Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grove Nursing Center during CMS and state inspections, most recent first.
Respiratory therapy orders and documentation were incomplete for two residents. One resident with COPD and sleep apnea had an oxygen order entered after an ER visit, but the TAR did not document the oxygen use for a period of time, and staff confirmed the order had not been properly shown on the TAR. Another resident with chronic respiratory failure and moderate cognitive impairment used NIV and oxygen, but the chart did not include the NIV settings or oxygen flow rate, the care plan lacked respiratory interventions, and staff confirmed there was no physician order for supplemental oxygen before the order was later found in the record.
Expired and outdated medications were found on two medication carts during observation, including an expired vitamin, an expired vibegron bottle, an expired anti-diarrheal box, and opened latanoprost eye drops that had exceeded the stated use period. Staff, including medication aides, an LPN, the DON, the Administrator, and the Pharmacy Consultant, acknowledged that carts should be checked for expired medications, but the expired items remained on the carts.
The facility failed to maintain infection control when a CNA did not perform hand hygiene between residents during meal service after touching resident belongings and equipment. Respiratory equipment for two residents was observed improperly cleaned or stored, with an NIV mask left with dried debris and oxygen tubing left on the floor, draped on furniture, or otherwise unsecured. The emergency cart was also observed dirty, and a suction tip was found removed from its package and left exposed on the cart surface.
Dignity Not Maintained During Meal Assistance: Two residents with severe cognitive impairment and significant eating assistance needs were observed being fed by a CNA who stood between them in the dining room instead of assisting from a seated position. Facility policy stated residents who need feeding assistance should be fed with attention to safety, comfort, and dignity, including not standing over residents, and the RN, DON, and ADM all stated staff should sit alongside the resident during meal assistance.
Two residents with intact cognition had medications stored at the bedside without documented IDT assessment for self-administration. One resident kept nasal sprays in the room and used them without telling staff, while the other kept eye drops at the bedside and used them as needed without notifying the nurse. The care plans and order summaries showed no documentation that either resident was approved to self-administer, and staff and leadership stated bedside medications required assessment and approval.
Resident room not maintained in good repair or homelike condition. Two residents shared a room with marked walls, black scuffs, and peeling paint, and one resident said the walls had gashes and needed painting. HK staff said chipped or peeling paint required a maintenance work order, while the Maintenance Director said rooms should be inspected and repaired before a new resident moved in; the DON and ADM stated repairs were expected before admission.
A facility failed to develop complete person-centered care plans for a resident on hospice and another resident receiving respiratory support. The hospice resident’s care plan lacked a hospice focus, goal, and interventions, while the respiratory resident’s plan omitted NIV and oxygen therapy despite orders and observations showing use of both. MDS staff and the DON stated care plans should reflect these needs, but the plans were not accurately maintained.
The facility failed to provide written notice of transfer or discharge to two residents with diabetes mellitus before they were transferred to other facilities. One resident was sent to an emergency room after a fall, and another was transferred to a hospital for behaviors. The facility's policy lacked instructions for providing such notices, and the DON confirmed the oversight.
The facility failed to attempt alternatives to bed rails, inspect bed rails for proper fit, educate residents and their representatives on risks and benefits, and obtain informed consent before use. This deficiency was observed in three residents, with the facility's policies on side rails and bed safety not being followed. The DON admitted that alternatives were not attempted, and consent was not obtained, while the Maintenance Supervisor and Administrator did not ensure proper inspection and compatibility of bed rails.
A facility did not include the use of an anticoagulant in a resident's care plan, despite a physician's order and documentation of its use. Interviews with LPNs and the DON confirmed that anticoagulants should be addressed in the care plan, with monitoring for bleeding and bruising.
A facility failed to monitor electrolyte levels for a resident on Furosemide, a diuretic medication, despite the resident's chronic systolic congestive heart failure diagnosis. The resident's medical records lacked documentation of electrolyte assessments since admission, and no lab work orders were found. The DON confirmed the absence of a policy for routine lab work with diuretics, relying on physicians to order labs as needed.
A CNA failed to change gloves and clean hands between handling soiled and clean surfaces while providing perineal care to a resident with pressure ulcers. The CNA touched the resident's skin, clothing, and moved a remote control with dirty gloves. The LPN and DON acknowledged the lapse in infection control practices.
