Grove of Lagrange Park, The

In the surveyor’s words

From the most serious findings on record at Grove of Lagrange Park, The, in the surveyor’s own words.

• Actual harm, isolatedF686Jan 12, 2023

  Based on observation, interview and record review, the facility failed to identify/implement specific pressure ulcer prevention measures to prevent the development of multiple pressure ulcers. The facility also failed to implement interventions and/or provide treatments for pressure ulcers per resident plans of care and as ordered by the physician. This failure resulted in the development of facility-acquired unstageable, necrotic pressure ulcers on a resident's foot who had a recently fractured leg and impaired mobility. This applies to 3 residents (R1-R3) reviewed for pressure ulcers in a sample of 6. […]

• No harm, potential for more than minimal, widespreadF812Sep 6, 2024

  Based on observations, interview and record review, the facility failed to maintain sanitizer in dish machine during dish washing and failed to ensure that cold foods are stored properly per facility policy guidelines. This applies to 114 residents who receives meals prepared in the facility kitchen. The findings include: Facility provided information that the census on September 3, 2024 was 116 residents with 2 (two) residents on NPO (nothing by mouth) status. On September 03, 2024 at 9:49 AM, V11 (Dietary Aide) was washing dishes at the dirty side of the low temperature dish machine and stacking the dirty dishes on racks to pass through the dish machine. Some newly washed dishes that were placed on racks were seen on the clean side of the dish machine. […]

• No harm, potential for more than minimal, widespreadF812Sep 20, 2023

  Based on observation, interview and record review the facility failed to handle and store bulk bin scoops in a sanitary manner. This failure has the potential to effect all residents in the facility. The findings include: The CMS 672 dated 9/18/23 shows the facility has 114 residents residing in the facility. On 9/19/23 at 9:41 AM, V4 (Cook) prepared puree crab cakes, puree spinach, and mashed potatoes for lunch. On 9/19/23 at 9:54 AM, V4 opened the food thickener bulk bin, grabbed the scoop from inside the bin, scooped food thickener into the scoop, and the food thickener to the puree spinach. When finished, V4 placed the used scoop back inside the food thickener bulk bin. […]

• No harm, potential for more than minimal, widespreadF880Sep 20, 2023

  Based on observation, interview, and record review the facility failed to ensure staff performed hand hygiene after direct care, failed to ensure enhanced barrier precautions were in place and failed to ensure staff wore PPE (Personal Protective Equipment) during direct care for residents on isolation to prevent cross contamination. This applies to 7 of 24 residents (R23, R1, R14, R76, R109, R270 & R267) reviewed for infection control in the sample of 24. The findings include: 1. On 9/18/23 at 10:30 AM, V10 (Certified Nursing Assistant) provided incontinence care to R23. R23's incontinent brief was soiled with urine and stool. V10 cleansed R23's peri-area and with the same contaminated gloves touched multiple surfaces including the bedding, R23's gown, and the bed control. […]

• No harm, potential for more than minimal, patternF690Oct 20, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents received timely and adequate incontinence care and hygiene assistance.This failure applies to 4 of 4 residents (R1, R4, R5, and R6) reviewed for incontinence care.The findings include:1. R1 is a [AGE] year-old male who was admitted to facility on September 18, 2023.R1's face sheet includes the following diagnoses: : bilateral osteoarthritis of the knee, strabismic amblyopia, cataracts, difficulty walking, muscle wasting, gait and mobility abnormalities, dysphagia, diabetes mellitus, protein calorie malnutrition, benign prostatic hyperplasia, dementia with agitation, sleep apnea, repeated falls, gout, atherosclerotic heart disease, hyperparathyroidism, gastroesophageal reflux, post-traumatic stress… […]