The Grove

Based on staff interview, record review, and facility policy review, the facility failed to implement individualized care plan interventions for two (2) of six (6) sampled residents. Resident #1 and Resident #2.Findings include:A review of the facility's Total Care Plan Policy, undated, revealed, It is the policy of this facility that the Interdisciplinary care plan will be done as follows.Reminders.Care Plan must be followed by all staff included in resident's care.Resident #1A record review of the facility's document, Fall During Staff Assist, dated 4/3/26, revealed Resident #1 fell during a chair-to-bed transfer when Certified Nurse Aide (CNA) #1 used a sit-to-stand lift.A record review of the facility's Staffing Disciplinary, dated 4/3/26, revealed, .CNA.noted to not follow proper transfer status for resident (Resident #1).This write did a phone interview with CNA who states that she asked the resident how she transferred.Made CNA aware that the care profile and transfer status are to be looked at prior to the start of every shift.A record review of the Nurse Notes, dated 4/3/26…

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, record review, and facility policy review, the facility failed to ensure a safe environment and implement interventions to prevent accidents for two (2) of six (6) residents reviewed with a history of falls. Resident #1 and Resident #2.Findings include:A review of the facility's Fall Protocol Policy, dated 2/2011, revealed, It is the policy of this facility that the fall protocol will be as follows.Fall review.Evaluate possible alternative interventions to help prevent falls.Resident #1A record review of the facility's document, Fall During Staff Assist, dated 4/3/26, revealed Resident #1 fell during a chair-to-bed transfer when Certified Nurse Aide (CNA) #1 used a sit-to-stand lift. A review of the facility's Staffing Disciplinary, dated 4/3/26 revealed .CNA.noted to not follow proper transfer status for resident (Resident #1).This write did a phone interview with CNA who states that she asked the resident how she transferred.Made CNA aware that the care profile and transfer status are to be looked at prior to the start of every shift.A record…

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, record review, and facility policy review, the facility failed to sanitize pots and pans according to manufacturer's guidelines and failed to calibrate food thermometers to ensure food remained hot for one (1) of four (4) kitchen observations.Findings include:A review of the facility's Calibration of Thermometers Policy, revised 10/17, revealed, .Facility shall ensure that a thermometer gives accurate recordings. Procedure: 1. All thermometers are to be calibrated: a. Before each use b. After being dropped c. When experiencing an extreme change in temperature. A review of the facility's Manual Warewashing Policy, dated 10/17 revealed, .Food service pots and pans that cannot fit in the dish machine or cleaned and sanitized in a three-compartment sink.Procedure.5) Third Compartment Sink a) Fill the third sink with water and sanitizer to the correct concentration. Hot water can be used as an alternative. B) Immerse items in the third sink in hot water or chemical sanitizing solution. I)If hot water immersion is used, the water must be a minimum of 171 F…

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, record review, and facility policy review, the facility failed to ensure a resident's right to dignity, as evidenced by standing over the resident while assisting to feed for one (1) of (18) sampled residents. Resident #34.Findings include:A review of the facility's Dignity Policy, undated, revealed, .Dignity means that staff carry out activities which assist the resident to maintain and enhance his/her self-esteem and self-worth as follows.Promoting resident independence and dignity in dining.A record review of Resident #34's Face Sheet revealed the facility admitted Resident #34 on 7/16/12 with diagnoses including Hemiplegia and Hemiparesis.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/25 revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of two (2), which indicated the resident's cognition was severely impaired.On 2/9/26 at 11:54 AM, during an observation, Certified Nursing Aide (CNA) #1 was observed assisting Resident #34 with feeding in the resident's room. 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, record review, and facility policy review, the facility failed to ensure a resident's right to privacy and confidentiality by posting personal care information in the resident's room for one (1) of two (2) residents sampled for privacy. Resident #8.Findings include:A review of the facility's Privacy of Health Information Policy, undated, revealed, . It is the policy of this facility that resident's health information will be protected as follows: . No health information allowed on counter tops or in areas visible to unauthorized persons . - Posting notes and reminders in the residents' rooms by staff members will be prohibited (unless resident and/or responsible party has given us permission to do so AND it has been added to the resident's care plan) .A record review of Resident #8's Face Sheet revealed the facility admitted Resident #8 on 2/7/24 with diagnoses including Encounter for Attention to Gastrostomy.A record review of the Order Summary Report with active orders as of 2/10/26 revealed Resident #8 had physician orders for . All Oral Meds to…

