The Grove at Carvalho

Based 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). Findings include: Review of the facility's policy titled Complaint/Grievance Policy Procedure, dated September 2023, indicated but was not limited to: - Voiced grievances (e.g. those about treatment, care, management of funds, lost clothing, or violation of rights) are not limited to a formal, written process and may include a resident's verbalized complaint to facility staff. - Grievance/Complaint forms will be available at the nurse's station or other designated area. - Residents and/or their responsible representative shall complete the form. - If a resident is unable to complete the form, a staff member shall assist them. - Staff shall complete…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. For Resident #50, to implement the Resident's nutritional care plan related to a fluid restriction; and 5. For Resident #72, to develop and implement a care plan for the resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. For Resident #1, to ensure that staff consistently implemented the prescribed fluid restriction of 1200 ml a day for the Resident who was on hemodialysis; 3. For Resident #43, to ensure injection sites for subcutaneous (SC-insertion…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled Medication Orders, undated, indicated but was not limited to: -Supervision by a Physician: -Physician orders/Progress notes must be signed and dated every thirty (30) days. (Note: this may be changed to every sixty (60) days after the first ninety (90) days of the resident's admission) Resident #14 was admitted to the facility in August 2016 and has diagnoses including diabetes mellitus, chronic kidney disease, major depression with severe psychotic symptoms, and bipolar disorder. Review of the medical record, Electronic Medical Record (EMR), and the Order Review History report, indicated the Resident's Physician last signed the Resident's orders on 11/8/24. There were no additional orders signed by the Physician. During an interview on 2/19/25 at 1:59 P.M., the Director of Nursing (DON) reviewed Resident #14's medical record and said the last signed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled Physician Visits and Physician Delegation Policy, dated as revised January 2025, indicated but was not limited to the following: - It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents - the physician should see the residents within 30 days of admission, and the resident must be seen at least once every 30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled Consultant Pharmacist Services Provider Requirements, effective date January 2024, indicated but was not limited to: - The consultant pharmacist provides consultation on all aspects of the provision of pharmacy services in the facility. In collaboration with facility staff, the consultant pharmacist helps to identify, communicate, address, and resolve concerns and issues related to the provision of pharmaceutical services. This…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of a facility document titled Labeling and Dating Inservice, undated, indicated but was not limited to the following: Guidelines for Labeling and Dating: -All foods should be dated upon receipt before being stored. Food labels must include: -The food item name -The date of preparation/receipt/removal from freezer -The use by date as outlined in the attached guidelines -Leftovers must be labeled and dated with the date they are prepared and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to: - Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of the facility's policy titled Self-Administration of Medications, undated, indicated but was not limited to: - Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for residents to do so. - As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled Resident Call System, undated, indicated but was not limited to the following: - The facility will be equipped with a communication to ensure residents have the ability to contact a staff member for assistance from their bedside and from toilet and bathing areas. - When in their rooms and toilet and bathing areas, residents will have a means of directly contacting caregivers. Resident #11 was admitted to the facility in July 2014 with diagnoses including Alzheimer's disease, history of falling, and anxiety. Review of Resident #11's Minimum Data Set (MDS) assessment, dated 11/17/24, indicated he/she had a severe cognitive deficit and required extensive assistance for activities of daily living. During the following days and times, the surveyor made the following observations: - On 2/12/25 at 8:05…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility's policy, Change in a Resident's Condition or Status, last revised November 2015, indicated but was not limited to: -The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: -A need to alter the resident's treatment significantly -Refusal of treatment or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility's policy titled Administering Medications, undated, indicated but was not limited to: -During administration of medications, the medication cart is kept locked and closed when out of sight of the medication nurse or aide. -No medications are kept on top of the cart. -The cart must be inaccessible to residents or others passing by. Review of the facility's policy titled Storage of Medications, undated, indicated but was not limited to: -Drugs and biologics used in the facility are stored in locked compartments. -Only persons authorized to prepare and administer medications have access to locked medications. On 2/13/25 at 8:56 A.M., the surveyor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled Pain Assessment and Management, undated, indicated but was not limited to the following: - Purpose: the purposes of this procedure are to help staff identify pain in the resident, and to develop interventions that are consistent with resident's goals and needs and that address the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the USAntibiotics website indicated that to reduce the development of drug-resistant bacteria and maintain the effectiveness of AUGMENTIN and other antibacterial drugs, AUGMENTIN should be used only to treat infections that are proven or strongly suspected to be caused by bacteria. Review of the [NAME] Pharmaceuticals website indicated that to reduce the development of drug-resistant bacteria and maintain the effectiveness of BACTRIM and other antibacterial drugs, BACTRIM tablets should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled Use of Psychotropic Medication, dated December 2024, indicated: - Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). 