Locust Grove Retirement Village

In the surveyor’s words

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

• Actual harm, isolatedF600May 3, 2024

  Based on observation, clinical record review, review of facility documents, and resident and staff interview, it was determined that the facility failed to protect the rights of a resident to be free from neglect by not providing the services necessary to avoid physical harm related to a sustained fracture on one of two nursing units, (Unit 100-300, Resident 33). This deficiency is cited as past noncompliance Findings include: Observation and interview with Resident 33 on May 1, 2024, at 9:49 AM revealed the resident was in bed. Resident 33 stated one person gave her a couple fractures and stated, She tried to get me into bed, she didn't use the lift. Resident 33 stated she hurt after that, and it was her fault, referencing the staff member. Resident 33 said her knee was broken. […]

• No harm, potential for more than minimal, patternF812Jul 10, 2026

  Based on observation and staff interview, it was determined that the facility failed to store food in accordance with professional standards for food service safety in the facility's main kitchen.Findings include: Observation of the facility's main kitchen on Tuesday, July 7, 2026, at 10:13 AM, Employee 4 (Certified Dietary Manager) revealed the following: An opened box of single serving Italian dressing packets in refrigerator one with June 2024, recorded in black marker on the box. Employee 4 indicated that was the date received. There was no evidence when the product needed used by or when it expired. A small metal pan labeled tuna salad, discard by July 4, 2026, in the walk-in cooler. […]

• No harm, potential for more than minimal, patternF684Jun 27, 2025

  Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered medication parameters for two of 17 residents reviewed (Residents 32 and 51) and failed to provide comprehensive skin assessments that are consistent with professional standards of practice, to promptly identify skin changes and to promote healing for one of three residents reviewed for skin condition concerns (Resident 1). Findings include: Clinical record review for Resident 51 revealed a diagnosis list that included essential hypertension (high blood pressure). […]

• No harm, potential for more than minimal, patternF697Jun 27, 2025

  Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for one of three residents reviewed (Resident 32) Findings include: Review of Physiopedia's and Wikipedia's definition of the numeric pain rating scale (parameters) from zero to 10 indicated that no pain was identified as zero, mild pain was identified as one to three, moderate pain was identified as four to six, and severe pain was identified as seven to 10. […]

• No harm, potential for more than minimal, patternF677May 3, 2024

  Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide bathing assistance for a resident dependent on staff assistance for five of seven residents reviewed for activities of daily living (Residents 33, 39, 47, 52, and 63). Findings include: Interview with Resident 33 on May 1, 2024, at 9:52 AM revealed she is to get showered on Tuesdays and Fridays, during the day, and she doesn't refuse them, but stated she had a fracture and maybe that's why she wasn't getting them. Clinical record review for Resident 33 did reveal the resident had sustained a fracture in her leg in March 2024, and was scheduled to receive showers on Tuesdays and Fridays on the 2-10:00 PM shift and as needed. […]