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, record review, and facility policy review, the facility failed to ensure a resident's right to be free from physical restraints by failing to identify and document the use of a lap belt as a restraint for one (1) of eighteen (18) sampled residents. Resident #55.Findings include:A review of the facility's Restraint Policy, undated, revealed, .Physical restraints are defined as any manual method or physical mechanical device, material, or equipment attached.to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.On 2/9/26 at 3:55 PM, during an observation, Resident #55 was observed with a soft belt secured across her lap while up in a wheelchair.On 2/10/26 at 11:46 AM, during an observation, Licensed Practical Nurse (LPN) #1 asked Resident #55 three (3) times to remove the belt. Resident #55 stared at the nurse and did not respond to the request.On 2/11/26 at 11:32 AM, during an interview, the Director of Nursing (DON) reported the facility failed to identify the resident's lap…

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, record review, and state board of nursing information review the facility failed to follow professional standards by permitting an unlicensed Certified Nursing Aide (CNA) to apply a medicated product, zinc oxide, during incontinent care for one (1) of three (3) residents observed for care. Resident #10.Findings include:A review of the Mississippi Board of Nursing website (www.msbn.ms.gov) revealed, Can a RN (Registered Nurse) delegate the administration of medicated ointments, lotions, and protective skin barriers to unlicensed personnel? .The registered nurse may .2. Assign duties of administration of patient medications to other licensed nurses only.On 2/11/26 at 12:35 PM, during an observation, CNA #2 provided catheter and incontinent care to Resident #10 and applied zinc oxide to the perineal folds.A record review of the Order Summary Report for Resident #10 revealed a Physician's Order, dated 2/2/26, for Zinc Oxide skin protection.CNA may apply per nurses' direction for skin protection only.On 2/11/26 at 12:45 PM, during an interview, 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.

Based on observation, interview, record review, and facility policy review, the facility failed to act upon a pharmacist-identified medication irregularity related to crushing an extended-release medication for one (1) of three (3) residents reviewed for medication administration. Resident #8.Findings include:A review of the facility's Pharmacy Consultant Policy, undated, revealed, . It is the policy of this facility that a licensed pharmacist will provide consultation . A monthly report of any irregularities found is made to the resident's physician (placed on the medical record) The Director of Nursing (DON) . Action taken based on the report will be documented . A file of monthly reports will be maintained by the Director of Nursing .A record review of the Pharmacy Recommendations for Nursing for Resident #8, dated 11/12/25 revealed, . Medication Administration Alert: Crushing of Meds. This resident's record indicates that their meds are (or can be) crushed. The following meds SHOULD NOT be crushed, (change to another form of therapy): . Toprol XL (metoprolol succinate ER) -…

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, record review, and facility policy review, the facility failed to ensure dietary staff demonstrated competency in sanitation procedures for the three-compartment sink for one (1) of three (3) kitchen observations.Findings include:A review of the facility's Manual Warewashing Policy, dated 10/17 revealed, .Food service pots and pans that cannot fit in the dish machine or cleaned and sanitized in a three-compartment sink.Procedure.5) Third Compartment Sink a) Fill the third sink with water and sanitizer to the correct concentration. Hot water can be used as an alternative. B) Immerse items in the third sink in hot water or chemical sanitizing solution. I)If hot water immersion is used, the water must be a minimum of 171 F and items must be immersed for 30 seconds. Ii) If chemical sanitizing is used, the sanitizer must be mixed to the proper concentration. Follow manufacturers' recommendations. The following are published guidelines. (1) Chlorine-Immerse for 7 seconds in water temperature 100 degrees F (Fahrenheit) (2) Iodine-Immerse for 30 seconds in…

