Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Groves Center during CMS and state inspections, most recent first.
Infection control was not maintained when the DON entered a room on droplet precautions without PPE or hand hygiene and handled resident care items, several staff delivered meal trays without offering hand hygiene to residents, and the laundry area was observed with dust, exposed wires, a deteriorating folding surface, and a washer gasket with flaking material contacting linens.
Failure to maintain an ongoing antibiotic stewardship program was identified when the IP and DON could not produce infection control logs, antibiotic use data, or hand hygiene audit records for most of the review period. The IP said McGeer's Criteria forms were not being completed and did not know whether the pharmacist reviewed meds for appropriateness. The DON could not explain how infection tracking was being completed or audited, and one resident with influenza was being treated with an antibiotic instead of an antiviral, per the DON.
Failure to assess self-administration of meds for a resident receiving nebulizer tx. The resident had intact cognition (BIMS 15/15), COPD, asthma, resp failure, and PE history, and stated the nurse brings the med while the resident turns the machine off when done. The care plan had no self-administration component, and staff gave differing accounts of whether the nurse must remain with the resident during the tx; the facility policy says the nurse should remain unless the resident has been assessed and authorized to self-administer.
Failure to obtain ordered Depakote level: A resident with anxiety and depressive disorders had an active Depakote order and a standing order for valproic acid levels every 90 days, but only one low level was found in the record and a later ordered lab was not documented as completed. The TAR was blank, and notes did not show refusal or physician notification; the resident was described as socially isolated with depressed mood, anxiety, irritability, grief, and tearfulness.
Failure to Refer Residents With Serious Mental Illness for Level II PASRR Review: Two residents with diagnoses including schizophrenia, schizoaffective disorder, bipolar disorder, depression, anxiety, and PTSD were not referred for Level II PASRR review. Records showed psychotropic medication use and ongoing psychiatric symptoms, while the DON and SSD stated a Level II was not needed if the resident was stable, managed by meds, or not displaying disruptive behaviors.
PASRR screenings were not accurately completed for two residents at admission. One resident had documented dementia, anxiety, depression, and behavioral concerns, yet the PASRR stated no MI/ID and no Level II was needed. Another resident had documented anxiety, depression, mood disorder, insomnia, and substance use, but the PASRR in the chart did not reflect those diagnoses and the electronic record lacked an uploaded PASRR. The DON and Traveling Social Service Director acknowledged the screenings were incomplete and should have been redone.
Care Plan Not Updated for Resolved Wound: A resident with DM2 and a history of a foot ulcer had a care plan that still listed an actual wound on the left heel even though skin checks, staff interviews, and a skin observation showed no wound or reddened areas. The LPN responsible for care plan updates and the DON both stated they did not know why the wound remained on the care plan, despite the facility policy requiring the interdisciplinary care plan to be reviewed and revised as needed.
A resident at risk for falls due to deconditioning and gait/balance problems was found on the floor between a low bed and an oversized floor mat after reportedly rolling from the mattress. The care plan called for non-slip material under the mat, but surveyors observed the mat folded with no visible non-slip material and found only two small pieces underneath; the CNA and DON stated the material was not enough to keep the mat from moving.
A resident receiving aspirin and clopidogrel had a consultant pharmacist recommendation for bleeding monitoring that was not reflected on the MAR/TAR when reviewed. The DON stated the recommendation was forwarded for physician review, but the monitoring order had only been added later, and the facility policy required follow-up on pharmacy recommendations within 30 days or per facility protocol.
Late Medication Administration Without Physician Notification: Two residents received multiple scheduled meds outside the accepted time window, including AM doses given several hours late and later doses administered well after the ordered times. One resident's metoprolol was ordered with meals but scheduled for 9:00 p.m., and the MAR/progress notes did not show documentation that the meds were late or that the MD was notified before administration. The DON acknowledged issues with late meds, and the CP stated meds should be given within the expected time frames.
Two residents with indwelling catheters did not receive necessary care to prevent or manage UTIs, including failure to follow physician orders for catheter changes, missed laboratory testing, and incomplete antibiotic administration. One resident developed a severe infection that progressed to Fournier's gangrene and sepsis, while another did not receive the full prescribed course of antibiotics, with no documentation or provider notification regarding the missed doses. Staff interviews revealed inconsistent training and documentation practices related to catheter care and change of condition.
The facility failed to follow physician orders for catheter care and lab monitoring, resulting in a resident developing a severe UTI that progressed to Fournier's gangrene and sepsis. Another resident did not receive the full course of prescribed antibiotics for a UTI, with no documentation of provider notification. Two residents with abnormal lab results did not have timely provider notification or documentation, and another resident experienced unmanaged pain for two days despite documented high pain levels and available orders for pain medication.
A resident with multiple medical conditions reported missing personal items, including a blanket and clothing. Despite repeated complaints to various staff members and a search of the laundry room, not all items were recovered and no formal grievance was filed or investigated, contrary to facility policy.
A resident with complex medical needs experienced a significant change in condition, including lethargy and pain, and received late medication administration. The resident's representative reported concerns to staff and the NHA, explicitly alleging neglect, but the incident was not reported or investigated as required by facility policy. Staff interviews confirmed the assigned LPN was absent from the unit for extended periods, and there was no documentation of provider notification or change of condition assessment.
The facility did not conduct a thorough investigation into an allegation of neglect involving a resident with a foley catheter. The NHA failed to contact the family, did not interview all relevant staff, and did not obtain necessary medical records or consult the resident's urologist. Key clinical details, such as the resident's pain complaints and the presence of wounds, were missed or unknown to the investigation team.
The facility did not ensure proper catheter care for several residents, including failure to change catheter bags as ordered, lack of securement devices for catheters, and inconsistent response to signs of infection such as cloudy lines and sediment. Staff interviews confirmed that securement devices were not used despite facility policy and best practice guidelines, and one resident developed a pressure injury at the catheter site due to lack of stabilization.
