The Grove at Carvalho

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Maintain an infection prevention and control program with a complete system of surveillance to identify any trends of actual or potential infections within the facility; and 2. Ensure appropriate personal protective equipment (PPE) was utilized when providing care to two Residents (#11, #5) on Enhanced Barrier Precautions (EBP: [...]

Inspectors wroteBased on record review and interview, the facility failed to implement an antibiotic stewardship program which included antibiotic use protocols and monitoring of antibiotic use in accordance with the facility's antibiotic stewardship program.

Inspectors wroteBased on observations, records reviewed, and interviews, the facility failed to ensure it was free from a medication error rate of 5% or greater when two out of three nurses observed during a medication pass made two errors out of 39 opportunities, resulting in a medication error rate of 5%. Those errors impacted two Residents (#33 and #64), out of five residents observed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in a safe and secure manner as required. Specifically, the facility failed to ensure:1. Licensed staff locked one of two treatment carts, which contained numerous topical treatments and biologicals, when it was not in use and left in the hallway where it could be accessed by residents or passersby on the Oak Grove unit; and2. Medications were dated once opened, and discarded according to manufacturer's guidelines, in one of three medication carts observed.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to ensure the main kitchen floor tile was maintained in a sanitary and safe condition and was free of standing, pooled water.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who per rehabilitation staff required the use of a mechanical lift for all transfers, and per facility policy two staff members were required to complete lift transfers, the facility failed to ensure that 1) Resident #1's individualized comprehensive plan of care, which included his/her care Kardex, clearly indicated the number of staff members required to provide assistance during the transfers, and as a result one staff member attempted to transfer him/her alone, he/she fell, and sustained a fracture to his/her left ankle, and 2) failed to ensure they developed and implemented a comprehensive plan of care related to Resident #1's ankle fracture, that accurately identified care and treatment needs associated with new placement of a fiberglass splint, that included appropriate interventions, [...]

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who required the use of a Sit/Stand Lift (mobility aid that helps people transition safely from sitting to standing), for all transfers, with two staff members present to assist and complete the transfer, the Facility failed to ensure he/she was provided with the necessary level of staff assistance, in accordance with facility policy, to maintain his/her safety and prevent an incident/accident resulting in a significant injury. On 01/01/26, Certified Nurse Aide (CNA) #1 transferred Resident #1 with a Sit/Stand Lift, without another staff member present to assist him, Resident #1 slid out of the sling, fell onto the floor, complained of pain to his/her left lower extremity, was transferred to the Hospital Emergency Department (ED) and diagnosed with a left ankle fracture.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who had recently sustained a fracture of the distal end of the tibia and left fibula (fracture of the ankle), the Facility failed to ensure nursing staff provided care and services that met professional standards of quality, when nurses were unaware of what type of orthotic device he/she was wearing and were documenting they were providing care and treatment to his/her left ankle that they could not have completed, based on the type of orthotic device he/she had in place.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was dependent on the physical assistance of staff with Activities of Daily Living (ADL), the Facility failed to ensure they maintained a complete and accurate medical record, when Certified Nurse Aide (CNA) ADL Flow Sheets, daily documentation by CNA's (for all three shifts) were not consistently completed, with flow sheets left blank.

Inspectors wroteBased on document review and interview, the facility failed to conduct and implement a comprehensive facility wide assessment that was inclusive of resources necessary to provide both emergency and day to day care of the population the facility currently serves.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and implemented an appropriate corrective action plan, to ensure satisfactory outcomes. Specifically, the facility failed to develop and implement a Quality Assurance Performance Improvement (QAPI) plan and a Performance Improvement Project (PIP) that focused on a high risk or problem-prone area identified through data collection and analysis.

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents' rights to personal privacy and confidentiality was promoted and protected for one Resident (#337), from a total sample of 21 residents, and unopened mail and other letters, packages and other materials delivered to the facility were promptly received by residents. Specifically, the facility failed to ensure: 1. Staff did not communicate Resident #337's private health information with his/her Nurse Practitioner (NP) via a text messaging application utilizing an unsecured mobile phone platform; and 2. United States Postal Service (USPS) mail and/or packages was promptly delivered to residents within 24 hours of delivery by the postal service.

Inspectors wroteBased on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, for nine of nine residents who attended the resident group meeting, the facility failed to ensure residents were aware of and had access to grievance forms, and were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop, implement and individualize comprehensive care plans for seven Residents (#1, #16, #78, #43, #14, #50 and #72), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #1, to implement the Resident's end stage renal disease (ESRD) care plan for fluid restriction; 2. For Resident #16 to ensure the Resident's urinary catheter care plan was Resident specific and included accurate information on the manner in which catheter care was provided and monitored; 3. For Residents #78, #43, and #14, to ensure a comprehensive care plan was developed to address the use of psychotropic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and measurable goals of treatment; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that met professional standards of practice for five Residents (#72, #50, #1, #43, and #78), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #72, to ensure Clonidine (antihypertensive drug) was administered within the parameter as prescribed by the physician to help prevent low blood pressure and heart rate; 2A. For Resident #50, who had end stage renal disease, to ensure the food service department was notified of the Resident's 1500 milliliter (ml) fluid restriction, fluids were not left at the bedside without being calculated into the daily fluid restriction, and fluid restriction for each shift was consistently followed per physician's orders; B. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the Physician signed and dated all orders for one Resident (#14), out of a total sample of 21 residents.

