The Grove Post Acute

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident and/or resident's representative were notified of changes of care and services for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1 and/or Resident 1's representative was notified and provided with information when Lispro (a fast-acting insulin used to control high blood sugar) was discontinued and Jardiance (a medication used to help control blood sugar level) was initiated. This failure had the potential to place the resident and/or the resident's representative at risk of not receiving adequate information needed to make informed decisions regarding the resident's care.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) was readmitted back to the facility. * The facility failed to readmit Resident 1 back into the facility during the seven-day bed hold period. This failure had the potential for Resident 1 to have an inappropriate discharge.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the proper discharge process was followed for three of four sampled residents (Residents 1, 2 and 3) when they were transferred/discharged from the facility. * The facility failed to show Resident 1's written Notice of Transfer/Discharge was provided to the resident upon transfer to acute care. * The facility failed to show Resident 1 was provided with written information about the bed-hold information upon the resident transferring to an acute care hospital. *The facility failed to show the Ombudsman was notified of Residents 1, 2, and 3's transfer/discharge. These failures had the potential for the residents not receiving accurate information about their transfer/discharge status and their rights.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the call light system was functioning for one of six sampled residents (Resident 2). * Resident 2's call light was not working when it was pressed. This failure had the potential for delayed provision of assistance to the resident.

Inspectors wrote5. Review of the facility's document titled Daily Spreadsheet, Korean Menu - Spring 2025 Week 1 Tuesday - Day 3, showed the following menu for Tuesday's (6/17/25) lunch for the pureed diet: - Pureed spinach doenjang soup - Pureed kimchi - Pureed dak bulgogi (Korean BBQ chicken) - Pureed steam white rice; and - Pureed stir-fried cabbage. a. Medical record review for Resident 27 was initiated on 6/16/25. Resident 27 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 27's Order Summary Report showed a physician's order dated 9/16/24, for a regular diet pureed texture. Review of Resident 27's Nutrition Progress Note dated 6/2/25 at 1716 hours, showed Resident 27 preferred Korean food for lunch and dinner. On 6/17/25 at 1320 hours, an observation was conducted of Resident 27. Resident 27 was observed lying in bed asleep. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure the foods in the kitchen were properly labeled and dated, and the expired items were thrown out. * The facility failed to ensure the kitchen utensils and equipment were clean and not worn out. * The facility failed to ensure the cutting boards were in sanitary condition. * The facility failed to ensure the refrigerator used to store residents' food from the outside was clean. * The facility failed to ensure the handwashing signage was posted and visible at the handwashing station in the kitchen. * Two pieces of bananas on Resident 22's bedside table were unlabeled and dated. [...]

Inspectors wroteBased on interview, medial record review, and facility P&P review, the facility failed to obtain and/or maintain the copies of the advance directive in the medical record for one of two final sampled residents (Resident 52) reviewed for advance directives. This failure had the potential for the resident's decisions regarding their healthcare and treatment not being honored.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to determine whether a resident's grievance allegation was resolved in accordance with the facility's P&P for one of 19 final sampled residents (Resident 53). * Resident 53 stated on 5/9/25, she sustained a skin abrasion to her thigh after a CNA changed her soiled adult brief. Resident 53 stated she sustained the abrasion form a towel the CNA used to clean her. Resident 53 stated the CNA was too rough and hard with the towel when cleaning her. Resident 53 stated the facility failed to address her concern (after having informed the facility on 5/9/25) thus she informed the facility again during a resident council meeting held on 6/12/25. Resident 53 stated the facility has yet to address her concern. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 1) reviewed for unnecessary medications was free from the unnecessary psychotropic medications. * The facility failed to ensure the non-pharmacological interventions were implemented prior to to the administration of the temazepam (a sedative medication used to relieve difficulty of falling asleep) to Resident 1. This failure had the potential to negatively affect the resident's well-being and had the potential for adverse effects from the psychotropic medications.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was developed for one of 19 final sampled residents (Resident 40) and two nonsampled residents (Residents 27 and 96). * The facility failed to develop a care plan specific to Residents 27 and 96's preference for Korean food and the residents were subsequently served American food. * The facility failed to develop a care plan problem to address Resident 40's food allergies to shrimp. These failures placed the residents at risk for not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the appropriate care and services to prevent UTI for one of one final sampled resident (Resident 68) reviewed for urinary catheter or UTI. * Resident 68 had an indwelling urinary catheter (an indwelling catheter used to drain urine from the bladder) and a history of recurrent UTIs. The facility failed to ensure proper positioning of Resident 68's urinary drainage bag to prevent urine from flowing back into the bladder. This failure posed the risk for Resident 68 to develop a CAUTI.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the physician's order for the oxygen therapy was followed for one of one final sampled resident reviewed for oxygen therapy (Resident 70). This failure had the potential to affect the respiratory health and well-being of Resident 70.

