Park Grove Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Park Grove Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Apr 5, 2024

  Based on observation, interview, record review, document review, and facility policy review, it was determined the facility failed to ensure residents' comprehensive care plans were developed and implemented for three (3) of eight (8) sampled residents assessed for elopement risk (Residents #13, #40, #52, #53). 1. The facility assessed Resident #13 to be at risk for elopement and was care planned as at risk for elopement and exhibited exit-seeking behavior. However, the resident exited the facility undetected by staff on 03/14/2024 at approximately 4:10 PM and was outside unsupervised for approximately five (5) minutes. 2. Resident #40 stated in interview she had carpal tunnel syndrome in both hands. […]

• Immediate jeopardy, isolatedF689Apr 5, 2024

  Based on observation, interview, record review, facility document and policy review, it was determined the facility failed to provide effective monitoring and supervision to prevent elopement for one (1) of eight (8) sampled residents assessed for elopement risk (Resident #13), out of the total resident sample of twenty-five (25). The facility assessed Resident #13 as at risk for elopement and care planned him/her for the elopement risk, Interventions included utilizing and monitoring a security bracelet for Resident #13 as per protocol. However, on 03/14/2024, facility staff failed to follow the resident's interventions, and allowed Resident #13, whose mobility was per wheelchair, to exit the facility without staffs' knowledge at approximately 4:10 PM. […]

• Actual harm, isolatedF655Feb 21, 2023

  Based on interview, record review, and the facility's policy, it was determined the facility failed to develop and implement a person-centered baseline care plan within forty-eight (48) hours of admission for one (1) of forty-four (44) sampled residents, (Resident #270). 1. The facility admitted the resident on 05/18/2022 and assessed the resident to be a falls risk upon admission. However, the facility failed to ensure the resident was care planned for falls within the forty-eight (48) hours of admission, as per the facility's policy. Subsequently, on 05/29/2022, the resident was found on the floor in the hallway. […]

• Actual harm, isolatedF689Feb 21, 2023

  Based on interview, record review and policy review it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision and assistive devices necessary to prevent accidents for one (1) of forty-four (44) sampled residents (Residents #270). The facility assessed the resident as a risk for falls, however, no care plan had been developed and the resident sustained a fall with major injury on 05/29/2022. On 05/18/2022, the facility assessed Resident #270 to be at risk for falls and required the assistance of one (1) staff and a gait belt for transfers and bed mobility. On 05/29/2022 at 10:02 PM, Resident #270 had a fall and was found lying on the floor in the hall. […]

• No harm, potential for more than minimal, widespreadF812Jun 26, 2026

  Based on observation, interview, and review of facility policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The failure had the potential to affect all residents who consumed meals from the kitchen.The findings include: Review of the facility's policy titled, Food Storage, dated 08/14/2025, revealed the facility was to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Per policy review, milk was to be rotated with each delivery and the carton with the earliest expiration date to be used first. Continued review revealed all foods were to be covered, dated, and labeled, to ensure the foods were safe to be consumed. […]