Respiratory Therapy Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to ensure appropriate respiratory services were provided for Resident #16 and Resident #34. A facility policy for CPAP/BiPAP/Non-Invasive Ventilator support stated that staff were to review the physician’s order, set the machine as prescribed, connect supplemental oxygen after the machine was turned on, and monitor oxygen saturation. The report identified that the facility did not consistently document respiratory therapy orders and settings in the residents’ medical records. Resident #16 had diagnoses including COPD and sleep apnea and was readmitted after an ER visit. The ER nurse reportedly said the resident may need oxygen at night at 1 L/min, and an order was entered allowing oxygen at 1 L/min at bedtime. However, the May 2026 TAR contained no transcription of the oxygen order, and the June 2026 TAR also had no transcription prior to 06/03/2026. During observation, an oxygen concentrator was present in the resident’s room, and the resident stated they wore oxygen at night and during naps and had started about a week earlier. Staff confirmed the oxygen use was not documented on the TAR because the order had not been entered correctly. Resident #34 had diagnoses including chronic respiratory failure with hypoxia and atrial fibrillation and had moderate cognitive impairment. The resident’s record showed use of oxygen therapy and non-invasive mechanical ventilation, but the care plan did not include respiratory focus areas or interventions for NIV or oxygen therapy. The non-invasive prescription listed pressure support settings, a backup rate, and oxygen bleed-in at 3 L/min when using NIV, yet the order recap did not include the NIV settings or oxygen flow rate, and there was no physician order for continuous or PRN supplemental oxygen before 06/03/2026. The June 2026 TAR documented NIV application and removal but did not show the settings or supplemental oxygen use. Observations showed the NIV machine and mask in the room, and the resident stated they used the machine nightly but did not know the settings or oxygen amount; the resident also stated they were supposed to be on 2 L via nasal cannula. Staff and the DON confirmed the record lacked the needed oxygen and NIV order details.
Expired Medications Found on Medication Carts
Penalty
Summary
The facility failed to ensure expired medications were removed from 2 of 3 medication carts reviewed for medication storage, including the 400 Hall and 500 Hall carts. Facility policy stated that nursing staff were responsible for maintaining medication storage areas in a clean, safe, and sanitary manner and that discontinued, outdated, or deteriorated drugs or biologicals were not to be used and were to be returned to the dispensing pharmacy or destroyed. A manufacturer package insert for latanoprost ophthalmic solution stated that once opened, it could be stored at room temperature for 6 weeks. During observation, an expired bottle of Vitamin B12 was found on the 400 Hall cart for one resident. On the 500 Hall cart, surveyors found a box of anti-diarrheal tablets with an April 2026 expiration date, two opened bottles of latanoprost eye drops for two residents with open dates of 04/16/2026 and 04/17/2026, a bottle of vibegron tablets with an expiration date of 01/10/2026, and a bottle of Metamucil powder with an expiration date of 05/2026. Staff interviews showed that medication aides, an LPN, the DON, and the Administrator all identified staff responsibility for checking carts for expired medications, while the Pharmacy Consultant stated he checked one cart each month and confirmed the medications found were expired.
Infection Control Failures With Hand Hygiene, Respiratory Equipment, and Emergency Cart Supplies
Penalty
Summary
The facility failed to maintain an infection prevention and control program when a CNA did not perform hand hygiene between residents during meal service. During observation, the CNA delivered meal trays to three residents, touched resident belongings and equipment, and exited rooms without sanitizing or washing her hands between each resident. The CNA later stated she should have sanitized her hands between residents and that she generally kept hand sanitizer in her pockets, but did not have it that day. The IP/ADON, DON, and Administrator each stated that staff should use hand hygiene between residents, especially after handling resident equipment or belongings. The facility also failed to properly clean and store respiratory equipment for two residents. One resident had chronic respiratory failure with hypoxia and paroxysmal atrial fibrillation, received NIV and oxygen therapy, and had moderate cognitive impairment. Observations showed the NIV mask repeatedly left on top of the machine with dried debris visible inside, while oxygen tubing and a cannula were tangled, lying on the floor, or draped across furniture without a storage bag. The resident stated staff had not cleaned the mask and that tubing was usually placed on a chair when not in use. An LPN stated she had not cleaned the mask and was unaware of the cleaning or storage procedures, while other staff stated the mask should be wiped, dried, and stored in a bag and the tubing should be kept off the floor. A second resident with COPD and sleep apnea had oxygen tubing left lying across the concentrator, on the over-the-bed table, and hanging down the side during multiple observations. The resident stated the tubing was placed on the table or machine when not in use because no one had told them otherwise. Staff interviews showed uncertainty about proper storage, with one LPN unsure where tubing should be kept and other staff describing different storage methods. The DON and Administrator stated respiratory equipment should be stored in a bag when not in use. The facility also failed to keep the emergency cart clean and maintain suction supplies in closed packaging. During observation, the cart had a sticky brown substance spilled on the top and on the plastic covering the suction machine, and a suction tip was attached to tubing and lying exposed in the substance. On recheck, the suction tip was still removed from its package and lying on the cart surface. The DON stated the suction tip should not be removed from the package until ready for use, and the Administrator stated the cart should be kept clean and the suction tip should remain unopened until use.
