The Groves Assisted Living Place Llc-Plum

Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order and documented in the resident's medical record, for one of two sampled residents. Findings include: A review of R2's medical record revealed a signed list of medication orders, dated December 1, 2025. This list included the following: "Levothyroxine sodium, 200 mcg / 1-PO /QAM." "Miconazole nitrate, 25MG / 1-PO / QD." A review of R2's medical record revealed a Medication Administration Record (MAR) dated February 2026. The MAR documented the medications which had been administered to R2 and included the following: "Levothyroxine 200MCG, 2PO, QAM," had been administered to R2 on each day in February 2026, instead of the single tablet ordered. "Miconazole Nitrate, 2% Ointment, Topical Under the Pannus, BID," had been administered to R2 on each day in February 2026, instead of 25 milligrams orally once per day. In an interview, E1 reported the MAR had the incorrect dosage of Levothyroxine, however, E1 reported the correct dosage had been administered. E1 reported the order for Miconazole was incorrect and could not be administered as ordered, because Miconazole was a topical cream, not an oral medication. In an exit interview with E1, the findings were reviewed and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a medication administration record (MAR) dated January 2026. The MAR indicated the following: R2 had been administered, "Pantoprazole 40mg, 1 PO BID," one time per day, instead of two times per day as stated on the transcribed order, starting on January 9, 2026 through the day of the on-site inspection; and R2 had been administered, "Alendronate 70 MG 1-PO QWK" every day, instead of one time per week as stated on the transcribed order, starting on January 9, 2026 through the day of the on-site inspection. 2. A review of R2's medical record revealed a medication list with print date of "12/31/2025," However, the medication list was not signed and did not include start dates for medications. The medication list included: "Pantoprazole 40 mg oral delayed release tablet, 1 tab oral, twice a day, Special instructions; To continue for 8 weeks and then daily," However, this order was not signed and without a start date, it was not possible to evaluate the 8 weeks condition; and "Alendronate 70 mg oral tablet, 1 tab oral, every 7 days." However, this order was not signed. 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 foods requiring refrigeration were maintained at 41\'b0F or below. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the following items requiring refrigeration in the pantry: - two jars of Jelly which had been opened and partially used. 2. During an environmental tour of the facility, the Compliance Officer observed a refrigerator in a storage room adjacent to the kitchen. The refrigerator contained foods requiring refrigeration, such as milk and horchata. However, a thermometer in the refrigerator read 45\'b0F. 3. In an interview, E1 acknowledged foods requiring refrigeration had not been maintained at 41\'b0F or below.

Based on observation and interview, the manager failed to ensure oxygen containers were secured in an upright position. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed three unsecured oxygen containers in a resident's bedroom. 2. In an interview, E1 acknowledged the oxygen containers were not secured.

Based on record review and interview, the manager failed to ensure a resident's written service plan was signed and dated by the resident or resident's representative when initially developed and when updated, for one of two residents sampled. Findings include: 1. A review of R1's medical record revealed service plans dated November 19, 2024 and January 13, 2025, for directed care services. However, the service plans were not signed and dated by R1 or R1's representative, and documentation of attempts to obtain representative signatures on the services plans was not available for review. 2. In an interview, E1 acknowledged the service plans provided for R1 had not been signed and dated by R1 or their representative when the service plans were updated.