1. Resident #78 was admitted to the facility in July 2024 and had diagnoses including major depressive disorder and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Resident #1 was admitted to the facility in October 2024. During an interview on 2/13/25 at 1:10 P.M., Nurse #3 said all Physician and Nurse Practitioner (NP) progress notes are scanned into the electronic medical record under the tab labeled Miscellaneous. Review of the Miscellaneous section of Resident #1's medical record on 2/13/25 indicated only one progress note was available since the Resident's admission, completed by NP #2 and dated 11/27/24. Review of the census section of Resident #1's medical record indicated they had a paid hospital leave since their admission in October 2024 but has remained an active Resident since that admission. During an interview on 2/18/25 at 10:32 A.M., the Medical Records Clerk said the Physicians and NPs send their progress notes to the facility receptionist by email and then the receptionist places them in the correct resident records. She said although she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of Lippincott Nursing Procedures, Eighth Edition. [Philadelphia; Wolters Kluwer, [2019], indicated, but was not limited to the following: - Hand Hygiene is a general term used by the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) to refer to hand washing, antiseptic hand washing, and antiseptic hand rubbing. Hand hygiene is the single most important procedure in preventing infection. Using an alcohol-based hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled Infection Prevention and Control Program, undated, indicated but was not limited to the following: - The elements of the infection prevention and control program consist of oversight, coordination, policies/procedures, surveillance, data analysis antibiotic stewardship, outbreak management and prevention of infection and employee health and safety. Antibiotic Stewardship: - culture reports, sensitivity data and antibiotic usage reviews are included in surveillance activities - medical criteria and standardized definitions of infections are used to help recognize and manage infections - antibiotic usage is evaluated and practitioners are provided feedback on reviews Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the Facility's policy, titled Notification of Changes, dated as revised March 2024, indicated the following: -the facility will promptly contact and consult the resident's physician, notify the resident's representative when there is a change requiring notification; -circumstances requiring notification include significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status; -for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the Facility Policy titled, Nursing Examination and Assessment, undated, indicated the following: -examine and assess the resident for any abnormalities in health status; -physical examination, obtain vital signs: blood pressure, pulse, respirations and temperature; -document all assessment data obtained in the resident's medical record; -notify the physician of any abnormalities such as abnormal vital signs. -report other information in accordance with facility policy and professional standards of practice. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the Facility's policy, titled Coordination of Hospice Services, dated as revised March 2024, indicated the following: -the facility will coordinate and provide care in cooperation with hospice staff; -the facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility; -the facility will immediately contact and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled Answer the Call Light, effective date 12/21/22, indicated but was not limited to the following: - The purpose of this procedure is to respond to the resident's requests and needs - When the resident is in the bed or confined to a chair be sure the call light is within easy reach of the resident. - Some residents may not be able to use their call light. If this is the case, another type of call light, a bell, or a buzzer may be appropriate. 1. Resident #16 was admitted to the facility in July 2014 with diagnoses which included unspecified dementia. Review of the most recent Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 99, which indicated the Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

2. 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. During an interview on 12/22/23 at 12:10 P.M., the Assistant Director of Nurses said Resident #75 had broken a tooth earlier in the month. She said there had been no care plan in place prior to the surveyor inquiry. Based on record review, policy review, and staff interviews,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the nursing schedules, timecards and agency staffing from July 1, 2023 through September 30, 2023 indicated there was no Registered Nurse coverage during the day, evening or night shift for the following days: - July 8, 2023 - July 9, 2023 - July 14, 2023 - August 6, 2023 - August 19, 2023 - August 20, 2023 - August 25, 2023 - September 3, 2023 - September 4, 2023 - September 16, 2023 - September 17, 2023 During an interview on 12/26/23 at 2:53 P.M., the Administrator said there was no RN for eight consecutive hours on the days identified in July, August, and September 2023. Review of the nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility's policy titled Food Brought in By Family/Visitors, dated as last revised on 1/1/20, indicated but was not limited to: - To allow residents to consume food safely that is brought in by families/visitors and/or outside vendors. - Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. - Perishable foods will be discarded on or before