Agave Grove Post Acute

In the surveyor’s words

From the most serious findings on record at Agave Grove Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 14, 2023

  Based on review of clinical records, staff interviews and review of policies and procedures, the facility failed to ensure one resident (#1) was free from staff abuse. The deficient practice could result in further resident abuse. Findings include: Resident #1 was admitted on [DATE] with diagnoses of severe protein-calorie malnutrition, essential hypertension, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The care plan with problem start date of January 20, 2023 included the resident had a potential for prolonged bleeding or unusual bleeding due to use of an antiplatelet; and, had a diagnosis of senile purpura to right shin. […]

• No harm, potential for more than minimal, patternF812May 9, 2025

  Based on observations, staff interviews, policy review, and observation of current practice, the facility failed to ensure that resident drinks were transported from the kitchen to the residents' rooms in accordance with professional standards. The sample size was 22. The deficient practice could result in contamination of the resident's drinks. Findings include: An observation was conducted on May 7, 2025 at 12:00 P.M., with a Certified Nursing Assistant (CNA/Staff #39) who was carrying a drink tray with 5 uncovered drinks down the hall, approximately 50 steps. Continued observation on May 7, 2025 at 12:05 P.M. revealed another CNA (Staff #30) carrying a tray with an uncovered drink into room [ROOM NUMBER]; approximately 50 steps. An interview was conducted on May 7, 2025 at 12:11 P.M. […]

• No harm, potential for more than minimal, patternF658May 12, 2023

  Based on clinical record reviews and staff interviews, the facility failed to ensure two residents (#33 and #97) were administered medications as ordered. The deficient practice could result in the underlying condition not being treated and the condition could worsen or persist. Findings include: -Resident #33 was admitted on [DATE] with diagnoses of Parkinson's disease, bipolar disorder, generalized anxiety disorder, and major depressive disorder. The Minimum Data Set (MDS) assessment dated [DATE] included a brief interview for mental status (BIMS) score of 8 indicating a mild cognitive impairment. […]

• No harm, potential for more than minimal, patternF567Apr 8, 2022

  Based on resident and staff interviews, observation, facility documents, clinical record review, and policy review, the facility failed to ensure two sampled residents (#91 and #121) had the right to access their personal funds on the weekend. The deficient practice could result in residents not being able to access their personal funds on the weekends. Findings Include: -Resident #91 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. […]

• No harm, potential for more than minimal, patternF880Feb 1, 2021

  Based on observations, staff interviews, facility documentation, policy review and the Centers for Disease Control (CDC) guidance, the facility failed to ensure infection control standards were maintained, by failing to ensure screening for COVID-19 was thorough for one staff (staff #151) and that one staff (staff #161) doffed personal protective equipment (PPE) appropriately. The deficient practice could result in spread of infection, including COVID-19 to residents and staff. […]