A resident with a colostomy and abdominal wounds experienced unmanaged pain for several days after admission, despite having orders for acetaminophen and Percocet. Nursing staff documented significant pain but did not administer the prescribed medications or notify a physician, and there was no documentation explaining the delay. Facility policy required prompt pain management, but these procedures were not followed, resulting in the resident's pain going untreated.
Two residents with complex medical conditions had abnormal lab results that were not communicated to their providers as required. In both cases, there was no documentation that the LPN or nursing staff notified the provider of the abnormal findings, despite facility policy and expectations for prompt notification and documentation. The DON and Regional Nurse Consultant confirmed the lack of documentation and acknowledged discrepancies in physician notifications.
Surveyors found that multiple residents did not receive timely incontinence care, with staff failing to respond promptly to call lights and leaving residents in soiled briefs for extended periods, particularly during night shifts. Residents with significant medical and functional needs were affected, and care plans requiring regular checks were not consistently followed, as confirmed by both resident interviews and care documentation.
Surveyors found that the facility did not ensure PPE was available or used for residents on Contact Precautions or Enhanced Barrier Precautions. Multiple rooms with posted precaution signs lacked accessible PPE, and staff entered rooms without donning required protective equipment. Staff interviews revealed confusion about isolation requirements and inconsistent application of infection control protocols for residents with MDROs, wounds, and IV access.
Surveyors observed live insects in multiple facility areas, including the dining and activity halls, and a resident reported persistent roaches in their room despite cleaning and spraying. Facility records showed ongoing pest control treatments for various pests, but interviews with the DOM and NHA revealed a lack of awareness and inconsistent responses to pest complaints, indicating the pest control program was not effective.
A grievance filed by a resident's family about missing dentures was not promptly or thoroughly addressed, with gaps in documentation, communication, and follow-up. The facility did not assign responsibility for the grievance, failed to document a resolution or satisfaction of the complainant, and did not maintain adequate records of communication, contrary to its own grievance policy.
A resident with chronic pain conditions did not receive a scheduled dose of Oxycodone because the medication supply ran out and was not reordered in time. Staff interviews revealed confusion about the process for obtaining narcotics from the automated dispensing machine and inconsistent communication with the pharmacy, resulting in a delay in medication delivery and a missed dose.
Several residents experienced significant delays and omissions in incontinence care, with reports of long wait times for assistance, incomplete documentation, and staff shortages leading to residents remaining in soiled briefs for extended periods. Staff interviews confirmed heavy workloads and insufficient staffing contributed to the failure to provide timely care as required by care plans and facility policy.
A facility failed to protect resident privacy and confidentiality when an RN disposed of used feeding bottles with identifiable information in an unsecured trash can and left a medication cart unattended with resident information exposed. The DON confirmed that staff should have marked off identifiable information before disposal.
Two residents with tracheostomies in a facility experienced deficiencies in care due to unconfirmed physician orders and lack of documentation for essential care activities. One resident, with severe cognitive impairment, had missing documentation for tracheostomy suctioning, medication administration, and vital sign monitoring. Another resident, cognitively intact, also faced similar issues with tracheostomy management and enteral feeding. The Director of Nursing confirmed the documentation gaps, which were against the facility's policies.
A resident with a tracheostomy did not receive care consistent with professional standards at an LTC facility. An RN failed to follow enhanced barrier precautions, including wearing a gown and performing proper hand hygiene, while providing care. The resident had a complex medical history and required specific care protocols, which were not followed, leading to a deficiency in care.
A facility failed to follow standard and enhanced barrier precautions during the care of two residents, leading to a deficiency in infection prevention and control. A registered nurse (RN) did not wear a gown or perform proper hand hygiene while providing care to a resident with a tracheostomy and gastrostomy tube, despite the requirement for enhanced barrier precautions. The facility's policies and the resident's care plan required the use of gloves and gowns during high-contact care activities, which the RN did not comply with.
Infection Control Program Not Maintained
Penalty
Summary
The facility failed to implement and maintain an infection prevention and control program related to staff not using appropriate PPE when entering a resident room under droplet precautions. During an observation, the DON entered the room without PPE or hand hygiene, exited without performing hand hygiene, then re-entered without gloves or gown, touched the privacy curtain, donned the gown while inside the room, and handled a clear bag containing disposable vital sign equipment that had not been opened. The DON later stated that staff entering a room on droplet precautions were expected to don a gown, mask, gloves, and face shield. The facility also failed to ensure residents were offered hand hygiene before meal service on the 400-hall. During observation of meal tray delivery, multiple staff members delivered trays to residents in their rooms without offering hand hygiene, including an LPN, the risk manager, a traveling social service director, and an RN. One staff member was observed offering hand hygiene to a resident, but several others did not. Interviews with staff indicated that hand hygiene was sometimes offered before meals and that sanitizer was available in multiple locations, while five randomly selected residents on the 100, 300, and 400 halls reported that hand hygiene was not offered before meals. The facility also failed to keep the laundry area in a manner to prevent the spread of infection. During observation, the laundry area contained a narrow walkway, a wooden frame table with a laminate top separating from the wood underneath, and exposed ceiling wires covered with dust. The laundry aide stated the wires were not cleaned and that the laundry area was cleaned only every other day. A washer was also observed with a missing portion of the black gasket and tan and white flaking material, and linens were in contact with that material. The NHA stated she was aware there were issues with the area, and the NHA reported the housekeeping supervisor was responsible for upkeep and auditing of the laundry area.
Failure to Maintain Antibiotic Stewardship Monitoring
Penalty
Summary
The facility failed to maintain an ongoing antibiotic stewardship program for 11 of 12 months reviewed. During an interview, the Infection Preventionist (IP) stated she did not have infection control logs prior to December 2025, and the DON said she had not been able to locate the logs. The IP also stated she did not know whether the pharmacist reviews medications for appropriateness, had not been completing the McGeer's Criteria form, and did not know whether the facility wanted her to complete it. In addition, she had not completed hand hygiene audits, and the hand hygiene audit book showed the last audit was completed on 4/22/25. The DON stated the facility reviews infection control prevalence rates each month in the QAPI meeting, but she was unable to provide the prevalence rates during the interview and could not explain how tracking was being completed or audited. No documentation was provided for antibiotic use, handwashing, or infection tracking, including signs and symptoms, for the prior 12 months. The report also noted one resident who was positive for influenza and was being treated with an antibiotic; the DON stated an antibiotic is not appropriate for a viral infection and that the resident should have been treated with an antiviral medication. Facility policies stated that the DON and IP monitor compliance with antibiotic stewardship, that antibiotic use and resistance data are reviewed at QAPI, and that the pharmacy reviews antibiotic courses for appropriateness.
