The Grove at Carvalho

In the surveyor’s words

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

• Actual harm, isolatedF656Feb 3, 2026

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who per rehabilitation staff required the use of a mechanical lift for all transfers, and per facility policy two staff members were required to complete lift transfers, the facility failed to ensure that 1) Resident #1's individualized comprehensive plan of care, which included his/her care Kardex, clearly indicated the number of staff members required to provide assistance during the transfers, and as a result one staff member attempted to transfer him/her alone, he/she fell, and sustained a fracture to his/her left ankle, and 2) failed to ensure they developed and implemented a comprehensive plan of care related to Resident #1's ankle fracture, that accurately identified care and treatment needs… […]

• Actual harm, isolatedF689Feb 3, 2026

  Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required the use of a Sit/Stand Lift (mobility aid that helps people transition safely from sitting to standing), for all transfers, with two staff members present to assist and complete the transfer, the Facility failed to ensure he/she was provided with the necessary level of staff assistance, in accordance with facility policy, to maintain his/her safety and prevent an incident/accident resulting in a significant injury. […]

• No harm, potential for more than minimal, widespreadF838Feb 19, 2025

  Based on document review and interview, the facility failed to conduct and implement a comprehensive facility wide assessment that was inclusive of resources necessary to provide both emergency and day to day care of the population the facility currently serves. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) memo titled Revised Guidance for Long-Term Care Facility Assessment Requirements, dated 6/18/24, indicated but was not limited to: -In conducting the facility assessment, the facility must ensure active involvement of the following participants in the process: - The facility's resident population, including, but not limited to: - The care required by the resident population; - The physical environment, equipment, services, and other physical plant… […]

• No harm, potential for more than minimal, widespreadF867Feb 19, 2025

  Based on record review and interview, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and implemented an appropriate corrective action plan, to ensure satisfactory outcomes. Specifically, the facility failed to develop and implement a Quality Assurance Performance Improvement (QAPI) plan and a Performance Improvement Project (PIP) that focused on a high risk or problem-prone area identified through data collection and analysis. […]

• No harm, potential for more than minimal, patternF880Apr 8, 2026

  Based on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to: 1. Maintain an infection prevention and control program with a complete system of surveillance to identify any trends of actual or potential infections within the facility; and 2. […]