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, record review, and facility policy review, the facility failed to follow Enhanced Barrier Precaution (EBP) requirements by not wearing required personal protective equipment (PPE), specifically a gown, during percutaneous endoscopic gastrostomy (PEG) tube care for one (1) of five (5) residents observed for care. Resident #8.Findings include:A review of the facility's Enhanced Barrier Precautions Policy, dated 4/30/25, revealed, .Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multidrug resistant organisms to residents .Policy Interpretation and Implementation EBPs employ targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply.Examples of high-contact resident care activities requiring the use of gowns and gloves for EBPs include.device care or use.feeding tube.Communication -Staff are trained prior to caring for residents on EBP and annually with PPE (Personal Protective Equipment) in-service.An orange sign will be…

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, staff interview, and facility policy review, the facility failed to safely store and lock hazardous cleaning chemicals in one (1) of four (4) shower rooms observed during the annual survey. Findings Include: A review of the facility policy titled Hazardous Materials/Chemicals and Waste-Storage, revised on 11/7/23, revealed, Purpose: To provide a policy whereby hazardous materials/chemicals and waste can be stored in a safe manner to prevent injury to patients, personnel, or visitors. Policy: It is the policy of this facility that all hazardous materials are received into the department by appropriate personnel and stored in a supply closet suitable for chemicals . Storage areas are kept locked and secured from the public at all times to prevent injury to patients, personnel, or visitors . Hazardous waste storage and processing areas will be free of clutter and effectively separated from patient care . All Hazardous Waste is to be kept in a locked and secure area inaccessible to the general public . An observation of the south shower room on 8/26/24 at 10:30 AM…

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 facility policy review, the facility failed to ensure proper sanitation procedures were utilized during dishwashing, as evidenced by, the minimum water temperature of the low-temperature dishwasher machine was not reached during two dishwasher observations for two (2) of four (4) dietary tours. Findings Include: A review of the facility's policy titled Machine Warewashing, revised on 09/12/11, revealed, Chemical Sanitizing Machines use a low temperature to clean and sanitize. Follow the dishwasher manufacturer's guidelines. Suggested temperature = 120 degrees. If the dish machine cannot be used, dishes should be washed according to the procedures for washing pots and pans in the three-compartment sink. During an observation on 08/28/24 at 12:01 PM, Dietary [NAME] #2 demonstrated how the low-temperature dishwasher worked. It was noted that the chemical sanitizer was within the recommended manufacturer's guidelines, however, the thermometer of the machine only measured 60 degrees Fahrenheit (F). At that time, the Dietary Supervisor ran 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, interviews, record review, and facility policy review, the facility failed to ensure resident rights were honored by prohibiting residents from group activities and restricting resident use of common areas of the facility without clinical justification for three (3) of 18 sampled residents, with the potential to affect 62 residents. Residents # 3, #4, and #45 Findings include: Record review of the facility's policy, Resident Rights Policy, updated 9/5/15, revealed, It is the policy of this facility that resident rights will be addressed as follows: .Exercise rights .Each resident will be able to exercise his/her rights as follows: As a resident in this facility . 2. To voice grievances to: .State Department of Health . Resident #3 On 1/08/23 at 11:25 AM, during an observation and interview with Resident #3, he was dressed and sitting in his room with the door open. Resident #3 revealed that because his unit of the facility has COVID-19 positive residents, the facility has prohibited the COVID-19 negative residents from having group activities by restricting 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 interviews, record review, and facility policy review, the facility failed to implement its protocol for antibiotic use and thereby failed to prevent the unnecessary and inappropriate antibiotic use for one (1) of five (5) residents reviewed for unnecessary medications. Resident #78. Findings Include: Review of the facility's, Antibiotic Stewardship Policy revised 9/9/22, revealed, It is the policy of this facility to observe the practice of Antibiotic Stewardship to monitor antibiotic use in the care and treatment of our residents. It is our goal to promote appropriate selection and use of antibiotics . Monitoring for accountability of provider and staff for following acceptable criteria (McGreer criteria) for initiation and continued treatment with an antibiotic . As part of the Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the infection preventionist (IP) . Review of the facility's, ESBL (Extended-Spectrum Beta-Lactamases) or VRE (Vancomycin Resistant Enterococci) in Urine Protocol, updated 3/28/22, revealed, In…

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.