Ginger Cove

Number of residents sampled: Number of residents cited: Based on record review and staff interview, it was determined that the facility failed to report an allegation of misappropriation of property in a timely manner. This was evident in 1 out of 3 facility reported incidents reviewed during the recertification survey. The findings include: On 11/20/2025 at 2:08 PM, a review of incident #347813 was conducted. The facility reported that Resident #43's family member alleged that the facility misplaced Resident #43's ring. On 11/21/2025 at 11:08 AM, a review of the facility's investigation was conducted. The facility was made aware of the missing ring on 3/26/2025 and the facility made the initial report to Office of Health Care Quality on 4/3/2025. On 11/21/2025 at 12:02 PM, an interview with the Director of Nursing (DON) was conducted. This surveyor questioned the DON on the submission dates for Incident #347813. The DON acknowledged the delay in reporting in a timely manner and stated that the facility realized on 4/3/2025 that the incident should have been reported within 24 hours…

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 and interview it was determined that the facility failed to ensure residents had a homelike environment. This was evident for 3 (#21, #34, and #39) of 16 residents reviewed during the initial pool process. The findings include: An observation of Resident #21's room on 5/28/24 at 12:29 PM revealed the walls on the right side of the hallway had 7 or more black marks varying from light to dark and measuring from 3-12 inches in length. In the bathroom the shower stall had grip strips that were partially peeled up. An observation of Resident #34's room on 5/28/24 at 12:06 PM revealed on the left side of the hallway there were multiple black marks varying from light to dark and measured between 47 inches to 3 inches in length and between the second and third picture hanging in the hallway there were 2 circular black marks measuring about 2 ½ inches. There were black marks on the right side of the hallway between the closet door and the corner wall. The door to the bathroom had two holes the size of a nail head on the right side. Inside the bathroom was a shower stall…

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 medical record review and interview it was determined that the facility failed to have a process in place to ensure that residents and resident representatives received a notice of transfer in writing. (Resident #40 and #246). This was evident in 2 of 3 residents reviewed for hospitalization during the survey. The findings include: 1. Review of Resident #40's medical record on 5/29/24 revealed the Resident was transferred to the hospital on 1/9/24. Further review of Resident #40's medical record revealed the Resident had 2 physician certifications of incapacity. Review of the facility's hospital transfer documents on 5/29/24 revealed no written notification to the Resident's representative of the transfer to the hospital on 1/9/24. On 6/3/24 at 11:05 AM, Interview with the Director of Nursing (DON) confirmed the facility staff failed to provide written notification to Resident #40's Representative of transfer to the hospital on 1/9/24. 2. An attempt to review the electronic medical record (EMR) on 5/31/24 at 10:30 AM revealed Resident #246 could not be viewed by 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 record review and staff interview it was determined that the facility failed to have a process in place to ensure that residents and resident representatives received the bed hold policy in writing within 24 hours after being sent to the hospital (Resident #40 and #246). This was evident for 2 of 3 resident records reviewed for hospitalization during an annual survey. The findings include: Bed hold notice includes providing written information to the resident; and bed charges, including the duration, during which the resident is permitted to return and resume residence in the nursing facility. 1. Review of Resident #40's medical record on 5/29/24 revealed the Resident was transferred to the hospital on 1/9/24. Further review of Resident #40's medical record revealed the Resident had 2 physician certifications of incapacity. Review of the facility's hospital transfer documents on 5/29/24 revealed no evidence that the Resident or representative received a bedhold notice on 1/9/24. Interview with the Director of Nursing on 6/3/24 at 11:05 AM confirmed the facility staff failed…

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 interview it was determined that the facility failed to have a process in place to ensure that a baseline care plan was provided to the resident and resident representative within 48 hours of admission to the facility (Resident #40 and #42). This was evident for 2 of 4 residents reviewed for baseline care plans during an annual survey. The findings include: The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. 1. Review of Resident #40's medical record on 5/29/24 revealed the Resident was admitted to the facility on [DATE] from the hospital and the facility staff developed a baseline care plan on 1/5/24. Further review of Resident #40's medical…

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 medical record review and interview with the resident and staff it was determined the facility staff failed to ensure residents' plans of care included individual resident care needs and interventions to assist each resident in reaching their highest practicable level of wellbeing. This was evident for 1 (#10) of 1 resident reviewed for Dialysis. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. In an interview on 5/29/24 at 10:36 AM, Resident #10 revealed he/she received dialysis 3 times per week. When asked if he/she was on a specialized diet he/she indicated yes but did not know what it involved. Resident #10 also stated he/she was on a fluid restriction but didn't know what the restriction was. Review of Resident #10's medical record on 6/3/24 at 9:37 AM revealed physicians' orders which included but were not limited to a diet order for: Regular diet, regular texture, thin liquids, renal precautions. No citrus fruit or juices; no bananas, no…

