Resident 12 told staff about "constant aching pain in the abdomen" that persisted both during movement and at rest, according to the facility's Director of Rehabilitation. The pain was directly related to the resident's colostomy care.
Federal inspectors found that acetaminophen was ordered for the resident on October 23, 2025, but staff never administered it that day or the following day. Percocet was then ordered on October 24, but the resident didn't receive that medication until October 25.
The facility's Director of Nursing reviewed the medical records during the inspection and confirmed the medication delays. She acknowledged that pain medication should have been provided for the resident's colostomy care and that a primary care provider should have been contacted for level 6 pain.
"Her expectation was something would have been ordered by then," inspectors noted about the Director of Nursing's response to the delayed treatment.
The nursing director outlined the facility's protocol for pain management during her interview with inspectors. If a resident's primary care provider cannot be reached, staff should contact the Medical Director. If the Medical Director is unavailable, the Director of Nursing should be contacted next.
None of these steps appear to have been taken during the resident's 48-hour period without pain relief.
Groves Center's own pain management policy, dated October 2021, commits the facility to "pain management through interdisciplinary data collection" and an "interdisciplinary approach" that considers "resident religious and cultural values."
The policy specifically instructs staff to "encourage the resident and family to report pain since the longer pain goes untreated, the harder it is to relieve." It also directs the interdisciplinary team to "reduce/eliminate the fears of addiction as it relates to pain medication."
The facility's guidelines require staff to collect data on pain intensity, analyze reported pain severity, and "develop individualized comfort interventions using collaborative proactive, not reactive, interdisciplinary approach."
During the inspection, the Director of Nursing stated there was "no reason not to provide the pain medication" and described the situation as "kind of cut and dry."
The inspection occurred in response to a complaint filed against the facility. Federal investigators classified the violation as causing "actual harm" to residents, though they noted that "few" residents were affected by the deficient practice.
The case highlights a fundamental breakdown in basic nursing care. A resident in significant pain had two different medications ordered by medical staff, yet received neither for two full days. The facility's own leadership acknowledged both the policy requirements and the clear need for intervention, describing the decision as straightforward.
Colostomy care typically involves sensitive medical procedures that can cause considerable discomfort, making pain management a critical component of quality care. Level 6 pain on a 10-point scale represents moderate to severe discomfort that significantly impacts a person's daily functioning and quality of life.
The inspection report cuts off mid-sentence while describing the facility's pain management protocols, suggesting additional policy violations may have been documented but are not included in the available records.
Groves Center operates at 512 South 11th Street in Lake Wales, a city in central Florida's Polk County. The facility was required to submit a plan of correction to address the medication administration failures identified during the October 29, 2025 inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Groves Center from 2025-10-29 including all violations, facility responses, and corrective action plans.