the use by date. - The nursing and/or food service staff must discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: Review of the facility's policy titled [NAME] Grove: Infection Control and Prevention Program, undated, indicated but was not limited to the following: - the infection preventionist (IP) is responsible for the integrity of the infection control program, and ensuring that integral parts of surveillance, tracking and trending are in place - the Director of Nurses (DON) participates in the assessment or analysis of the key processes of the infection prevention and control program - the IP conducts surveillance for facility associated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Resident #75 was admitted to the facility in May 2023. Review of the comprehensive admission Minimum Data Set from May 2023 indicated Resident #75 had obvious or likely cavity or broken natural teeth. Review of the Social Service progress note from 11/13/23 indicated the HCP for Resident #75 had requested the Resident be seen by a dentist. 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. During an interview on 12/26/23 at 4:00 P.M., the HCP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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)). Findings include: Review of the facility's policy titled PASRR, last revised 11/01/21, included but was not limited to the following: -when an individual who resides in a nursing facility has experienced a significant change or the individual is newly identified as having a condition that may impact the individual's PASRR disability status, the appropriateness of the individual's nursing facility placement or the individual's need for specialized services the facility must submit a PASRR -in all instances the nursing facility (NF) must request a resident review from the PASRR office no later than the next business day following the date on which the facility detects that the member: experienced a significant change or is newly identified as having a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled O2 Safe Solutions Equipment Changing, undated, included but was not limited to: - All respiratory therapy equipment must be changed in order to prevent nosocomial infections. - The equipment should be marked with the date it was changed. - All equipment should be changed on a weekly basis as well as prn if it becomes soiled or falls on the ground. The equipment includes but is not limited to: (1) nasal cannulas, (3) nebulizer treatment equipment. Review of the facility's policy titled Oxygen Administration Policy and Procedures, dated 12/6/22, included but was not limited to: - Oxygen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled Behavioral Health Services, dated as revised on 12/7/21, indicated but was not limited to the following: -The facility will initiate referrals to psychiatric services, having the resident or responsibly party signed consent, as behavioral health concerns are identified. -The facility will ensure that, a resident who displays or is diagnosed with a mental disorder, psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services. -The resident will receive and the facility will provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Resident #55 was admitted to the facility in November 2023 with diagnoses which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled Consultant Pharmacist Services Provider Requirements, undated, indicated but was not limited to the following: -The consultant pharmacist documents activities performed and services provided on behalf of the residents and the facility. -A written or electronic report of findings and recommendations resulting from the activities as described above is given to the attending physician, director of nursing, medical director and others as may be appropriate (e.g. administrator, regional manager, etc.) at least monthly. -The facility has a process to ensure that the findings are acted upon. -Resident-specific recommendations are documented (in the resident's active record). Resident #2 was admitted to the facility in April 2018 with diagnoses of major depressive disorder and anxiety. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled Anticoagulant Policy, dated as revised 10/10/22, indicated but was not limited to: -Anticoagulants are medicines that help prevent blood clots. They are given to people at a high risk of getting clots, to reduce their chances of developing serious conditions such as strokes and heart attacks. -All residents receiving anticoagulants will be monitored for abnormal signs/symptoms of bleeding. The Physician/Designee will be updated on any abnormal signs/symptoms of bleeding for further treatment/monitoring follow up. Resident #46 was admitted to the facility in February 2023 with diagnoses which included acute thrombosis (clotting of the blood). Review of the Minimum Data Set (MDS) assessment, dated 11/4/23, indicated Resident #46 had a Brief Interview for Mental…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Review of the facility's policy titled Use Psychotropic Drugs, dated 12/6/21, indicated but was not limited to: -A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotic, antidepressants, anti-anxiety, and hypnotics. -The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regime in collaboration with residents, their families and/or representatives, or other professionals, and the interdisciplinary team. -PRN orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e., 14 days).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to facilitate dental services for one Resident (#75), out of a total of 19 residents. Findings include: Resident #75 was admitted to the facility in May 2023. Review of the medical record indicated Resident #75 had an activated Health Care Proxy (HCP) who had signed the consent form for dental service in May 2023. Review of the comprehensive admission Minimum Data Set (MDS) assessment from May 2023 indicated Resident #75 had obvious or likely cavity or broken natural teeth. Review of the Social Service progress note from 11/13/23 indicated the HCP for Resident #75 had requested the Resident be seen by a dentist. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.