Inspectors wroteBased on interview, medical record review, and facility's P&P review, the facility failed to provide the adequate and appropriate pain management for one of one final sampled resident reviewed for pain management (Resident 49). * The facility failed to ensure an accurate pain level was assessed and documented prior to the administration of the pain medication for Resident 49. * The facility failed to ensure non-pharmacological interventions were provided prior to the administration of the pain medication for Resident 49. These failures had the potential for Resident 49 to not receive the appropriate pain management.

Inspectors wrote5. Medical record review for Resident 50 was initiated on 6/16/25. Resident 50 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 50's Order Summary Report showed a physician's order dated 1/3/24, for insulin glargine 23 units to be administered by subcutaneous injection at bedtime for diabetes. Review of Resident 50's Location of Administration Report for the months of May and June 2025, showed Resident 50's insulin injections sites were not rotated on the following dates and times: - On 5/7/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. - On 5/8/25 at 2100 hours, the insulin glargine was administered subcutaneously to the left lower quadrant of Resident 50's abdomen. [...]

Inspectors wrote3. Review of the facility's P&P titled Medication Storage dated 1/2025 showed outdated, contaminated, or deteriorated medication and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, dispose disposed off according to procedure for medication disposal, and reorder from the pharmacy if a current order exists. On 6/17/25 at 0846 hours, an inspection of Treatment Cart A was conducted with LVN 5. Multiple packets of Dermaseptin ointments and Dermarite Boarder Gauzes, each packaged in separate plastic, were observed without the expiration date. LVN 5 verified the observation and stated multiple staff including other treatment nurses, LVNs, used Treatment Cart A. [...]

Inspectors wrote2. Medical record review for Resident 27 was initiated on 6/16/25. Resident 27 was admitted to the facility on [DATE], and readmitted to the facility on [DATE]. Review of Resident 27's Nutrition Progress Note dated 6/2/25 at 1716 hours, showed Resident 27 preferred Korean food for lunch and dinner. On 6/17/25 at 1320 hours, an observation was conducted of Resident 27. Resident 27 was observed lying in bed asleep. Resident 27's lunch tray was observed on a bedside table adjacent to Resident 27's bed. Resident 27's lunch tray was observed with pureed food items from the American menu (pureed Dijon pork cutlet, pureed orzo with vegetables, and pureed seasoned beets). 3. Medical record review for Resident 96 was initiated on 6/16/25. Resident 96 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 61) observed during the dining observation task received the appropriate mechanically altered diet as ordered by the physician. This failure posed the risk of aspiration and resident's nutritional needs not being met.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. A plan to maximize recruitment and retention of direct care staff; and 4. A contingency plan for staffing needs. This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wrote3. On 6/19/25 at 1129 hours, an observation of the facility's laundry room and concurrent interview was conducted with the Laundry Aide. The counter designated for clean laundry sorting was observed with clean bed linens folded and stacked on top of the counter. The Laundry Aide's cell phone charger, plastic water bottle, and water [NAME] were observed stored on the clean laundry counter adjacent to the clean resident bed linens. The Laundry Aide verified the findings and stated his personal items should not be stored adjacent to resident clean linens. On 6/19/25 at 1133 hours, an interview was conducted with the IP. The IP stated the staff's personal items should not be stored on the residents clean laundry sorting area adjacent to the clean resident laundry, to prevent contamination of the clean residents' laundry from potentially unclean staff personal items. 2. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to offer PCV15 or PCV 20 vaccination to one of five final sampled residents (Resident 23) reviewed for immunizations. * Resident 23 received the PPSV23 vaccine on 12/5/13, however, the facility failed to offer Resident 23 PCV15 or PCV 20 vaccination, in accordance with the facility's P&P and CDC's recommendations. This failure increased the resident's risk for being inadequately vaccinated for the pneumococcal disease and its associated complications.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the reasonable accommodations to meet the needs of two of 19 final sampled residents (Residents 1 and 28). * The facility failed to ensure Residents 1 and 28's bed remote control was within the residents' reach. This failure had the potential to negatively impact the residents' psychosocial well-being or result in a delay to receive care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the MDS was coded accurately for one of 19 final sampled residents (Resident 399). This failure had the potential for the resident to not receive individualized plans of care to address the resident's individual care needs.

