Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Grove Manor during CMS and state inspections, most recent first.
The facility failed to give written bed-hold notices to two residents upon hospital transfer and failed to communicate required clinical information to the receiving provider for three residents. The affected residents had diagnoses including DM, HF, HTN, COPD, GERD, and dementia, and their records lacked evidence of the required bed-hold policy notice or transfer documentation. The DON confirmed the missing documentation.
A resident with COPD, GERD, and bladder cancer was assessed for smoking and declined a nicotine patch, stating a desire to continue smoking. The resident was later observed smoking in the designated outdoor area, but the clinical record lacked evidence of a care plan addressing smoking, and the DON confirmed no such care plan had been developed.
Outdated and improperly labeled medications were found in storage. An open Lantus insulin pen in a medication cart was beyond the 28-day use limit, and an LPN confirmed it should have been discarded. In the medication room refrigerator, an open Aplisol vial had no opened date, and staff could not determine its discard date.
The facility did not meet the required nurse aide (NA) staffing ratios, failing to provide one NA per 10 residents during the day shift on six occasions and one NA per 11 residents during the evening shift on two occasions. The Human Resource Manager/Scheduler confirmed these staffing shortages.
A resident with dementia and other health issues did not receive scheduled showers for seven days, as confirmed by facility documentation and staff interviews. The resident's care plan specified showers on Wednesdays and Saturdays, but there was no evidence of showers being provided or refused during this period.
Two residents suffered from neglect in a facility, resulting in the development and worsening of Stage Three pressure ulcers. Despite being at risk, the facility failed to conduct regular skin assessments and implement necessary interventions like turning and repositioning. This neglect led to significant harm, as confirmed by the DON and NHA.
Two residents suffered harm due to the facility's failure to monitor, assess, and implement preventative measures for pressure ulcers. One resident's Stage Two ulcer worsened to Stage Three, and a new Stage Three ulcer developed, while another resident developed multiple Stage Three ulcers. The facility did not conduct regular skin assessments or follow recommended interventions, as confirmed by the DON and NHA.
Failure to Provide Bed-Hold Notices and Transfer Information
Penalty
Summary
The facility failed to provide residents and/or their resident representatives with a written notice of the bed-hold policy, including how long a bed could be held during a leave of absence and the cost per day, upon transfer to the hospital or within 24 hours of transfer for two residents reviewed. The facility policy stated that residents or resident representatives were to be informed in writing of the bed-hold and return policy prior to transfers and therapeutic leaves. Resident R1 had diagnoses including diabetes, heart failure, and high blood pressure, and Resident R57 had diagnoses including diabetes, high blood pressure, and dementia. The clinical records for these residents lacked evidence that the bed-hold policy was provided as required. The facility also failed to ensure that necessary resident information was communicated to the receiving health care provider when three residents were transferred to the hospital. Resident R1, Resident R12, and Resident R57 each had progress notes documenting hospital transfers, but their clinical records lacked evidence that the required clinical information was sent to the receiving provider. The facility policy for transfer/discharge documentation stated that information such as the basis for transfer, practitioner contact information, resident representative information, advance directive information, special instructions or precautions, care plan goals, and other necessary information was to be communicated during a transfer. During interview, the DON confirmed that the records lacked evidence of the required communication and that the bed-hold policy was not documented for Residents R1 and R57.
Failure to Develop Care Plan for Smoking
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident with an admission date of 5/17/25 and diagnoses including COPD, GERD, and bladder cancer. Clinical records showed that a smoking assessment was completed on 5/28/25, at which time the resident was offered a nicotine patch but declined it and stated a desire to continue smoking. The resident was observed on 9/17/25 at 3:00 p.m. smoking in the designated area outside the facility. The resident’s clinical record did not contain evidence of a care plan addressing smoking, and the DON confirmed during interview on 9/17/25 at 1:15 p.m. that no care plan had been developed to address the resident’s smoking.
Outdated and Undated Medications Found in Storage
Penalty
Summary
Drugs and biologicals were not appropriately labeled and stored in accordance with accepted professional principles because outdated medications were found in the facility. Review of facility policies showed that medications were to be monitored to ensure they were not expired, contaminated, or unusable, and that all medications were to be properly labeled according to current state and federal guidelines and regulations. Manufacturer guidance also stated that an open Lantus/Basaglar insulin pen must be discarded within 28 days after opening, even if insulin remains in the pen. During observation of medication Cart A, an open Lantus insulin pen was found with an open date and discard date that showed it was beyond the 28-day limit. An LPN confirmed at the time of observation that the pen was beyond 28 days and should have been discarded. In the medication storage room refrigerator, an open vial of Aplisol was observed with no date indicating when it had been opened. Manufacturer guidance stated that Aplisol vials in use for more than 30 days should be discarded, and the LPN confirmed that the vial lacked an opened date and staff were unable to determine the discard date.
