The Grove Post-acute Care Center

Based on interview and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure licensed nurses and social services monitored Resident 1's psychological (anything concerning the mind, mental processes, or emotions) and psychosocial (a person's mental, emotional, social, and spiritual health) health after Resident 1's reported allegation of being inappropriately touched by the transportation company personnel.

This deficient practice placed Resident 1 at risk of not being provided necessary care and services.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/3/2024 with diagnoses including aftercare following joint replacement surgery, major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy), and anxiety disorder (persistent and excessive worry that interferes with daily activities).

During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 6/13/2025, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/24/2025, the MDS indicated Resident 1's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact.

During a review of the facility-provided Grievance/Complaint Resolution Report, dated 7/3/2025, the Grievance/Complaint Resolution Report indicated Resident 1 reported to the SSD about the allegation that happened on 7/2/2025 at 2 p.m. to 3 p.m., where the transportation company personnel inappropriately touched her face and called the resident beautiful.

During an interview on 8/13/2025 at 9:41 a.m. and a concurrent record review of Resident 1's Progress Notes, reviewed with the Social Services Director (SSD), the SSD stated Resident 1 reported to her on 7/3/2025 that the transportation company personnel allegedly touched the resident's face and had unspecified inappropriate actions towards Resident 1.

The SSD stated there was no documented evidence in Resident 1's Progress Notes, dated 7/2/2025 to 8/13/2025, that the resident was monitored after the reported allegation of being inappropriately touched.

The SSD stated she did not document her follow-up visits to Resident 1.

The SSD stated that if the monitoring was not documented, it did not happen.

The SSD stated Resident 1 had the potential to experience depression.

During an interview on 8/13/2025 at 2:23 p.m. with the Director of Nursing (DON), the DON stated the licensed nurses, and the social services did not document the monitoring of Resident 1's psychological and psychosocial well-being after the resident reported the allegation of being inappropriately touched.

The DON stated Resident 1's depression and anxiety had the potential to worsen if the resident's psychological and psychosocial health were not monitored.

The DON stated the facility failed to monitor the psychological and psychosocial effects of the reported allegation on Resident 1.

During a review of the facility's policy and procedure (PnP) titled, Prevention, Reporting, and correction of Inappropriate Conduct Including Abuse, neglect, and Mistreatment of Residents and Investigations of Injuries of Unknown Origin, last reviewed on 1/2/2025, the PnP indicated Evaluation of facts as deemed appropriate based on a case -by-case analysis, which may include. the assessment, care planning, and monitoring of residents with needs and behaviors that might lead to conflict or neglect.

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