Failure to Assess Self-Administration of Nebulizer Medication
Penalty
Summary
The facility failed to ensure an assessment of self-administration of medications for one resident, who was observed sitting in a wheelchair near the side of a bed and holding a clear mask with white fog coming from the mask during a nebulizer treatment. The resident stated that the nurse brings in the medication and that the resident turns the machine off once finished. The resident was admitted with diagnoses including COPD with acute exacerbation, other asthma, respiratory failure, and other pulmonary embolism without acute cor pulmonale. Review of the resident’s MDS showed a BIMS score of 15 out of 15, indicating intact cognition. The care plan dated 08/05/2025 did not include a care plan for self-administration of medications. During interviews, an LPN/UM stated that when giving a nebulizer treatment, the nurse should stay in the room until the treatment is complete and keep the resident in eyesight, while the DON stated the nurse should return in 15 minutes to check on the resident and did not need to stay in the room until the treatment finished. The facility policy for nebulizer administration stated the nurse should remain with the resident unless the resident has been assessed and authorized to self-administer.
Failure to Obtain Ordered Depakote Level
Penalty
Summary
The facility failed to obtain a blood test to monitor the therapeutic level of Depakote for one resident with diagnoses including generalized anxiety disorder, recurrent major depressive disorder, mood disorder, and anxiety disorder. The resident had an active order for Depakote 125 mg, 3 tablets by mouth twice daily for mood disorder, and an order for Depakote/valproic acid levels every 90 days. Laboratory review showed only one valproic acid level, obtained in September 2025, with a subtherapeutic result of 31, and no additional Depakote levels were found in the record. A November 2025 TAR showed a Depakote valproic acid level was to be obtained, but the documentation did not show the sample was completed, and the nursing documentation section was blank. Progress notes from the relevant period did not show that the resident refused the blood draw or that the physician was notified that the lab had not been obtained. The resident’s psychiatry note described depressed mood, loss of energy, irritability, and inability to control worry, and the psychology note described social isolation, anxiety, depressed mood, grief, sadness, tearfulness, and an underlying depressed mood.
Failure to Refer Residents With Serious Mental Illness for Level II PASRR Review
Penalty
Summary
The facility failed to ensure residents with serious mental disorders were referred to the State Mental Health authority for a Level II PASRR review for two sampled residents. Resident #10 was admitted with diagnoses including unspecified schizophrenia, unspecified depression, unspecified anxiety disorder, and chronic post-traumatic stress disorder. The resident’s MDS showed antipsychotic, antianxiety, and antidepressant use, and the PASRR listed anxiety disorder, depressive disorder, schizophrenia, chronic PTSD, and unspecified insomnia based on documented history, family or legal representative report, and medications. A psychiatric note also documented ongoing anxiety symptoms, depersonalization, persistent worry, depression-related symptoms, and grief. Resident #10’s care plan addressed psychotropic medication use for depression, anxiety, and schizophrenia with delusions. During interview, the DON reviewed the PASRR and stated a Level II may not be necessary if the resident was not currently affected by mental illness. The traveling SSD similarly stated that a Level II PASRR was not automatically submitted solely because the resident had schizophrenia and that if symptoms were managed with medication and the resident was not exhibiting disruptive behaviors, a Level II was not needed. Resident #9’s record showed diagnoses including bipolar type schizoaffective disorder, unspecified schizophrenia, adjustment disorder with mixed disturbance of emotions and conduct, and unspecified recurrent major depressive disorder. The resident’s PASRRs listed anxiety disorder, bipolar disorder, depressive disorder, schizoaffective disorder, schizophrenia, cognitive communication disorder, adjustment disorder, psychosis, and later depressive disorder, schizoaffective disorder, schizophrenia, adjustment disorder with mixed disturbance of emotions and conduct, bipolar type schizoaffective disorder, and cognitive communication deficit. A psychiatry note documented continued treatment with Depakote and Risperdal and referenced prior behavioral health confirmation of hallucinations and delusions. Staff interviews showed the PASRR process was based on diagnoses, behaviors, and medications, but staff stated schizophrenia was not automatically considered a Level II trigger if the resident was stable and not displaying behaviors.
PASRR screenings were not accurately completed for two residents
Penalty
Summary
The facility failed to ensure PASRR screenings were completed accurately at the time of admission for two residents. Resident #42 was admitted with diagnoses including cognitive communication deficit, dementia, anxiety, recurrent major depressive disorder, generalized anxiety disorder, and unspecified Alzheimer's disease. The PASRR Level I in the paper chart, dated 11/11/25, indicated no mental illness, suspected mental illness, or intellectual disability, and stated no Level II was required, despite the resident’s documented diagnoses and behavioral concerns. Resident #42’s care plan documented behaviors including attempting to get out of bed without assistance, becoming agitated easily, preferring to be on the floor at times, and verbal and physical behaviors directed at others. A psychiatry note dated 1/20/26 documented loss of energy related to depression, obsessions/compulsions related to anxiety, and impairment of complex attention, learning, memory, and perceptual motor function related to dementia. A facility-provided PASRR dated 2/2/26 listed anxiety disorder, depressive disorder, dementia in other diseases classified elsewhere, and unspecified Alzheimer's disease, but still indicated no functional limitations, no difficulty with interpersonal functioning, concentration, persistence, pace, or adaptation to change, and no need for Level II review. The DON stated the PASRR should have been redone to include all diagnoses. Resident #118 was admitted with diagnoses including generalized anxiety disorder, recurrent major depressive disorder, insomnia, cannabis use, mood disorder, and anxiety disorder. The paper chart contained a PASRR dated 9/19/24 from an acute care facility that did not identify mental illness, suspected mental illness, or intellectual disability, and the electronic record did not show a PASRR uploaded at the time of review. A PASRR provided by the facility on 2/3/26 listed anxiety disorder, depressive disorder, substance abuse, insomnia, and mood disorder, but still indicated no functional limitations or need for more intensive treatment. A psychology note dated 1/21/26 described ongoing stress-related symptoms, anxiety, crying episodes, bitterness, irritability, depressed mood, and grief-related concerns. The DON stated the PASRR should have been redone prior, and Staff J confirmed the PASRR had missing diagnoses and was redone after an audit.