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 medical record review and interview with staff it was determined the facility staff 1) failed to measure resident centered objectives in order to determine the effectiveness of the residents care plan interventions; (Resident #10) and 2) failed to ensure resident's care plan reviews were completed by an interdisciplinary team which included the attending physician, a registered nurse and nurse aide involved in the resident's care, a member of food and nutrition services staff and the resident/representative; (Resident #10) and 3) failed to hold quarterly care plan meetings to include the interdisciplinary team, resident and resident's representative for residents. (Resident #40). This was evident for 2 out of 5 residents reviewed for care planning during an annual survey. The findings include: Once the facility staff completes an in-depth assessment (MDS) of the resident, the interdisciplinary team meet and develop care plans. A care plan is a guide that addresses the unique needs of each resident. It…

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 staff interview it was determined that the facility failed to ensure that a discharge summary was complete and accurate. This was evident for 1 (#42) of 3 closed records reviewed. The findings include: A medical record review for Resident #42 on 5/30/24 at 11:18 AM revealed a history and physical visit conducted by the attending physician on the day of the resident's admission. The physician noted that the resident had progressing weakness, reoccurring falls, Parkinson's disease, and worsening dementia. The plan for treatment was noted as physical and occupational therapy, continue the same mediations, and repeat labs. The physician noted that the resident's potential for rehab was fair, and the resident had a poor prognosis. A review of the discharge summary revealed that the physician documented the resident had completed their course of treatment and was being discharged back to independent living with family. The physician failed to include the medications that the resident was on and which one that should be continued after discharged . An interview…

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 staff interview it was determined that the facility failed to develop and implement policies and procedures to ensure all residents were offered and/or receive the appropriate pneumococcal vaccinations as per the national standards. This was evident for 2 (#21 and #34) of 5 residents reviewed for pneumococcal vaccinations. The findings include: The Centers for Disease Control (CDC) and the Advisory Committee on Immunization Practices (ACIP) releases an Adult Immunization Schedule which assist healthcare workers in determining the vaccinations that are recommended for their residents. CDC released a Morbidity and Mortality Weekly Report (MMWR) on January 28, 2022, with further guidance for determining which pneumococcal vaccination is recommended based on previous vaccinations. Pneumococcal vaccinations are available in a formulation of pneumococcal conjugate vaccine (PVC) followed by the number of strands of pneumonia it protects against and a 23 - valent pneumococcal polysaccharide…

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, medical record review and staff interview it was determined that the facility failed to implement a comprehensive person-centered care plan. This was evident for 1 of 2 residents (Resident #36) reviewed for ADL's during an annual recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. An observation was made of Resident #36 on 06/05/19 at 2:44 PM sitting in his/her room watching television and seated next to his/her companion. The surveyor attempted to speak to Resident #36 but Resident #36 was having difficulty hearing the questions and had to ask his/her companion to repeat the surveyor's questions. Resident #36's companion indicated Resident #36 did not have his/her hearing aids in. In interview with Staff #3 on 06/05/19 at 2:50 PM, she/he indicated Resident #36 should have his/her hearing aids applied each morning. Staff #3 checked the medicine cart and Resident #36's hearing aids were still present in 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 observation, medical record review and staff interview it was determined that the facility failed to follow a physician order and insert a resident's hearing aids daily at 8 am. This was evident for 1 of 2 residents (Resident #36) reviewed for ADL's during an annual recertification survey. The findings include: An observation was made of Resident #36 on 06/05/19 at 2:44 PM sitting in his/her room watching television and seated next to his/her companion. The surveyor attempted to speak to Resident #36 but Resident #36 was having difficulty hearing the questions and had to ask his/her companion to repeat the surveyor's questions. Resident #36's companion indicated Resident #36 did not have his/her hearing aids in. In interview with Staff #3 on 06/05/19 at 2:50 PM, she/he indicated Resident #36 should have his/her hearing aids applied each morning. Staff #3 checked the medicine cart and Resident #36's hearing aids were still present in the medication cart. A review of Resident #36's ADL (activities of daily living) care plan revealed a nursing intervention instructing 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.