectors wroteBased on observations, staff interviews, medical record reviews personnel record reviews and training records, the facility failed to have competent staff to identify abuse, protect residents during abuse investigations and investigate abuse allegations to prevent reoccurring abuse; the facility failed to have competent staff to accurately assess residents' medical conditions and to provide care and treatment to prevent worsening of conditions, for pressure ulcers, and significant change in condition after a fall. The facility failed to provide ongoing staff training and monitoring to ensure nursing skills and competencies to provide safe and adequate care for the residents to achieve their highest practicable level of well-being for 10 residents (#164, #207 #90, #100, #32, #12, #308, #6, #36, and #106) of 112 residents in the facility census. [...]

Inspectors wroteBased on interviews, record reviews and review of job descriptions, the facility's administration failed to utilize resources to ensure adequate supervision to effectively implement a systematic process to carry out the facility's abuse policy for seven residents (#32, #90, #100, #6, #36, #12, #164), failed to ensure the facility staff provided care and services to prevent the worsening of wounds for two residents (#308 and #106), failed to ensure hot water temperatures were maintained at a comfortable level for residents on one hallway (Hall 100), and failed to ensure oversight of nurse competency training with the potential to affect a total census of 112 residents. These systemic failures resulted in Immediate Jeopardy which began on 09/19/23 and was ongoing at the time of survey exit on 01/12/2024.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to utilize the Quality Assurance and Performance Improvement (QAPI) process to investigate, develop, and implement an effective Performance Improvement Plan (PIP) to ensure the facility was free from abuse and neglect. During a survey conducted on 01/08/24 to 01/12/24 non-compliance was found for 9 of 12 residents reviewed for abuse and neglect. The incidents/allegations included resident to resident physical/sexual abuse (#32, #90, #100), staff to resident physical abuse (#6, #164), staff to resident verbal abuse (#36), and neglect resulting in worsening of wounds (#308, #106), and failure to investigate a fracture of unknown origin (#12). [...]

Inspectors wroteBased on interviews, record review and policy review, the facility failed to provide necessary treatment and services to prevent worsening of a pressure ulcer for 1 of 2 residents sampled for pressure ulcers (Resident #308).

Inspectors wroteBased on observations interviews and facility records review, the facility failed to ensure hot water temperatures were maintained at comfortable levels in one hall (Hall 100) of four halls for four days (1/8/24, 1/9/24, 1/10/24 and 1/11/24) of a five day survey.

Inspectors wroteBased on observations interviews and record review, the facility failed to ensure hand splints were applied and range of motion (ROM) was provided for one resident (#8) of two residents sampled for limited range of motion.

Inspectors wroteBased on observation, staff interview and record review the facility nursing staff failed to accurately conduct assessments from 1/1/24 to 1/11/24 following a fall, identify a change in condition of a swollen right shoulder and provide treatment and care in accordance with standards of practice for one resident (#207) of forty two residents sampled.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure post dialysis care was completed per physician orders for one resident (#12) of five dialysis residents sampled.

Inspectors wroteBased on interviews, record reviews, and review of facility policy, the facility failed to provide ongoing monitoring for complications before and after dialysis treatments for 2 (Resident #92 and Resident #35) of 2 resident sampled for dialysis care.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure medications were stored appropriately in three of four medication carts and one of two medication preparation rooms.

Inspectors wroteBased on interviews and record reviews, the facility failed to conduct ongoing COVID-19 outbreak testing in accordance with testing frequency parameters for four (Resident #68, Resident #30, Resident #13, and Resident #79) of five residents sampled for COVID-19 testing requirements.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure one (#63) out of thirty-seven sampled residents had the right to be treated with dignity and respect related to staff restricting the residents' ability to self-propel in a wheelchair.

Inspectors wroteBased on record reviews, interviews, and review of facility policy, the facility failed to provide written notification of Transfer/Discharge to Resident Representatives and failed to notify the Office of the State Long-Term Care Ombudsman of a resident transfer for two (Resident #56 and Resident #200) of four residents sampled for hospitalizations.

Inspectors wroteBased on record reviews, interviews, and review of facility policy, the facility failed to provide written notification of the Bed Hold Policy to Resident Representatives for for one (Resident #56) of four residents sampled for hospitalizations.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to maintain and store respiratory equipment in a sanitary manner for one (#57) out of 7 residents who utilized a continuous positive airway pressure (CPAP).

Inspectors wroteBased on interviews, record reviews, and review of facility policy, the facility failed to act upon a pharmacy recommendation in a timely manner for one (Resident #59) of six residents sampled for unnecessary medications.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure proper monitoring for psychotropic medication use was consistently implemented for two (Resident #59 and Resident #68) of six residents sampled for unnecessary medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and three errors were identified for two (#74 and #15) of four residents observed. These errors constituted a 12.00% medication error rate.

Inspectors wroteBased on observation and interview, the facility failed to ensure that the call light was functioning properly for Resident's #17 and #89 during 4 of 4 days of survey.