Care Plan Not Updated for Resolved Wound
Penalty
Summary
The facility failed to update and revise the person-centered comprehensive care plan for one resident sampled. Resident #50 was admitted with diagnoses including needing assistance with personal care and type 2 diabetes mellitus with foot ulcer. Her MDS dated 1/05/2026 showed a BIMS score of 14, indicating she was cognitively intact. Review of her evaluations showed skin checks completed within the last two months revealed no skin impairments, yet her care plan still identified an actual wound on her left heel with a goal to minimize additional wound development and interventions to provide ordered treatment and observe that the dressing was covered and adhering. During interviews, Staff B, RN stated the resident did not have any wounds or reddened areas on her bottom or feet. An observation of the resident’s skin with Staff C, LPN present showed no wound on the left heel or on her bottom. Staff C stated she was responsible for updating the care plan but did not know why the care plan reflected a wound and did not remember the resident ever having one. The DON also stated the resident did not have a wound on her bottom or feet and did not know why she was care planned for an actual wound on her left heel. Facility policies stated the comprehensive care plan is an interdisciplinary communication tool that is reviewed and revised periodically, with ongoing updates added as needed and new, revised, or discontinued problems, goals, or interventions dated when documented.
Failure to Secure Floor Mat for Resident at Fall Risk
Penalty
Summary
The facility failed to provide one resident with an environment free from avoidable accidents and hazards related to the use of moveable floor mats. Resident #42 was identified as being at risk for falls or fall-related injury due to deconditioning and gait/balance problems, and the care plan included non-slip material between the floor and fall mat to prevent movement, with floor mats on both sides of the bed while the resident was in bed. On 2/2/26, the resident was observed lying on the floor between a low bed pushed against the wall and an oversized floor mat that was approximately the same height as the bed. The air mattress on the bed was uneven with distinct lumps, bumps, and an irregular surface, and the resident was fidgeting on the floor, appeared to be trying to raise up, and said “ouch” while grasping the back of the head. The SBAR dated 2/2/26 stated the nurse was notified that the resident had rolled from the mattress onto the floor and was immediately removed using a Hoyer lift. The resident was assessed, vital signs were within normal limits, the MD and family were notified, and the resident was to be transferred for a CT scan of the head. On 2/3/26, the floor mat under the resident was observed folded in half with no non-slip material visible, and the mat could be moved without difficulty. Two small pieces of non-slip material were found under the mat, and both the CNA and DON stated the material was not enough to keep the mat from moving. The facility policy required evaluation of fall risk factors, implementation of a plan of care based on resident needs, communication of interventions to staff, and review and revision of the plan of care as needed.
Pharmacy recommendation for bleeding monitoring not implemented
Penalty
Summary
The facility failed to implement a consultant pharmacist’s recommendation for one resident (#118) related to monitoring for signs and symptoms of bleeding while the resident was receiving aspirin and clopidogrel. The pharmacist had recommended on 10/20/25 that the medication administration record be updated to include monitoring for bleeding, but the recommendation was marked only as “Added” by an unknown person. Review of the resident’s December 2025 MAR and TAR did not show the monitoring order, and the current physician orders showed the monitoring instruction had been added later, with an order date of 2/3/26. Resident #118 was observed on 2/2/26 lying in bed with eyes closed, and other observations showed the resident propelling self in a wheelchair in the hallway and on the covered porch leading to the smoking area. During interview, the DON stated recommendations were forwarded from the consultant pharmacist to her, and that she printed them and gave them to the physician for review. She also stated the monitoring order had been added later and that it should have been added earlier. The facility policy stated that the nursing care center follows up on recommendations to verify appropriate action has been taken and that recommendations should be acted upon within 30 calendar days or per facility-specific protocols.
Late Medication Administration Without Physician Notification
Penalty
Summary
The facility failed to ensure that two residents received medications within the scheduled time frame and failed to ensure the physician was notified before late medications were administered. The medication administration schedule showed daily medications were to be given at 9:00 a.m., twice-daily medications at 9:00 a.m. and 5:00 p.m., three-times-daily medications at 9:00 a.m., 1:00 p.m., and 5:00 p.m., and medications ordered with meals at 8:00 a.m. and 6:00 p.m. The facility policy stated medications were to be administered within 60 minutes of the scheduled time, with documentation required when medications were given at other than the scheduled time. For one resident, the RN was observed at the medication cart with the resident's profile marked red for late medications and administered six oral medications and one liquid at 11:52 a.m. The medications included Eliquis, gabapentin, metoprolol tartrate, potassium chloride, torsemide, tramadol, and valproic acid. The MAR showed several of these medications were scheduled for 9:00 a.m., but the audit report showed they were administered around 11:53 a.m. to 11:59 a.m., approximately 3 hours late. The progress notes and electronic MAR notes did not show that the medications were documented as late or that the physician was notified before administration. For the second resident, another RN was observed dispensing multiple medications while the resident's profile was also marked red for late medications. The medications included amiodarone, Eliquis, furosemide, gabapentin, hydralazine, Jardiance, magnesium oxide, metformin, metoprolol tartrate, sacubitril-valsartan, tolterodine tartrate, and insulin glargine. The audit report showed the scheduled 9:00 a.m. medications were administered between 12:14 p.m. and 12:28 p.m., and later doses were also given outside the scheduled times, including hydralazine at 2:02 p.m. and evening doses at 7:29 p.m. or 8:20 p.m. The resident's metoprolol was ordered with meals but was scheduled for 9:00 p.m., after meals had been served. The progress notes did not show documentation that the medications were late or that the physician was notified before administration.