Inspectors wroteBased on document review and interview, the facility failed to ensure residents were provided Physician/Nurse Practitioner (NP) visits every 30 days within the first 90 days of admission and then every 60 days thereafter for three Residents (#1, #43, and #14), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #1, to ensure the Resident was seen at least every 30 days for the first 90 days of his/her admission to the facility; 2. For Resident #43, to have visits completed by the Physician or NP every 60 days; and 3. For Resident #14, to ensure the Resident was provided oversight of their care and visits by a clinician.

Inspectors wroteBased on record review and interview, the facility's Consultant Pharmacist failed to identify irregularities in medications during the monthly Medication Regimen Review (MRR) for two Residents (#30 and #1), out of a total sample of 21 residents. Specifically, the facility failed to ensure: 1. For Resident #30, the Pharmacist reviewed and reported irregularities related to the administration of a pain medication; and 2. For Resident #1, the Pharmacy consultant identified a lack of rationale documentation for the ongoing use of an as needed (PRN) psychotropic benzodiazepine/anti-anxiety medication.

Inspectors wroteBased on observation, interview, and document review, the facility failed to follow professional standards of practice for food safety to prevent the potential of foodborne illness to residents who are at high risk. Specifically, the facility failed to: 1. Properly label and date food products stored in the free-standing refrigerators in the main kitchen and discard food when past their use by date; 2. Ensure food was properly stored in the walk-in freezer in the main kitchen; and 3. Ensure food was discarded when past their manufacturer's expiration date in one of two resident nourishment kitchen refrigerators reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure medications were not self-administered without a physician's order and an assessment for self-administration was completed for two Residents (#58 and #73), out of a total sample of 21 residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure one Resident (#11), out of a total sample of 21 residents, had their call light accessible and within reach in order to utilize to call for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the Physician and/or responsible party of recommendations or changes in condition for two Residents (#43 and #1), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #43, to notify the physician/physician extender of STAT x-ray (a medical imaging technique that uses electromagnetic radiation to create images of internal structures in the body) results in order to make a treatment decision; and 2. For Resident #1, to notify the attending physician group of Resident #1 exceeding their daily fluid restriction of 1200 milliliters (ml) a day.

Inspectors wroteBased on observation and interview, the facility failed to maintain an environment that was free of accidents and hazards on one ([NAME] Unit) out of three units. Specifically, the Nurse failed to secure an insulin vial in her medication cart while not in her sight leaving it accessible to residents in the immediate vicinity.

Inspectors wroteBased on observations, interviews, and records reviewed for two Residents (#30 and #57) of 21 sampled residents, the facility failed to ensure that pain management was provided to the Resident consistent with professional standards of practice, the comprehensive person-centered care plan, and the Resident's goals and preferences. Specifically, the facility failed: 1) For Resident #30, to administer his/her prescribed, as needed, opioid (pain medication) medication in accordance with physician's orders and implement a comprehensive person-centered care plan addressing his/her pharmacological and non-pharmacological needs; and 2) For Resident #57, to administer his/her prescribed, as needed, opioid medication in accordance with physician's orders.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that one Resident (#43), out of a total sample of 21 residents, was free from unnecessary medication administration. Specifically, the facility failed to ensure the Resident was not treated with two different antibiotics (Augmentin and Bactrim) by two different clinicians concurrently without adequate indications for their use.

Inspectors wroteBased on record review and interview, the facility failed to ensure for two Residents (#78 and #1), out of a total sample of 21 residents, that each Resident's drug regimen was free from unnecessary psychotropic medications. Specifically, the facility failed: 1. For Resident #78, to monitor the Resident for potential adverse consequences for the use of antianxiety medication; and 2. For Resident #1, to ensure a documented rationale was in place for the ongoing extended use of an as needed (PRN) psychotropic benzodiazepine/anti-anxiety medication.

Inspectors wroteBased on record review and interview, the facility failed to maintain an accurate up to date medical record for one Resident (#1), out of a total sample of 21 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed for one Resident (#72), out of a total sample of 21 residents, to ensure that staff performed hand hygiene after doffing (removing) gloves and prior to donning (putting on) new gloves during a wound dressing change to help prevent the potential for healthcare-associated infections.

Inspectors wroteBased on interview, record review, and document review, the facility failed to implement their antibiotic stewardship program by failing to monitor the use of dual antibiotics for one Resident (#43), who did not meet criteria for a urinary tract infection (UTI) using the facility's pre-defined McGeer criteria, out of a total sample of 21 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the availability of statements of deficiencies and plans of correction from complaint investigations conducted since the previous recertification survey were prominent and readily accessible to residents, family members, and legal representatives of residents without having to ask to see them, as required.