Dignity Not Maintained During Meal Assistance
Penalty
Summary
The facility failed to treat residents in a manner that maintained dignity and respect during meal assistance for two residents who required help with eating. A facility policy titled, Assistance with Meals, stated that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals. Resident #15 was admitted with diagnoses including anxiety disorder, unspecified dementia, gastro-esophageal reflux disease, and recurrent depressive disorders, and had severe cognitive impairment, short- and long-term memory problems, and dependence on staff for all ADLs. Resident #15's care plan indicated the resident required assistance to eat. Resident #46 was admitted with diagnoses including Alzheimer's Disease, dementia in other diseases classified elsewhere, and restlessness and agitation, and had severe cognitive impairment, short- and long-term memory problems, and required substantial/maximal assistance with eating. During an observation in the dining room, CNA #12 was seen assisting Resident #15 and Resident #46 with eating while standing between the two residents instead of providing the assistance from a seated position. During interview, CNA #12 stated she sometimes sat and sometimes stood while assisting residents and could not recall what was taught about the best practice for meal assistance. RN #3, the DON, and the Administrator each stated that staff should be sitting next to the resident during meal assistance and should not stand over or stand up while feeding the resident.
Failure to Assess Residents Before Allowing Bedside Medications
Penalty
Summary
The facility failed to ensure that two residents with medications at their bedside were assessed by the interdisciplinary team to determine whether self-administration was clinically appropriate and safe. The facility policy stated that residents may self-administer medications only if the IDT determines it is clinically appropriate and safe, and that staff and the practitioner must assess the resident’s mental and physical abilities, including understanding medication labels, purpose, dosage, timing, administration, and risks. Resident #1 was admitted and later re-admitted with diagnoses including pneumonia and hypertensive heart disease. The resident had a BIMS score of 15, indicating intact cognition. During observations, bottles of saline nasal spray, Afrin nasal spray, and later saline nasal spray and Vicks Severe nasal spray were found on the resident’s counter next to the television. The resident stated the medications were brought from home, the facility was aware, and the resident did not tell staff when the medications were used. The resident’s care plan contained no documentation regarding self-administration, and the order summary showed no order for a nasal spray or evidence that the resident was able to self-administer medication or keep medication at the bedside. Resident #22 was admitted with diagnoses including paroxysmal fibrillation and essential hypertension and also had a BIMS score of 15. During observations, two bottles of Refresh Tears and one bottle of Visine were found on the bedside table. The resident stated the eye drops were used as needed and that staff were not told when they were used. The resident could not recall whether the drops came from the facility or family. The care plan contained no documentation regarding self-administration, and the order summary showed an order for artificial tears as needed but no evidence that the resident was able to self-administer medication or keep medication at the bedside. Staff interviews indicated they were unaware of the bedside medications, and the DON and ADM stated that residents had to be assessed and approved before keeping medications at bedside, with no residents in the building self-administering medications.
Resident Room Not Maintained in Good Repair or Homelike Condition
Penalty
Summary
The facility failed to ensure a shared resident room was in good repair and homelike for two residents. A facility policy titled, Quality of Life - Homelike Environment, stated residents are to be provided with a safe, clean, comfortable, and homelike environment, with clean, sanitary, orderly surroundings and inviting colors and decor. Resident #65 was admitted with a history of heart failure, and Resident #66 was admitted with diagnoses of generalized anxiety disorder, depression, unspecified, and adult failure to thrive. During observation of the shared room, surveyors found several white marks on a blue accent wall, black marks on a white wall, and a spot of peeling paint about three inches long by three inches wide. Resident #66 stated the room walls had gashes and needed to be painted. Housekeeping staff stated chipped paint and peeling paint required a maintenance work order, and the Maintenance Director stated rooms should be inspected after residents moved out for needed paint or repairs. He also stated he was the only maintenance staff member and had not been notified about the chipped and old paint in the room. The DON stated repairs were expected before a new resident moved in, and the Administrator stated there was no excuse for the room to be in that condition.