Failure to Prevent and Manage UTIs in Residents with Indwelling Catheters
Penalty
Summary
The facility failed to provide necessary care and services to prevent urinary tract infections (UTIs) from developing or worsening in two residents with indwelling catheters. For one resident, the facility did not follow physician orders for a silver coated Foley catheter, failed to order and perform required laboratory tests, and did not change the catheter according to the prescribed schedule. The resident's medical records showed missed documentation of a urology appointment, lack of evidence that the ordered silver coated catheter was ever provided, and a significant gap between catheter changes. The resident experienced escalating pain, with pain levels documented as high as 10 out of 10, and there was a lack of timely assessment and documentation of vital signs and laboratory testing during a period of worsening symptoms. The resident ultimately developed a severe UTI that progressed to Fournier's gangrene and sepsis, as confirmed by hospital records, which also noted the resident had been requesting to be sent to the emergency room for several weeks prior to transfer. In the second case, another resident with a history of chronic health conditions and an indwelling catheter was prescribed a five-day course of Ertapenem for a UTI. The medication administration records showed that only three out of five doses were given, with no documentation explaining the missed doses or indicating that the provider was notified about the incomplete antibiotic course. There was also no evidence in the progress notes to account for the missed doses or any follow-up actions taken in response to the incomplete treatment. Interviews with staff revealed inconsistencies in knowledge and practice regarding catheter care, change of condition, and documentation. Some staff reported receiving only occasional in-service training, and there was a lack of demonstration-based education. Facility policies required staff to notify providers of abnormal findings and to document all relevant communications and follow-up actions, but these procedures were not consistently followed. The facility's own abuse prevention policy defined neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or distress, which was reflected in the findings for both residents.
Failure to Provide Necessary Care, Timely Provider Notification, and Pain Management
Penalty
Summary
The facility failed to provide necessary care and services as ordered and according to residents' preferences and goals, resulting in multiple deficiencies. For one resident with a history of neurogenic bladder and recurrent UTIs, the facility did not follow physician orders for a silver-coated Foley catheter, failed to change the catheter as scheduled, and did not order or document required laboratory tests to monitor for infection. The resident experienced escalating pain, which was documented but not adequately addressed, and there was a lack of timely provider notification regarding abnormal findings. Ultimately, the resident developed a severe UTI that progressed to Fournier's gangrene and sepsis, with hospital records indicating the resident had been requesting to go to the emergency room for weeks due to feeling unwell and experiencing foul-smelling drainage. Another resident with a UTI did not receive the full course of prescribed antibiotics, with only three out of five doses administered. There was no documentation explaining the missed doses or indicating that the provider was notified of the incomplete antibiotic therapy. This lapse in care placed the resident at risk for worsening infection or delayed recovery. Additionally, the facility failed to ensure that providers were notified of abnormal laboratory results for two other residents. In both cases, there was no documentation that the physician was informed of critical lab values, despite facility policy requiring prompt notification and documentation of such events. The facility also failed to manage pain appropriately for another resident who reported significant pain upon admission. Despite documented pain levels of 6 out of 10 and orders for pain medication, the resident did not receive any pain medication for two days, and there was no documentation of provider notification or explanation for the delay. Interviews with staff confirmed that pain of this severity should have prompted provider contact and administration of ordered medications. Facility policies reviewed emphasized the importance of timely pain management, provider notification, and documentation, all of which were not followed in these cases.
Failure to File and Investigate Grievance for Missing Resident Items
Penalty
Summary
The facility failed to ensure that a grievance was filed, investigated, and resolved for a resident who reported missing personal items. The resident, who was admitted with diagnoses including muscle wasting, atrophy, MRSA infection, and osteomyelitis, reported missing a blanket and several blouses. The resident and a family member searched the laundry room for the missing items, but not all items were recovered. Despite the resident's repeated complaints and the involvement of multiple staff members, including the Admissions Director and Housekeeping Director, no formal grievance was filed regarding the missing items. Interviews with staff revealed a lack of clarity and communication regarding the grievance process. The Social Services Director was unaware of the missing items and confirmed that no grievance had been logged. The Admissions Director and Housekeeping Director both acknowledged the resident's complaints but did not initiate the grievance process, assuming the issue was being addressed informally. The facility's policy requires staff to assist residents in filing grievances and to document and investigate concerns, but this procedure was not followed in this case.
Failure to Report and Investigate Alleged Neglect Following Change in Resident Condition
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely reporting and investigation of an allegation of neglect for one resident. The resident's representative reported concerns to staff regarding the resident's lethargy, pain, and delayed medication administration. The representative was unable to locate the assigned nurse for over an hour, and when the nurse was found, she was dismissive of the concerns. The representative explicitly told the Nursing Home Administrator (NHA) that he believed the resident was neglected, but did not receive any follow-up from the facility. Medical record review revealed that the resident, who had a complex medical history including end-stage renal disease, lupus, and chronic kidney disease, experienced a change in condition with increased lethargy and pain. Despite these changes and abnormal laboratory results, there was no documentation that a change of condition assessment was completed or that a provider was notified. Medications were administered late throughout the day, and staff interviews confirmed that the nurse assigned to the resident was repeatedly absent from the unit for extended periods without proper coverage. The facility's own policy required immediate reporting and investigation of alleged neglect, but the incident was not documented in the facility's reportable log, and there was no evidence that the required notifications or investigations were completed. Interviews with the DON and Regional Nurse Consultant confirmed that the expected procedures for assessment and provider notification were not followed. The NHA acknowledged that the nurse's actions could constitute neglect but did not ensure the incident was reported as required.