Nurse Aide Staffing Deficiency
Penalty
Summary
The facility failed to meet the required nurse aide (NA) staffing ratios as per the regulation effective July 1, 2024. Specifically, the facility did not maintain the minimum NA ratio of one NA per 10 residents during the day shift on six occasions and one NA per 11 residents during the evening shift on two occasions within the review period from November 17, 2024, to December 7, 2024. On the day shift, the facility was short of the required number of NAs on November 17, 21, 29, 30, December 3, and 5, 2024, with the number of NAs working being less than required based on the resident census. Similarly, on the evening shift, the facility did not meet the required NA ratio on November 18 and 30, 2024. The Human Resource Manager/Scheduler confirmed these staffing shortages during an interview on December 11, 2024.
Plan Of Correction
There were no negative care impacts to any resident as a result of the identified concern. The daily per patient day (PPD) staffing numbers remained over the state minimum. The facility cannot retroactively correct this finding. Nursing leadership will be re-educated on the Pennsylvania licensed professional staffing requirements by the Director of nursing or designee. The Scheduler was re-educated on CNA ratios by the Nursing Home Administrator. The facility will continue to recruit their own staff and contract with various agencies to meet CNA ratios. The Director of nursing or Designee will audit staffing ratios five times per week for four weeks, then re-evaluate for need to increase or decrease monitoring to verify that all measures are being taken to meet licensed practical nurse staffing ratios. Audit findings will be submitted to the Quality Assurance and Performance Improvement Committee for further review and recommendations.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident R26, received showers as scheduled. Resident R26, who was admitted with diagnoses including dementia, dysphasia, Parkinsonism, and a history of falling, was supposed to receive showers on Wednesdays and Saturdays according to their care plan. However, a review of the nurse aide documentation revealed no evidence that the resident received a shower from October 16 to October 23, a period of seven days. This lack of documentation also did not indicate whether the resident was offered or refused a shower during this time. Interviews with Resident R26's family member raised concerns about the resident not receiving routine showers and being observed in the same clothes on consecutive days. The Director of Nursing and Assistant Director of Nursing confirmed the absence of documented evidence for the showers during the specified period. This deficiency highlights a failure in the facility's responsibility to provide necessary assistance with activities of daily living, such as bathing, for residents who are unable to perform these tasks independently.
Neglect Leads to Pressure Ulcer Development in Two Residents
Penalty
Summary
The facility failed to protect residents from neglect, resulting in the development and worsening of pressure ulcers for two residents. Resident CR1 was admitted with a Stage Two pressure ulcer on the right buttocks, which worsened to a Stage Three ulcer, and a new Stage Three ulcer developed on the left heel. The facility's records lacked evidence of regular skin assessments and turning/repositioning interventions, despite the resident's moderate risk for pressure ulcers as indicated by the Braden Scale. The facility's failure to conduct these assessments and interventions led to the deterioration of the resident's skin condition. Resident CR2 was admitted with no pressure areas, but within a short period, developed Stage Three pressure ulcers on the coccyx, right buttocks, and left buttocks. The resident was initially assessed as low risk for pressure ulcers, but the facility did not perform the required weekly skin assessments or implement the recommended turning and repositioning interventions. This neglect resulted in the rapid development of severe pressure ulcers, indicating a lack of adequate care and monitoring. Both residents' clinical records showed a lack of compliance with physician orders for weekly skin assessments and the absence of documented interventions to prevent pressure ulcers. The Director of Nursing and the Nursing Home Administrator confirmed these deficiencies, acknowledging the facility's failure to provide necessary care to prevent harm to the residents. The neglect led to actual harm, as evidenced by the development and worsening of pressure ulcers in both residents.
Failure to Prevent and Monitor Pressure Ulcers
Penalty
Summary
The facility failed to ensure proper monitoring, assessment, and implementation of preventative measures for pressure ulcers, resulting in actual harm to two residents. Resident CR1 was admitted with a Stage Two pressure ulcer on the right buttocks, which worsened to a Stage Three ulcer, and developed a new Stage Three ulcer on the left heel. The facility's records lacked evidence of regular skin assessments and turning/repositioning interventions, as recommended by the Wound Certified Registered Nurse Practitioner (CRNP). The Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the absence of these assessments and interventions. Resident CR2 was admitted with no pressure ulcers but developed Stage Three pressure ulcers on the coccyx, right buttocks, and left buttocks within a 23-day period. Despite being assessed as low risk for pressure ulcers, the facility failed to conduct weekly skin assessments and implement recommended interventions, such as limiting sitting time and ensuring regular repositioning. The lack of documentation for these preventative measures was confirmed by the DON and NHA. Both residents' clinical records showed a lack of adherence to physician orders and facility policies regarding skin assessments and pressure ulcer prevention. The facility's failure to monitor and implement necessary interventions led to the development and worsening of pressure ulcers, causing actual harm to the residents. The deficiencies were identified through a review of clinical records, facility policies, and staff interviews.
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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 City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Quality Life Services - Grove City | 0.2 mi | ★★★★★ | 6 | 0 |
| Orchard Manor | 1.1 mi | ★★★★★ | 26 | 1 |
| Transitions Healthcare Autumn Grove Care Center | 4.6 mi | ★★★★★ | 0 | 0 |
| Avalon Springs Care Center | 10.4 mi | ★★★★★ | 6 | 0 |
| Quality Life Services - Mercer | 10.5 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 July 2026) and official state health department websites.