Incomplete care plans for hospice and respiratory needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timetables for Resident #5 and Resident #34. The facility policy stated that care plans must include measurable objectives, timeframes, services to be furnished, identified problem areas, and the professional services responsible for each element of care. However, the care plan for Resident #5, who was admitted on 04/28/2026 with diagnoses including acute on chronic systolic congestive heart failure, paroxysmal atrial fibrillation, anxiety disorder, COPD with exacerbation, major depressive disorder, and obstructive sleep apnea, did not include a hospice focus area, goal, or interventions before 06/03/2026 even though the resident was receiving hospice care and had a BIMS score of 15 indicating intact cognition. During interviews, RN MDS staff stated they were responsible for developing and updating care plans using nursing documentation, physician orders, and staff or resident interviews, and that hospice information should be incorporated into the comprehensive care plan. RN MDS staff also stated that care plans were not reviewed for accuracy after MDS completion. The DON stated Resident #5 had been on hospice since admission and that the facility relied on hospice information being scanned in before staff created the comprehensive care plan. The DON also stated care plan reviews were set by review dates and were not reviewed for accuracy because administration did not micromanage. The facility also failed to include respiratory care in Resident #34’s care plan. Resident #34, admitted on 10/25/2023 and readmitted on 12/26/2025, had diagnoses including chronic respiratory failure with hypoxia and paroxysmal atrial fibrillation, a BIMS score of 10, and was receiving oxygen therapy and non-invasive mechanical ventilation. Observations showed an NIV machine on the over-bed table with the mask lying on top of it, and the resident later seated in the dining room wearing oxygen via nasal cannula connected to a portable tank at 2 L/min. The care plan did not include a respiratory focus area for NIV or oxygen therapy, and it lacked interventions for cleaning or storage of the NIV mask or oxygen tubing, or for the resident’s oxygen use. RN MDS staff stated the respiratory care plan had been mistakenly resolved because the resident was refusing NIV, but acknowledged it should have been updated to reflect refusal rather than discontinued since the resident still required supplemental oxygen.
Failure to Provide Written Notice of Transfer or Discharge
Penalty
Summary
The facility failed to provide residents or their representatives with a written notice of transfer or discharge prior to the residents leaving the facility. This deficiency was identified for two residents, both diagnosed with diabetes mellitus. One resident was transferred to a community emergency room following a fall, and another was transferred to an acute care hospital due to behaviors. The facility's Transfer or Discharge Documentation policy, dated December 2016, did not include a requirement to provide written notice of transfer or discharge to residents or their legal representatives before the transfer or discharge occurred. The Director of Nursing confirmed that the residents were not given written notices before being sent to other facilities for treatment.
Failure to Follow Bed Rail Safety Protocols
Penalty
Summary
The facility failed to ensure that alternatives to bed rails were attempted before their use, that bed rails were inspected for proper fit and condition, and that residents and their representatives were educated on the risks and benefits of bed rails. Additionally, informed consent was not obtained from the residents or their legal representatives before attaching bed rails to the beds. This deficiency was observed in three residents who were reviewed for accident hazards, with the facility's policies on the proper use of side rails and bed safety not being followed. The facility's policies required obtaining consent after informing residents or their representatives of the benefits and risks of bed rails and ensuring bed rails were properly installed according to the manufacturer's instructions. However, the Director of Nursing admitted that alternatives to bed rails were not attempted, and written consent was not obtained. The Maintenance Supervisor stated that bed rails were not inspected prior to first use by residents, and the Administrator assumed compatibility of bed rails and beds without inspection. These oversights led to the deficiency identified by the surveyors.
Failure to Include Anticoagulant in Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident who was prescribed an anticoagulant medication, apixaban, for conditions including paroxysmal atrial fibrillation and hypertension. Despite a physician's order for the medication and documentation of its use in the resident's admission assessment, the care plan did not address the anticoagulant. Interviews with two LPNs and the DON confirmed that the use of anticoagulants should be included in the care plan, along with monitoring for signs of bleeding and bruising.
Failure to Monitor Electrolyte Levels for Resident on Diuretics
Penalty
Summary
The facility failed to ensure that a resident receiving Furosemide, a diuretic medication, was monitored for electrolyte levels, which is crucial for residents with conditions such as chronic systolic congestive heart failure. Resident #28, who was admitted and readmitted to the facility, had no documented assessment or review of electrolyte levels by a healthcare professional since admission. Despite being prescribed Furosemide 20 mg daily for congestive heart failure, there was no physician order for lab work to monitor these levels. The Director of Nursing (DON) confirmed the absence of documentation for electrolyte level assessment and stated that the facility did not have a policy for routine lab work when administering diuretics, relying instead on physicians to order labs as needed.
Inadequate Infection Control During Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the care of a resident with pressure ulcers. During an observation, a CNA was seen providing perineal care to a resident without changing gloves or cleaning their hands between handling soiled undergarments and touching clean surfaces. The CNA, while wearing dirty gloves, also touched the resident's skin, clothing, and moved the television remote control closer to the resident. The LPN present during the care acknowledged that the CNA did not change gloves during the procedure, and the Director of Nursing confirmed that the CNA should have changed gloves and cleaned their hands between steps of the care process. The CNA admitted to being nervous and forgetting to change gloves and clean their hands after providing perineal care.
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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.
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Nursing homes near Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand Lake Villa | 0.9 mi | ★★★★★ | 10 | 3 |
| Betty Ann Nursing Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Monroe Manor | 10.5 mi | ★★★★★ | 1 | 0 |
| Maple Healthcare And Rehab | 12.1 mi | ★★★★★ | 0 | 0 |
| Mcdonald County Living Center | 20 mi | ★★★★★ | 0 | 0 |
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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 August 2026) and official state health department websites.