Failure to Conduct Thorough Investigation of Neglect Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of neglect involving a resident with a foley catheter. The Nursing Home Administrator (NHA) became aware of the allegation when a Department of Children and Families (DCF) agent arrived and reported that the resident's family alleged the facility did not replace the resident's foley catheter or provide catheter care, which they believed led to an infection. The NHA did not contact the family for further information and was unsure about the details of the catheter order. The investigation did not include contacting the resident's urologist, and the NHA was unaware of the resident's complaints of severe pain that began several days before the resident was sent to the emergency room. The NHA stated that interviews were conducted with some staff, but could not provide records of these interviews, and did not interview all relevant staff involved in the resident's care. Additionally, the facility did not obtain hospital records related to the resident's care, citing difficulty in obtaining them, and was unaware of the presence of a perineal wound and an unstageable pressure injury where the foley catheter would lay. The Senior Regional Nurse Consultant (SRNC) was the only attendee aware of the hospital report indicating gangrene. The facility's own policy required a complete and thorough investigation, including interviews with all relevant parties and review of documentation, but these steps were not fully completed in this case.
Failure to Provide Proper Catheter Care and Securement
Penalty
Summary
The facility failed to provide proper catheter care for four residents, as evidenced by observations, interviews, and record reviews. Catheter drainage bags were not changed according to physician orders, with some bags dated well beyond recommended intervals. Multiple residents were observed with catheters lacking adhesive or stabilization devices, despite facility policy requiring securement to prevent movement and urethral traction. Cloudy catheter lines and sediment were noted, and staff responses to these findings were inconsistent, with some staff indicating irrigation or culture requests, but not adhering to established protocols. One resident had a pressure injury corresponding to the location of an unsecured catheter, and the Director of Nursing confirmed that securement devices were not in use, contrary to both facility policy and best practice guidelines. Staff interviews revealed that while in-service training on catheter care had occurred recently, there was no consistent application of securement practices, and demonstration training had not yet started. The facility's own policy and external best practice guidelines both emphasize the importance of securing catheters to prevent complications, but this was not implemented. Residents with a history of frequent UTIs and catheter-related wounds were not receiving care in accordance with these standards, as evidenced by the lack of securement and timely bag changes.
Failure to Provide Timely Pain Management for Resident with Colostomy
Penalty
Summary
A deficiency occurred when a resident with a history of Crohn's disease, abdominal wounds, and a colostomy experienced unmanaged pain upon admission. The resident reported that it took several days to receive pain medication, during which time her pain increased, especially when her colostomy bag broke and her skin became raw. The resident described the pain as severe, particularly during colostomy care and cleaning, and expressed distress over the delay in receiving pain relief. Review of the resident's records showed that pain was documented at a level of 6 out of 10, but neither acetaminophen nor Percocet, both of which were ordered, were administered on the days the pain was recorded. There was no documentation explaining why pain medication was not provided, nor any evidence that a physician was notified about the resident's pain levels during this period. Interviews with nursing staff and the DON confirmed that pain medication should have been administered and that a pain level of 6 warranted contacting the provider, but this did not occur. Facility policy required prompt assessment and management of pain, including obtaining physician orders and administering medication as needed. Despite these guidelines, the resident's pain was not addressed in a timely manner, and the care plan interventions to observe and manage pain were not followed. The lack of documentation and failure to provide ordered pain medication led to unmanaged pain for the resident.
Failure to Notify Providers of Abnormal Lab Results
Penalty
Summary
The facility failed to ensure that providers were notified of abnormal laboratory results for two out of three residents reviewed. In the first case, a resident with a complex medical history including end-stage renal disease, systemic lupus erythematosus, and chronic kidney disease experienced seizures and was noted by her representative to be lethargic, in pain, and not her usual self. Despite laboratory tests being ordered and drawn, the assigned LPN informed the resident's representative that results would be reviewed when the doctor returned and did not notify the provider of the abnormal findings, which included low iron, glucose, and chloride, as well as elevated BUN, creatinine, and potassium. There was no documentation in the progress notes that the physician was informed of these abnormal results, and the primary care provider confirmed he was not contacted regarding the resident's pain, change in condition, or lab values on that day. In the second case, another resident with end-stage renal disease, epilepsy, thrombocytopenia, and a history of transient ischemic attack had STAT labs ordered due to tremors and feeling cold. The labs, which revealed multiple abnormal values such as low RBC, hemoglobin, hematocrit, platelet count, and high neutrophils, were completed and available the same day. However, there was no documentation that the provider was notified of these abnormal STAT lab results. The provider's assistant stated that notification and documentation of such results would be expected, but neither she nor the provider recalled being notified, and the facility's records did not show evidence of such communication. Interviews with the DON and Regional Nurse Consultant confirmed that the facility's policy requires prompt notification and documentation of abnormal lab results, especially for STAT and critical values. They acknowledged discrepancies in physician notifications and verified that there was no documentation of provider notification for either resident prior to discharge. The facility's policy also specifies that such communications should be documented in the progress notes or on the lab results sheet, but this was not done in these cases.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Surveyors identified that the facility failed to provide timely and appropriate incontinence care for four residents who were sampled. Multiple residents reported that staff did not respond promptly to call lights, especially during night shifts, resulting in residents remaining in soiled briefs for extended periods, sometimes until the next shift. In some cases, staff turned off call lights without providing care, and residents had to wait for significant periods, sometimes up to an hour and a half, before receiving assistance. These incidents were corroborated by resident interviews and review of care documentation, which showed missed incontinence care tasks across various shifts. The residents involved had significant medical histories and functional limitations. One resident had diagnoses including overactive bladder, muscle weakness, and required substantial assistance with toileting hygiene, being always incontinent for bowel and bladder. Another resident, with a history of femur fracture and diabetes, also required assistance and was always incontinent, but reported that staff response was slow, leading to prolonged periods in soiled briefs. A third resident, with severe cognitive impairment and hemiplegia, was dependent on staff for all toileting needs and was not a candidate for a toileting program, yet did not receive incontinence care as scheduled. A fourth resident, with a history of fracture and muscle atrophy, was occasionally incontinent and dependent on staff, but also experienced significant delays in care. Care plans for these residents specified the need for regular incontinence checks and care, including checking and changing upon arising, before and after meals, at bedtime, and as needed. Staff interviews revealed that CNAs relied on residents to use call lights to request care and checked on residents when time permitted, rather than following scheduled checks. The Director of Nursing acknowledged previous issues with night shift care and stated that residents should be checked every two hours, with documentation required for each shift. However, documentation and resident reports indicated that these protocols were not consistently followed, resulting in unmet care needs.
