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Deficiency Records for The Grove Post-Acute Care Center
A list of the most recent deficiencies for The Grove Post-Acute Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for The Grove Post-Acute Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Provide and implement an infection prevention and control program. | Health | 2024-07-09 | 2024-07-24 | Y |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-07-09 | 2024-07-24 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-07-03 | 2024-07-05 | Y |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-07-03 | 2024-07-05 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-07-03 | 2024-07-05 | Y |
List the names and contact information of those in the facility. | Fire Safety | 2023-12-10 | 2024-01-05 | N |
Establish staff and initial training requirements. | Fire Safety | 2023-12-10 | 2024-01-05 | N |
Conduct testing and exercise requirements. | Fire Safety | 2023-12-10 | 2024-01-05 | N |
Implement emergency and standby power systems. | Fire Safety | 2023-12-10 | 2024-01-05 | N |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-12-10 | 2024-01-05 | N |
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-12-10 | 2024-01-05 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-10 | 2024-01-05 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-10 | 2024-01-05 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-10 | 2023-12-21 | N |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-12-10 | 2023-12-21 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-10 | 2023-12-21 | N |
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-12-10 | 2023-12-21 | N |
Keep residents' personal and medical records private and confidential. | Health | 2023-12-10 | 2023-12-21 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-10 | 2023-12-21 | N |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-10 | 2023-12-21 | N |
Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-12-10 | 2023-12-21 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-10 | 2023-12-21 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-12-10 | 2023-12-21 | N |
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2023-12-10 | 2023-12-21 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-12-10 | 2023-12-21 | N |
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-12-10 | 2023-12-21 | N |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-12-10 | 2023-12-21 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-10 | 2023-12-21 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-10 | 2023-12-21 | N |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-12-10 | 2023-12-21 | N |
Provide and implement an infection prevention and control program. | Health | 2023-12-10 | 2023-12-21 | N |
Implement a program that monitors antibiotic use. | Health | 2023-12-10 | 2023-12-21 | N |
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2023-12-10 | 2023-12-21 | N |
Provide and implement an infection prevention and control program. | Health | 2023-10-08 | 2023-10-18 | Y |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-10-08 | 2023-10-18 | Y |
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-10-08 | 2023-10-18 | Y |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-09-28 | 2023-10-10 | Y |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-28 | 2023-10-10 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-09-28 | 2023-10-10 | Y |
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-08-23 | 2023-08-27 | Y |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-23 | 2023-08-27 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-08-23 | 2023-08-27 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-28 | 2023-07-10 | Y |
Ensure that residents are free from significant medication errors. | Health | 2023-06-28 | 2023-07-10 | Y |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-24 | 2022-07-29 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-07-24 | 2022-07-29 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-05-10 | 2022-06-14 | Y |
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2021-12-17 | 2022-04-15 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-27 | 2022-02-16 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-02-16 | Y |
Address subsistence needs for staff and patients. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Construct fire resistant interior walls. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2022-01-06 | 2022-01-28 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-17 | 2022-01-10 | N |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-12-17 | 2022-01-10 | N |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-12-17 | 2022-01-10 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-17 | 2022-01-10 | N |
Assist a resident in gaining access to vision and hearing services. | Health | 2021-12-17 | 2022-01-10 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-17 | 2022-01-10 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-17 | 2022-01-10 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-17 | 2022-01-10 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-17 | 2022-01-10 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-17 | 2022-01-10 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-12-17 | 2022-01-10 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-17 | 2022-01-10 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-12-17 | 2022-01-10 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-12-17 | 2022-01-10 | N |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-12-17 | 2022-01-10 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-17 | 2022-01-10 | N |
Provide and implement an infection prevention and control program. | Health | 2021-12-17 | 2022-01-10 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-17 | 2022-01-10 | Y |
Conduct testing and exercise requirements. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-30 | 2019-11-20 | N |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-11-04 | 2019-11-13 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-04 | 2019-11-13 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-11-04 | 2019-11-13 | N |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-11-04 | 2019-11-13 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-04 | 2019-11-13 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-04 | 2019-11-13 | N |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-11-04 | 2019-11-13 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-04 | 2019-11-13 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-04 | 2019-11-13 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-11-04 | 2019-11-13 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-04 | 2019-11-13 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-04 | 2019-11-13 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-04 | 2019-11-13 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-11-04 | 2019-11-13 | N |
Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-11-04 | 2019-11-13 | N |
Provide and implement an infection prevention and control program. | Health | 2019-11-04 | 2019-11-13 | N |
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-11-04 | Not Fixed | N |
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