Grove Manor

In the surveyor’s words

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

• Actual harm, isolatedF600Aug 22, 2024

  Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to ensure that residents were free of neglect during care, which resulted in actual harm of Stage Three (full-thickness skin and tissue loss) pressure ulcer development of the coccyx (small triangular bone at the base of the spinal column), buttocks, and heel for two of two closed records reviewed for pressure areas (Residents CR1 and Resident CR2). Findings include: Review of a facility policy entitled Identifying Resident Neglect dated 7/22/24, revealed Neglect is defined as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical pain, mental anguish, or emotional distress. […]

• Actual harm, isolatedF686Aug 22, 2024

  Based on review of facility policy and clinical record and staff interviews, it was determined that the facility failed to ensure that residents were monitored, adequately assessed, and preventative measures were implemented to prevent ulcers from developing or worsening, resulting in actual harm of Stage Three (full-thickness skin and tissue loss) pressure ulcer development of the coccyx (small triangular bone at the base of the spinal column), buttocks, and heel for two of two closed records reviewed for pressure ulcers (Residents CR1 and Resident CR2). Findings include: Review of a facility policy entitled Prevention of Pressure Ulcer/Injury dated 7/22/24, revealed the facility would Assess the resident on admission (within eight hours) for existing pressure/injury risk factors. […]

• No harm, potential for more than minimal, patternF655Nov 15, 2023

  Based on review of facility policy, clinical records and staff interview, it was determined that the facility failed to ensure that a baseline care plan was developed/implemented within the required timeframe and failed to ensure that a written copy was provided to residents and resident's representatives for six of 14 residents reviewed (Residents R5, R35, R47, R50, R54, and R58). Findings include: Review of a facility policy entitled, Care Plans - Baseline dated 7/14/23, revealed, A baseline care plan will be developed within 48 hours of the resident's admission. The interdisciplinary team will . implement a baseline care plan to meet the resident's immediate care needs . And The resident and their representative will be provided a summary of the baseline care plan . […]

• No harm, potential for more than minimal, patternF880Nov 15, 2023

  Based on observations, review of facility policies, manufacturer's guidelines, Pennsylvania Department of Health PAHAN 694, and clinical records, and staff interviews, it was determined that the facility failed to properly clean and prevent the potential for cross contamination during the use of a blood glucose meter (BGM-a device to collect and measure the level of glucose [sugar] in the blood) for three of 12 residents observed during the administration of medications (Residents R58, R4, and R47), prevent the potential for cross contamination during a dressing change for two of 14 residents (Residents R6 and R22), and failed to ensure SARS-CoV-2 (COVID-19) infection control protocols were followed to help prevent the development and transmission of communicable diseases and infections on… […]

• No harm, potential for more than minimal, patternF558Jun 14, 2023

  Based on observations, review of clinical records and facility policies and staff and resident interviews, it was determined that the facility failed to ensure water was accessible to one of 54 residents (Resident R1), and failed to ensure the call bell was accessible for resident use for four of 54 residents (Residents R1, R2, R3 and R4). Findings include: Review of the Serving Drinking Water policy, dated 1/04/22 revealed .(11). place the water pitcher and cup within easy reach of the resident . Review of the Call System, Resident policy, dated 1/04/22, stated each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. […]