Failure to Provide PPE and Implement Isolation Precautions for Residents on Contact and Enhanced Barrier Precautions
Penalty
Summary
Surveyors observed that the facility failed to ensure appropriate implementation of infection prevention and control measures for residents requiring isolation precautions. Multiple observations revealed that personal protective equipment (PPE) was not available outside or near the rooms of residents on Contact Precautions or Enhanced Barrier Precautions (EBP). Staff were seen entering rooms with posted precaution signs without donning PPE, and PPE storage was inconsistent, with mesh bags inside rooms often found empty. Signs indicating the need for EBP or Contact Precautions were posted, but the required PPE was not accessible as per facility policy and CDC guidelines. Residents involved had significant medical histories, including bacteremia, MRSA, ESBL infections, wounds, and intravenous access, all of which necessitate strict adherence to isolation protocols. Orders and care plans for these residents specified the need for EBP and Contact Precautions, yet observations showed that these precautions were not consistently followed. Staff interviews revealed confusion regarding which residents required which type of precautions, and there was a lack of clarity about the correct placement and availability of PPE. Some staff were unaware of the specific organisms present or the correct isolation status of residents, leading to further lapses in infection control. The facility's own policy required gloves and gowns to be donned before entering rooms under Contact Precautions, and for PPE to be available for EBP during high-contact activities. However, surveyors found that in at least five rooms with posted precaution signs, PPE was not supplied as required. Interviews with the infection preventionist, DON, and other staff confirmed inconsistencies in the application of precautions and the stocking of PPE. The lack of PPE availability and staff adherence to protocols directly contributed to the deficiency in the facility's infection prevention and control program.
Ineffective Pest Control Program Resulting in Ongoing Insect Infestations
Penalty
Summary
Surveyors observed multiple live insects in various areas of the facility during two consecutive days of inspection. On the first day, a live insect was seen crawling near the conference room in the 400-hall, and small flying insects were observed landing on surfaces in the dining hall/activity area while residents were present. The following day, another live insect was seen crawling near the 100-hall, with staff present in the area. Additionally, a resident reported the presence of roaches in their room, stating that staff had been notified, drawers were cleaned, and spraying had occurred, but the issue persisted. Facility documentation, including pest control service inspection reports, confirmed ongoing treatments for flies, rats, ants, and roaches, with pest sightings documented. Interviews with the Director of Maintenance and the Nursing Home Administrator revealed that pest control services were contracted and provided weekly, with additional visits arranged for emergencies. However, the Director of Maintenance denied the presence of roaches, attributing sightings to a local Florida bug, and was unaware of any pest complaints. The facility's pest control policy requires maintaining contracts, service logs, and evaluating service effectiveness, but observations and resident reports indicated the pest control program was not effective in preventing or addressing infestations.
Failure to Promptly Address and Resolve Grievance Regarding Missing Dentures
Penalty
Summary
The facility failed to ensure that a grievance regarding a resident's missing bottom dentures was promptly addressed and resolved to the satisfaction of the complainant. The grievance was filed by the resident's family member, and the facility's Grievance/Concern Log indicated the concern was resolved within two days. However, documentation revealed that the facility did not designate a specific individual or department to handle the grievance, and there was no documented conclusion or summary of findings. The log also did not indicate whether the grievance was resolved to the satisfaction of the resident or their representative. Interviews with facility staff, including the Nursing Home Administrator (NHA), Risk Management Consultant (RMC), Business Office Manager (BOM), and Social Service Director (SSD), revealed inconsistencies and gaps in communication and documentation. The BOM reported only one documented contact with the family on the day the resident left the facility, and a follow-up attempt was made nearly two months later. The SSD was unaware of the grievance and confirmed there were no social service notes in the resident's record regarding the missing dentures or related conversations with the family. The facility's policy required prompt efforts to resolve grievances, assignment of concerns to appropriate departments, and documentation of resident or representative satisfaction, none of which were fully met in this case. The resident involved had multiple medical diagnoses, including a femur fracture, diabetes, alcohol abuse, and malnutrition, and was transferred to the emergency room and did not return to the facility. The admission inventory indicated the resident had both top and bottom dentures, but the form was undated. Progress notes did not document the representative's concern or any facility communication regarding the missing dentures. The lack of thorough investigation, documentation, and follow-up led to the failure to resolve the grievance in accordance with facility policy.
Failure to Provide Timely Pain Medication Due to Reordering and Communication Lapses
Penalty
Summary
The facility failed to provide pain medication as ordered for one resident, resulting in a missed dose of Oxycodone 10 mg for non-acute pain. The resident, who had a history of spinal stenosis, neuralgia, neuritis, monoarthritis, and unspecified pain, reported issues with receiving pain medication over the past month. Record review confirmed that the medication count for Oxycodone reached zero on 4/25/2025, and a dose was missed on 4/26/2025. The prescription for the medication was faxed to the pharmacy on the morning of 4/26/2025, but the medication was not delivered until after 7:30 p.m. that day. Interviews with nursing staff and pharmacy representatives revealed that the process for obtaining narcotics from the automated medication dispensing machine was not consistently followed, and there was confusion regarding when and how to access emergency supplies. Staff indicated that nurses are expected to reorder narcotics when the count reaches ten pills, and that a warning is present on the medication card to prompt reordering. However, the medication was not reordered in time, and the resident went without the prescribed pain medication. The facility's policy requires timely communication of orders to the pharmacy, but this process was not effectively implemented in this instance.
