Inspection Reports for
Grove Manor Estates

Emergency call response: Documentation of hourly safety checks for March 2023 through the date of compliance review had multiple instances where staff failed to document the hourly safety checks of the Residents during the hours of 7:00 p.m. and 7:00 a.m.

Resident care plans: Four of the 22 records were missing documentation of a current assessment noting that the Resident can independently navigate around a bed rail/ U-bar were missing (repeat finding).

Quality assurance program: Documentation of the target date and person responsible for follow up action were missing for the 2023 and 2024 calendar years. Documentation of the target date and staff person responsible for the follow-up was missing for the 2023 and 2024 calendar years. Observed medication storage and labeling issues. (repeat finding).

Incident reporting: The Residence filed 19 incident reports greater than 24 hours after the occurrence of the incident or accident (repeat finding).

Controlled medication handling: The Residence policy does not include steps regarding the safeguards for storage and disposal of controlled substances.

Recordkeeping: Three personnel records were missing documentation of a signed job description and two Personal Care records were missing documentation of current licensure or certification.

Resident records: The Residence did not use the Traditional Correspondence Log to communicate all significant or pertinent information necessary to maintain the continuity of care for all Residents (repeat finding).

Staff health screening: Four personnel records were missing documentation to confirm seasonal influenza vaccinations or declination statements for the 2024/2025 flu season (repeat finding).

Staff training: Two records were without documentation to support that Introductory Visits were consistently conducted with all applicable staff. Documentation confirming the completion of SAMM and skills evaluations every six months was missing from three records for the 2024 calendar year (repeat finding).