Inspectors wroteBased on interviews and review of the Health Care Facility Reporting System (HCFRS- State agency reporting system), the facility failed to provide written notice to the State agency when a change in the facility's Administrator occurred.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP) and had been admitted on to Hospice Services, the Facility failed to ensure nursing immediately notified his/her Health Care Agent (HCA), when on 08/21/24, Resident #1 was found lying in a bathtub, with his/her clothes on, cold water was running out from the tub faucet, and he/she was noted to be surrounded in about three inches of cold water. Resident #1's HCA as not made aware of the incident until close to six hours later, when the Hospice Nurse notified her.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was found lying in a bathtub in three inches of cold water with his/her clothes on, was observed by staff to be visibly cold, was shivering and cold to the touch, the Facility failed to ensure that he/she was provided with nursing services that met acceptable standards of practice related to nursing assessment of his/her vital signs (indicators of body's basic functions and help assess the general physical health) immediately after the incident.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who had been admitted on to Hospice Services, the Facility failed to ensure nursing immediately communicated to the Hospice an incident that occurred with a need to potentially alter his/her plan of care, when on 08/21/24, Resident #1 was found lying in a bathtub, fully clothed, with the cold water faucet running, he/she was surrounded by three inches of cold water, was observed by staff to be visibly cold, was shivering, and was cold to the touch, however the Hospice Agency was not notified of the incident until six hours later, when the Hospice Nurse arrived at the facility.

Inspectors wroteBased on observations, interviews, and policy review, for six Residents (#16, #19, #47, #23, #40, and #30), out of a total sample of 19, the facility failed to ensure reasonable accommodations were made. Specifically, the facility failed to ensure the call system button was accessible to Residents to call for assistance per facility policy.

Inspectors wrote2. Resident #75 was admitted to the facility in May 2023. Review of the comprehensive admission MDS assessment from May 2023 indicated Resident #75 had obvious or likely cavity or broken natural teeth. Review of the nursing Oral Health Assessment, dated 12/2/23, indicated Resident #75 had natural teeth which were unhealthy with decay or very worn down. Review of the nursing progress notes indicated on 12/4/23 Resident #75 had a bloody nose and blood coming from his/her mouth. The note indicated upon assessment the nurse noted one of the front bottom teeth had cracked and come out. The note indicated the area had stopped bleeding, but there continued to be swelling. Review of the medical record on 12/22/23 failed to include a care plan with goals and interventions regarding the poor dentition for Resident #75. [...]

Inspectors wroteBased on staffing time sheets and interviews, the facility failed to ensure staffing included the services of a Registered Nurse (RN) for a minimum of eight consecutive hours a day, seven days a week as required. Specifically, between July 1, 2023 through September 30, 2023 there was no RN coverage in a 24-hour period for 11 out of 92 days and between December 1, 2023 and December 25, 2023 there was no RN coverage in a 24-hour period for 2 out of 25 days.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to store and serve food in accordance with professional standards for food safety in two out of two nourishment kitchenettes. Specifically, the facility failed to properly label and date resident items in unit refrigerators, as well as maintain safe and clean equipment.

Inspectors wroteBased on document review, policy review, record review, and interviews, the facility failed to maintain an infection prevention and control program as dictated by their infection control plan and policies. Specifically, the facility failed to maintain complete and accurate surveillance line listings and analyze their collected surveillance data to identify any trends of actual or potential infections within the facility to validate the effectiveness of their program.

Inspectors wroteBased on interviews and record review, the facility failed to notify the Health Care Proxy (HCP) of Resident #75 when the Resident broke a tooth, requiring dental follow-up. The total sample was 19 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident (#55), out of a total sample of 19 residents, was referred for a Level II Preadmission Screening and Resident Review (PASRR) evaluation (an evaluation to determine if a resident needs specialized services to address his/her Serious Mental Illness (SMI)).

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to provide necessary respiratory care and services for two Residents (#50 and #70), out of a total sample of 19 residents. Specifically, the facility failed: 1. For Resident #50, to ensure oxygen tubing and filters were changed and cleaned weekly; and 2. For Resident #70, to maintain oxygen equipment for respiratory care consistent with professional standards.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to provide behavioral health services for one Resident (#55), out of a total sample of 19 residents.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to ensure pharmacy recommendations from medication regimen reviews (MRR) were reviewed and addressed timely for one Resident (#2), out of a total sample of 19 residents.

Inspectors wroteBased on record review, policy review, and staff interviews, the facility failed to monitor for signs/symptoms of adverse consequences (i.e., side effects) of an anticoagulant agent (blood thinner) prescribed for one Resident (#46), out of a total sample of 19 residents.

Inspectors wroteBased on record review, policy review, and staff interviews, the facility failed to ensure that as needed (PRN) psychotropic medication for one Resident (#9), out of a total sample of 19 residents, was prescribed with a 14-day duration order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to facilitate dental services for one Resident (#75), out of a total of 19 residents.