The Grove Care and Wellness

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing services were provided in accordance with professional standards of practice and facility's policy and procedure, when a licensed nurse failed to verify G-tube (gastrostomy tube - a soft plastic tube inserted through the abdomen directly into the stomach, which provides a direct route for liquid nutrition, hydration, and medications when a person cannot eat or drink safely by mouth) placement and assess for gastric residual (the volume of fluid-comprising food, water, medication, and digestive secretions-remaining in the stomach of a patient receiving tube (enteral) feeding) prior to administering medications through the G-tube, for one of one resident (Resident 12) observed receiving medications through the G-tube. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) recommendation by the pharmacy consultant to evaluate the use of heparin (an injectable anticoagulant {blood thinner} used to prevent and treat blood clots in blood vessels, the heart and the lungs) was acted upon by the physician, for one of six residents reviewed (Resident 12) for the use of unnecessary medication. This failure has the potential to place Resident 12 at high risk for complications related to heparin use.

Inspectors wroteBased on observation and interviews, the facility failed to ensure the food preferences were honored and provided, for one of 32 sampled residents (Resident 17), when the resident was served food listed in the food dislikes. This failure had the potential for Resident 17 to reduce their nutritional intake, which may have adversely impacted on their nutritional status and compromised their overall medical condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation was conducted to address a grievance filed regarding care provided, for one of three residents reviewed (Resident A), when Resident A notified the facility staff that the Registered Nurse smelled alcohol while providing care to her. This failure resulted in Resident A's grievance not being investigated in a prompt manner and the resident was fearful of the RN caring for her. In addition, this failure had the potential for other residents' psychosocial well-being to be affected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure transmission-based precautions (additional infection control measures used for patients with suspected or confirmed highly transmissible pathogens) were implemented according to the facility's policy and procedure, for two of three residents reviewed (Residents A and B). This failure had the potential for Residents A and B to be exposed to further infections.

Inspectors wroteBased on interview and record review, the facility failed to develop a plan of care (POC) with specific goals and objectives to address the injury, for one of four sampled residents (Resident 4) when Resident 4's rib fracture was identified. This failure had the potential for Resident 4 not to receive appropriate interventions tailored to her needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food practices were provided, when: 1. Lettuce and stalks of celery were found in the walk-in refrigerator, open to air; 2. A small container of elbow macaroni was not dated or labeled; and 3. One tin container was placed on top of another tin container touching cut up watermelon. These failures had the potential to cause growth of harmful bacteria in food served to a medically compensated population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was developed and implemented to address a personal monitoring device used to measure blood glucose levels, for one of 15 residents (Resident 14). This failure had the potential for staff to not be aware of Resident 14 care needs and provide appropriate treatment related to the blood sugar monitoring device.

Inspectors wroteBased on observaton, interview, and record review, the facility failed to ensure care and treatment was provided according to the physicians orders and plan of care, for two of 15 residents (Residents 14 and 286) when: 1. For Resident 14 and 286, the blood sugar levels were outside of the parameters and; 2. For Resident 14, the blood pressure (B/P - force exerted by blood against the walls of the arteries) was not monitored prior to administering the medication to treat high blood pressure. These failures had the potential for a delay in care and treatment and could cause a decline in the residents overall health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents, when Resident 18 was missing documentation for the administration of a controlled substance (CS - those with high potential for abuse and addiction) medications, during the medication cart inspection. The CS medication was signed out of the Controlled Medication Count Sheet (an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate it was administered to the resident. Additionally, the CS medication was wasted (not administered to the resident and discarded) without two licensed nurses' documentation on the count sheet according to the facility's policy for Resident 18. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR), for one of five residents reviewed for unnecessary medications (Resident 10), when Resident 10 received sertraline (brand name for Zoloft, medicatuion used to treat depression) without an appropriate indication and/or clinical justification for its use. This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure, one of five residents reviewed for unnecessary medications (Resident 10), was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when Resident 10 was administered sertraline (brand name Zoloft, used to treat depression) without an appropriate indication and/or clinical justification for its use. This failure resulted in unnecessary medications for Resident 10, which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of sertraline that included but not limited to sexual dysfunction, diarrhea, nausea, and seizures.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure infection control practices were followed when the Certified Nursing Assistant (CNA) was observed not to perform hand hygiene prior to and after passing out lunch trays. This failure had the potential for staff to spread infection to residents who are already medically compromised.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse to the State Agency (SA) as required within two hours, for one of two residents reviewed (Resident 2). This failure had the potential to put residents at risk for further abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure necessary treatment and services to promote healing of pressure injuries (a localized area of skin damage caused by prolonged or intense pressure on the skin, often over bony parts of the body) are provided in a timely manner, for one of three residents (Resident A), when: - The pressure injury on the sacral area (lower portion of spinal column) was not identified on admission and treatment orders not initiated timely; and - Treatment orders were not administered as ordered by the physician. These failures had the potential in the delay in care and treatment of Resident A's pressure injury which could affect healing.