Inspectors wroteBased on interview and closed medical record review, the facility failed to ensure the medical record was accurate, for one of three resident closed records. * The facility documented Resident 94's vital signs were obtained on 6/12/25, however, Resident 94 was not in the facility on 6/12/25, having been transferred to the acute care hospital on 6/10/25. This failure had the potentail to negative impact Resident 94's well-being as the medical record information was inaccurate.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of three sampled residents (Residents 1 and 2) were provided the necessary care and services to maintain their ADL capabilities. * The facility failed to ensure Residents 1 and 2's dentures were cleaned and stored properly according to the facility's P&P. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the necessary care and services were provided to meet the needs for one of two final sampled residents (Resident 1). * The facility failed to ensure Resident 1's levothyroxine medication was continued upon his discharge from the acute care hospital. This failure had the potential to affect Resident 1's health and wellbeing.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent the accidents for one of two sampled residents (Resident 1). * The facility failed to conduct the initial fall risk assessment for Resident 1. This failure had the potential for the resident to sustain additional falls and possible injuries.

Inspectors wroteBased on observation, record review, interviews, and facility policy reviews, the facility failed to ensure an assessment was completed before they applied a bolster mattress to 1 (Resident #292) of 1 sampled resident reviewed for physical restraints to determine whether the bolster mattress was a physical restraint.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a level II mental health evaluation was completed for 1 (Resident #4) of 4 sampled residents reviewed for preadmission screening and resident review (PASARR).

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the safe food handling practices and sanitary conditions were maintained in the dietary services as evidenced by: * The facility failed to ensure the food items were labeled with an open date and/or received date, the expired food items and dented cans were discarded, and the food items were not exposed to leaking water from the refrigerator condenser (one of the main operating components that make up the cooling system on a standard refrigerator). The facility also failed to ensure the facility staff's personal food items were not stored in the walk-in refrigerator and dry storage room; and the facility staff's personal belongings were not stored in the food preparation area or on top of the clean towels used for cleaning the surfaces in the kitchen. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement their infection control P&Ps designed to provide a safe and sanitary environment; and help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to implement their P&P related to caring for the residents who were known or suspected to have COVID-19 by donning full PPE as per the facility's P&P. * The facility failed to identify, test, and prevent Legionella (a bacteria that can cause a serious type of lung infection) and other opportunistic waterborne pathogens These failures had the potential for cross-contamination and spread of infectious organisms in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 442) self- administered the medication only as ordered by the physician. * During the medication pass observation, LVN 3 provided ofloxacin solution (antibiotic medication) 0.3 % bottle to Resident 442. Resident 442 self- administered the ofloxacin ear drop medication; however, there was no physician's order for Resident 442 to self-administer the ear drop medication. This failure had the potential risk for Resident 442 for unsafe self-administration of the medication.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to determine whether one of 18 sampled residents (Resident 61) had formulated an advance directives. This had the potential for the resident's decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the physician when one of 18 sampled residents (Resident 1) refused the medication as per their P&P. This failure had the potential risk to affect the resident's health.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to implement the plan of care of one of 18 final sampled residents (Resident 58) related to fall prevention. This posed the risk for the resident to sustain the repeated falls.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the non-pharmacologic interventions were attempted for one of 18 final sampled residents (Resident 16) prior to initiating the use of psychotropic medication (drug that affects brain activities associated with mental processes and behaviors). In addition, the facility failed to monitor Resident 16's targeted behavior for the use of the psychotropic medication. This failure had the potential for unnecessary medications, which placed the resident at risk for experiencing harmful adverse effects from the psychotropic medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 14.81% during the medication administration observations as evidenced by: * Resident 442 had physician's orders to administer fluticasone-salmeterol aerosol powder breath activated (medication that helps control the symptoms of asthma and improve breathing) 500-50 mcg one puff inhale orally two times a day; and ofloxacin solution 0.3 % (used to treat infection of the ear canal) instill three drops in the left ear two times a day for left otitis media ok to use in ear. However, LVN 3 failed to administer the medications as per the facility's P&P. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals as per the facility's P&P in one medication room (Station 1 Medication Room). * The facility failed to ensure Resident 191's medication was disposed after the medication's expiration date. This failure had the potential for the medication to be accidentally administered and/or diverted.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the arbitration agreement was explained to one nonsampled resident (Resident 76). This failure posed the risk for the resident to not have the right to file an appeal if there was any issue of medical malpractice.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement their P&P addressing antibiotic stewardship program designed to monitor infections and implement actions to ensure the appropriate use of antibiotics for one final sampled resident (Resident 30) and five non-sampled residents (Residents 24, 27, 28, 59, and 291) as evidenced by: * The facility failed to ensure the McGeer's criteria was utilized when considering initiation of antibiotic medication and at 72 hours after administration of antibiotic medication, each resident was reassessed for consideration of antibiotic need. The Infection Control Surveillance Log for November 2022 failed show documentation that the residents who were prescribed antibiotic medication had signs and symptoms of the conditions indicated. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the quarterly MDS assessment was completed for one nonsampled resident (Resident 74). This had the potential to not provide appropriate care when there was no MDS assessment information was available.