Inspection Reports for
The Grove Care and Wellness

The investigation was triggered by a complaint related to an injury of unknown origin concerning Resident 4. The complaint was substantiated by findings that the care plan was not developed as required.

The facility failed to develop a complete care plan with specific goals and measurable actions to address Resident 4's rib fracture, which was identified on February 18, 2025. Licensed nurses did not initiate a care plan for the fracture, potentially preventing appropriate interventions tailored to the resident's needs.

The facility was found deficient in developing and implementing care plans for personal monitoring devices, providing care according to physician orders, ensuring accurate controlled substance documentation, identifying irregularities in medication regimen reviews, preventing unnecessary psychotropic medication use, maintaining safe food handling practices, and enforcing infection control hand hygiene protocols.

The complaint investigation was triggered by an allegation of abuse between Resident 1 and Resident 2 on January 2, 2025. The facility staff delayed reporting the incident to the Administrator and State Agency beyond the required two-hour window. The Administrator confirmed the late reporting and acknowledged the facility's policy on timely abuse reporting.

The facility failed to report an allegation of abuse to the State Agency within the required two-hour timeframe for one of two residents reviewed. Interviews and record reviews confirmed the delay in reporting the incident that occurred on January 2, 2025.

The investigation was triggered by complaints and a facility-reported incident concerning quality of care and neglect related to pressure ulcer management for Resident A. The complaint was substantiated by findings of delayed wound identification, treatment, and documentation.

The facility failed to provide timely identification and treatment of a pressure injury on Resident A's sacral area, including delayed documentation and inconsistent administration of treatment orders. The wound care consultant was not engaged as per protocol, and treatment documentation was often late by several days, potentially delaying healing and contributing to infection and hospital transfer.

The complaint investigation found that Resident A exhibited hallucinations and increased confusion that were not properly addressed by the facility. The Registered Nurse confirmed no change of condition documentation or care plan updates were made despite awareness of symptoms. Resident A was transferred to the hospital after three days of deterioration.

The facility failed to ensure timely recognition and appropriate care for Resident A's hallucinations and confusion, resulting in delayed treatment and transfer to a hospital three days after symptom onset. No updated care plan or proper documentation of the change in condition was completed.

The facility was found deficient in multiple areas including failure to administer bowel preparation medications as ordered, exceeding prescribed fluid restrictions for a dialysis resident, expired IV supplies in the IV cart, improper food sanitation and storage practices, inadequate infection prevention related to reusable equipment storage, and presence of pests in the kitchen.

The visit was complaint-related, investigating a quality care issue regarding inadequate monitoring and documentation of a resident's skin condition. The complaint was substantiated by findings of missing weekly skin assessments and inconsistent documentation regarding the resident's right big toe condition.

The facility failed to evaluate and document weekly assessments of Resident 1's right big toe discoloration between December 31, 2022, and January 26, 2023, contrary to facility policy. This failure led to staff being unaware of changes in the resident's condition, potentially delaying appropriate treatment and worsening the wound.

The investigation was complaint-driven, focusing on the COVID-19 outbreak and infection control practices. The complaint was substantiated as the facility did not test healthcare personnel timely and failed to report the outbreak within the required timeframe.

The facility failed to ensure timely COVID-19 testing of healthcare personnel and did not report the COVID-19 outbreak to the state agency within the required timeline, contrary to facility policy and CDC guidelines. Several staff members worked while potentially infectious, and testing for staff was delayed until five days after the outbreak began.

The visit was complaint-related, triggered by concerns about infection control practices during a COVID-19 outbreak. The complaint investigation found failures in timely testing and reporting as well as inadequate infection prevention measures.

The facility failed to ensure timely COVID-19 testing of healthcare personnel and did not report the COVID-19 outbreak to the state agency within the required timeline, contrary to facility policy and CDC guidelines. Several staff members worked while potentially infectious without proper testing or protective measures.

The facility failed to ensure sanitary conditions in food storage and labeling, including unlabeled and expired food items, and failed to keep trash containers properly closed and not overfilled, increasing the risk of food-borne illnesses in a vulnerable population of 34 residents.

The inspection found that the facility had appropriate infection control measures and supplies in place, including PPE and signage, and staff were wearing face coverings. However, one deficiency was cited for allowing a staff member to work without criminal record clearance, posing an immediate health and safety risk.