Inspectors wroteBased on interview and record review the facility failed to ensure a change in cognitive status was addressed, for one of three residents reviewed (Resident A), when Resident A exhibited hallucinations (a perception of having seen, heard, touched, tasted, or smelled something that wasn't actually there) and increasing confusion. In a addition, there was no plan of care developed to address Resident A's hallucinations and confusion. This failure resulted in a delay in the care and treatment for Resident A when the resident was transferred to the general acute hospital three days after onset of hallucinations and increasing confusion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe, sanitary food preparation and storage practices were followed in the kitchen when: 1. Clean water pitchers were stored on dirty grey plastic shelves; 2. Dust was observed in several kitchen and storage areas, equipment, and ventilation vents; 3. Four rusting silver storage shelves were found in the disposable item storage room; 4. One roast beef was observed defrosting in a shallow two-inch pan; 5. Two Dietary Aides (DA) were observed with their hair not fully covered with hair net; and 6. Several open packages of food items were observed in the walk-in-freezer. These failures had the potential to cause food-borne illnesses in a highly susceptible resident population.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to follow the policy and procedure to provide an environment free of pests, when fruit flies and one mosquito were observed flying and landing in the kitchen. This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in the facility residents who eat food prepared in the kitchen.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. Dietary Aide (DA) 1 did not follow manufacturer's guideline time length for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces). 2. Certified Dietary Manager (CDM) was unable to accurately verbalized how long the [NAME] test strip need to dip into the red bucket Quat sanitizer for testing the concentration of Quat sanitizer. 3. DA 3 did not follow manufacturer's guideline time length for placing kitchen wares into sanitizing solution in sanitizer sink. 4. DA 3 was unable to accurately test the sanitizing solution in sanitizer sink. 5. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the cleanliness of their reusable equipment, when seven clean oxygen concentrators (a medical device that gives patients extra oxygen) and two Intravenous (IV) poles (a medical device used to hang medicine to administer to patients) were observed partially covered and found in the soiled linen room. This failure had the potential for the transmission of microorganisms from the contaminated linen to residents during the delivery of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was sufficiently prepared for a scheduled colonoscopy (a procedure in which a flexible fiber-optic instrument is inserted through the anus in order to examine and take pictures of large intestines), for one of 12 residents reviewed (Resident 5), when the bowel preparation medications were not administered according to the physician's orders. This failure resulted in Resident 5 not being adequately clear of her bowels, prompting the family member (FM) to cancel the scheduled colonoscopy, resulting in a delay of care for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was receiving dialysis (the process of removing waste products and excess fluid from /the body when the kidneys are not able to adequately filter the blood) received more than the prescribed fluid per day, for one of two sampled residents reviewed for dialysis (Resident 285) (Cross Reference F656). This failure placed Resident 285's care needs to go unmet and had the potential to result in fluid overload.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were no expired intravenous (IV- within a vein) supplies in the IV cart. This failure had the potential to expose residents to bloodborne pathogens (infectious germs in the blood) and diseases.

Inspectors wroteBased on observation, interview, and record review the facility failed to evaluate the status and to document weekly assessments for one of three sampled residents' (Resident 1) right big toe discoloration, in accordance with the facility's policy and procedures. This failure led to facility staff being unaware of the changes in the condition of Resident 1's right big toe, which could delay the provision of the appropriate treatment resulting in worsening of the resident's wound.