The Groves Assisted Living Place Llc-Pepper

Based on record review and interview, the manager failed to ensure a resident's service plan was signed and dated by the resident or resident's representative when the service plan was updated. Findings include: 1. A review of R1's medical record revealed a service plan, dated November 24, 2025, for directed care services. However, the service plan was not signed and dated by the resident or resident's representative. 2. A review of R1's medical record revealed documentation of attempts to obtain a signature on R1's service plan were not available for review. 3. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed the water temperature in a shared bathroom adjacent to the kitchen measured 125.9º F on the Compliance Officer's Department issued thermometer. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were in a locked area and were inaccessible to residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed a cabinet below the kitchen sink had a magnetic lock. However, the lock was found to be stuck in the open position during the on-site inspection and the Compliance Officer was able to open the cabinet without a magnet. Inside the cabinet, the Compliance Officer observed oven cleaner, bleach spray, and window cleaner. 2. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on documentation review and interview, the governing authority failed to administer a training program for all staff regarding fall prevention and fall recovery to include continued competency training. Findings include: 1. A review of E3's personnel record revealed documentation of continued competency training in fall prevention and fall recovery was not available for review. 2. In an interview, E1 acknowledged E3 'personnel record did not include documentation of initial training in fall prevention and fall recovery.

Based on documentation review, record review, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training for applicable employees to include the method and content of cardiopulmonary resuscitation training, to include a demonstration of the employee's ability to perform cardiopulmonary resuscitation, for one of two personnel records reviewed. The deficient practice posed a risk if the employee was unable to meet a resident's needs during an emergency. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "CPR and First Aid Policy and Procedure." This policy stated, "This assisted living facility requires a caregiver who provides direct care to residents to obtain and provide documentation of cardiopulmonary resuscitation training specific to adults, which includes a demonstration of the caregiver's ability to perform cardiopulmonary resuscitation....No on-line CPR training will be allowed." 2. A review of E3's personnel record revealed E3 had been hired in January of 2021 as a caregiver. 3. A review of E3's personnel record revealed a CPR and First Aid training certification card from "NationalCPRFoundation," an online only provider for which the training had not included a hands on demonstration of E3's ability to perform CPR. 4. In an interview, E1 acknowledged E3's CPR training had not included a demonstration of E3's ability to perform CPR.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents sampled who received medication administration. Findings include: 1. A review of R2's medical record revealed a service plan, updated November 9, 2024, for directed care services including medication administration. 2. A review of R2's medical record revealed a prescription, dated January 20, 2025, which stated, "Metoprolol tartrate 25 mg tablet - take 1 tablet(s) twice a day by oral route." 3. A review of R2's medical record revealed a Medication Administration Record (MAR) dated January 2025. However, the MAR documented Metoprolol Tartrate was administered once per day at 8 AM on January 21, January 22, and January 23. The MAR did not document administration of the second ordered daily dose of Metoprolol tartrate. 4. In an interview, E1 acknowledged the MAR provided for R2 did not accurately document the medications administered to R2. E1 reported R2's mediset included Metoprolol in the morning and evening sections.

Based on record review and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for one of two residents sampled. Findings include: 1. A review of R2's medical record revealed a service plan, updated November 30, 2023, which included medication administration. 2. A review of R2's medical record revealed an order,signed September 5, 2023, which stated, "Hydralazine 10 MG / 1-PO / BID Hold for SBP <100 or HR < 60." 3. A review of R2's medical record revealed a medication administration record (MAR) dated December 2023. The MAR documented R2 had been administered, "Hydralazine 10MG 1-PO BID, hold for SBP < 100 or HR < 60," at 8 AM and at 8 PM on each day in December 2023 prior to the day of the on-site inspection. However, documentation of R2's blood pressure and heart rate prior to each administered dose was not available for review. 4. In an interview, E1, acknowledged the provided order and MAR for R2 did not document Hydralazine had been administered in compliance with a medication order.

Based on observation and interview, the manager failed to ensure foods requiring refrigeration were maintained at 41\'b0F or below. Findings include: 1. During a facility environmental inspection, the Compliance Officer observed a cabinet above the kitchen sink. Inside the cabinet, the Compliance Officer observed open containers of frosting and fruit jelly. However, both packages indicated the product required refrigeration after opening. 2. During a facility environmental inspection, the Compliance Officer observed a mini-refrigerator in the kitchen below the medication cabinet. The refrigerator contained a thermometer which read 52 degrees. The refrigerator also contained an open container of fruit juice. 3. In an interview, E1 acknowledged potentially hazardous foods requiring refrigeration were not maintained at 41\'b0F or below.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of the facility work schedule revealed the facility worked on two 12 hour shifts per day. 2. A review of facility disaster drills conducted during the previous twelve months revealed disaster drills were conducted on both shifts on January 7, 2023, April 8, 2023, and July 8, 2023. However, disaster drills for both shifts conducted on or before October 8, 2023 were not available for review. 3. In an interview, E1 acknowledged documentation of disaster drills conducted on each shift at least once every three months had not been provided to the Compliance Officer upon request.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months. Findings include: 1. A review of facility documentation revealed an evacuation drill had been conducted on January 4, 2023. However, an evacuation drill conducted on or before July 4, 2023 was not available for review. 2. In an interview, E1 acknowledged documentation of evacuation drills conducted at least once every six months had not been provided to the Compliance Officer upon request.