Failure to Provide Timely and Consistent Incontinence Care
Penalty
Summary
Multiple residents experienced significant delays and omissions in receiving incontinence care, as evidenced by both resident interviews and documentation reviews. One resident reported that after activating her call light at night, a staff member entered, turned off the light, and left without providing care, resulting in her remaining in a wet brief until the next shift. This resident stated that such incidents occurred three to four nights per week, and that staff did not check on her during the night as care plans required. Documentation for this resident showed missing entries for incontinence care across several shifts, indicating a lack of consistent care and documentation. Another resident, who was always incontinent for bladder and bowel, reported that staff response to her requests for incontinence care was slow, often resulting in her waiting over forty-five minutes after urinating before being assisted. This was described as a daily occurrence. Documentation for this resident also revealed missing entries for incontinence care on multiple shifts. Additional residents described similar issues, including long wait times for call lights to be answered, especially during night shifts, and having to remain in soiled briefs for extended periods. One resident reported waiting up to an hour and a half for care, with staff sometimes turning off call lights without providing assistance. Staff interviews corroborated these findings, with CNAs reporting being assigned to care for large numbers of residents alone, making it difficult to provide timely incontinence care. Staff also indicated that care was sometimes left undone between shifts due to heavy workloads and insufficient staffing. The DON acknowledged ongoing struggles with staffing and confirmed that documentation of incontinence care was often incomplete, despite facility policies requiring residents to be checked every two hours and care to be documented on each shift.
Failure to Maintain Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records for three of the seven sampled residents. On October 1, 2024, a Registered Nurse (RN), identified as Staff A, was observed placing used tube feeding bottles with resident-identifiable information into an unsecured, publicly accessible trash can. This occurred for two residents, as the RN detached the feeding tubes from their gastrostomy sites and disposed of the bottles without removing or marking off the resident information. Additionally, the RN left a medication cart unattended with a computer open displaying a resident's medical information and a resident roster exposed on top of the cart. This lapse in security occurred while the RN went to the supply room and again when she returned to provide care to another resident, leaving the information accessible to other residents, staff, and visitors. The Director of Nursing confirmed that staff should have marked off any resident-identifiable information before disposal, as per the facility's policy on resident rights.
Deficiencies in Tracheostomy and Enteral Feeding Care
Penalty
Summary
The facility failed to provide care consistent with the comprehensive person-centered care plan for two residents with tracheostomies. For one resident, the facility did not confirm physician orders related to tracheostomy care, enteral feeding, and medication administration. There were multiple instances where documentation was lacking for essential care activities, such as tracheostomy suctioning, medication administration, and monitoring of vital signs. The resident's care plans indicated the need for enhanced barrier precautions, enteral nutrition, and pain management, but these interventions were not consistently documented as performed. Another resident, who was cognitively intact, also experienced deficiencies in care related to tracheostomy management and enteral feeding. Documentation was missing for the administration of medications, oxygen therapy, and the maintenance of enhanced barrier precautions. The resident's care plans included interventions for nutritional support, pain management, and respiratory care, but these were not consistently documented, indicating a failure to adhere to the prescribed care plan. The Director of Nursing acknowledged the lack of documentation and confirmed that staff were expected to document care activities. The facility's policies required accurate transcription and confirmation of physician orders, as well as documentation of procedures and observations. However, these policies were not followed, leading to gaps in care and documentation for both residents.
Inadequate Tracheostomy and Suctioning Care
Penalty
Summary
The facility failed to provide tracheostomy and suctioning care consistent with professional standards of practice and the resident's comprehensive person-centered care plan for a resident. During an observation, a registered nurse (RN) entered the resident's room without wearing a gown, which was required under enhanced barrier precautions due to the resident's tracheostomy and other medical devices. The RN performed various tasks, including detaching feeding tubes and suctioning the resident, without adhering to proper hand hygiene protocols. The RN did not perform hand hygiene between glove changes and handled equipment and resident care items without appropriate infection control measures. The resident involved had a complex medical history, including anoxic brain damage, respiratory disorders, and acute and chronic respiratory failure, among other conditions. The resident was dependent on staff for care and had a tracheostomy, requiring specific care and precautions. The facility's care plan for the resident included enhanced barrier precautions, which mandated the use of gloves and gowns during high-contact care activities. However, the RN did not follow these precautions, and there was a lack of documentation for tracheostomy care, including the recording of secretions and vital signs post-suctioning. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed that the staff did not follow the expected infection control protocols. The DON confirmed that the RN should have worn a gown and performed hand hygiene between tasks. The ADON, who also served as the Infection Control Preventionist, reiterated the importance of hand hygiene and the proper use of personal protective equipment (PPE). The facility's policies on hand hygiene and barrier precautions were not adhered to, contributing to the deficiency in care provided to the resident.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to standard and enhanced barrier precautions during the care of two residents, leading to a deficiency in infection prevention and control. On multiple occasions, a registered nurse (RN) entered the room of a resident with a tracheostomy and gastrostomy tube without donning a gown, despite the requirement for enhanced barrier precautions. The RN was observed performing various care tasks, such as detaching feeding tubes and suctioning the tracheostomy, without proper hand hygiene between glove changes and without wearing the necessary personal protective equipment (PPE). The RN admitted to not following the enhanced barrier precautions, which were indicated by an orange sign on the resident's door. The resident had multiple medical conditions, including anoxic brain damage and respiratory failure, and required enhanced barrier precautions due to the presence of a tracheostomy, gastrostomy tube, and suprapubic catheter. Despite the facility's policy and the resident's care plan requiring the use of gloves and gowns during high-contact care activities, the RN did not comply with these protocols. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed the expectations for staff to wear appropriate PPE and perform hand hygiene as per the facility's policies. The DON and ADON acknowledged that the RN's actions did not align with the facility's infection control protocols, which emphasize the importance of hand hygiene and the use of gowns and gloves during high-contact care activities to prevent the transmission of infections.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 26 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lake Wales
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Wales Health And Rehabilitation Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Astoria Health And Rehabilitation Center | 10.7 mi | ★★★★★ | 0 | 0 |
| Palm Garden Of Winter Haven | 11.4 mi | ★★★★★ | 0 | 0 |
| Lake Mariam Health And Rehabilitation Center | 11.4 mi | ★★★★★ | 4 | 2 |
| Life Care Center Of Winter Haven | 11.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.