Groves Center
GROVES CENTER in LAKE WALES, FL — inspection on October 29, 2025.
Found 8 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Resident #9 since there were missing clothes.
Review of the facility policy titled The Grievance/ Concern Management Policy, effective May 2025, showed residents and their representative have the right to present concerns on behalf of themselves, and/or others to the staff and /or administrator of the facility to work for improvements in resident care, free from restraint, interference, coercion discrimination, or reprisal.The procedure showed:-Residents and their representatives who are unable to complete a written concern will be assisted by staff to prepare and submit the form-The Social Services representatives/ Grievances Official in collaboration with the NHA will be responsible for assigning the concern to the appropriate department for investigation.
Social Service will monitor and document resident/ representative satisfaction up completion of the investigation and the summary of findings/conclusion-The department involved will document the concern and record the resident/ resident representative's satisfaction with the resolution to the concern-Complete a concern report investigation with summary and conclusion-Social Services staff will provide information regarding compliance line information for unresolved concerns
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident #13's progress note did not show any documentation detailing why the doses were missed, or if the provider was notified that the resident did not receive all doses of the prescribed antibiotic for the UTI.
Review of a facility policy titled Lab/Radiology Process Guidelines, undated, showed: 5.
Upon receiving the results, notify the physician and resident/resident representative of the results, and file the results in the medical record under Labs/Radiology tab.
- Document in a progress note the labs/radiology tests you received and who the results were reported to.
- Stat and critical labs must be called to the physician as soon as they have resulted, with the nurse
Include any additional follow up or new physician orders received in the progress.
documenting the communication and follow-up in the electronic medical record.
Review of a facility policy titled, Physician Notification, dated October 2021 revealed, The facility strives to ensure each resident's health is supervised by a qualified attending physician.
The attending physician in the facility is ultimately responsible for supervision and management of the care of the resident/patient.
Review of a facility policy titled Abuse Prevention Program, reviewed September 2025, showed: Policy: The facility has designated and implemented processes, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property.
These policies guide the identification, management, and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education of staff and residents, as well as early identification of staff bum out, or resident behavior which may increase the likelihood of such events.
Definitions: Neglect -Failure of the facility, its employees, or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
SUMMARY STATEMENT OF DEFICIENCIES
she was supposed to do and was just taking a break.
The NHA said neglect is not doing what you are supposed to do for a resident. He said of course he would consider it neglect if a nurse left the unit, didn't have a covering nurse, and medications or something was needed during that time, and the resident didn't get it.
When asked if he felt like Resident #1 was neglected on 9/27/25 seeing as the nurse left the facility multiple times and was unable to be found when the resident/RR had concerns he stated not as long as the nurse was able to get accomplished what had to be done. He said some nurses are able to do more in a less amount of time.
The NHA said he was not aware Resident #1's medications were two hours late. He said if the DON reviewed the records and said the nurse did what she was supposed to do then he wouldn't look at that. An interview was conducted on 10/29/25 at 5:25 p.m. with the DON.
She said if a nurse left the facility she would expect that nurse to turn over with another nurse and let staff know where they would be to ensure the residents are covered if they needed anything.
She said it did not matter what the facility thought, if a resident or resident representative alleged abuse or neglect it should have been reported.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
SUMMARY STATEMENT OF DEFICIENCIES
possible re-enactment of the event.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
SUMMARY STATEMENT OF DEFICIENCIES
Review of a facility policy titled Clinical Programs Manual - Pain Management, dated 10/2021 revealed – Overview: The facility is committed to pain management through the following: Interdisciplinary data collection Interdisciplinary approach Resident/patient religious and cultural values Education of residents/patient and caregivers Residents/patients, families and caregivers will be educated on appropriate pain control.
The inter disciplinary team will strive to reduce/eliminate the fears of addiction as it relates to pain medication and/or other issues the resident/patient and family may have.
The team will encourage the resident/patient and family to report pain since the longer pain goes untreated, the harder it is to relieve.
GUIDELINES
- Collect data on the intensity of the resident/patient's pain.
- Identify the current analgesic regimen (i.e., analgesic usage covering a 24-hour period for several days
- Analyze the reported pain severity on the current regimen.
- Include the resident/patient and family in development of the Plan of Care.
- Develop individualized comfort interventions using collaborative proactive, not reactive, interdisciplinary
admission Data Collection Monthly, Return & PRN Data Collection
as applicable.)
approach.
Obtain physician's orders as needed. d.
Identify the sources of pain. e.
Maintain prescribed levels.
- Obtain an order for around-the-cl
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
SUMMARY STATEMENT OF DEFICIENCIES
indwelling catheter is taped to the thigh to straighten the angulation of the penoscrotal junction, thus reducing pressure on the urethra exerted by the catheter.On 10/29/25 at 5:25 p.m., an interview was conducted with the DON.
She stated if a resident had wounds from their catheter rubbing and gangrene, then it did not happen overnight.
The DON said, I would expect that to be on skin assessments.Review of The Association for Professionals in Infection Control and Epidemiology (APIC) guide titled Guide to Preventing Catheter-Associated Urinary Tract Infections (CAUTI): Best Practices for Prevention, with a date of March 2025, revealed the following on page 16: Ensure securement devices are available and applied appropriately. https://apic.org/wp-content/uploads/2025/07/2025_CAUTI_Implementation_Guide-2.pdfReview of The Joint Commission's article: Managing medical device-related pressure injuries, with an issue date of July 2018, revealed the following: Device care: Ensure that the patient receives the proper size and type of device; that the device is secure, to decrease movement or slippage; that the skin is padded, to reduce friction; and that the manufacturer's recommendations for use and care of the device are followed. https://digitalassets.jointcommission.org/api/public/content/ac5d5d5c77b34380a6dfab91ec1677f0?v=49e66b16
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
SUMMARY STATEMENT OF DEFICIENCIES
Review of a facility policy titled Clinical Programs Manual - Pain Management, dated 10/2021 revealed - Overview: The facility is committed to pain management through the following: Interdisciplinary data collection Interdisciplinary approach Resident/patient religious and cultural values Education of residents/patient and caregiversResidents/patients, families and caregivers will be educated on appropriate pain control.
The inter disciplinary team will strive to reduce/eliminate the fears of addiction as it relates to pain medication and/or other issues the resident/patient and family may have.
The team will encourage the resident/patient and family to report pain since the longer pain goes untreated, the harder it is to relieve.GUIDELINES1.
Collect data on the intensity of the resident/patient's pain. admission Data Collection Monthly, Return & PRN Data Collection2.
Identify the current analgesic regimen (i.e., analgesic usage covering a 24-hour period for several days as applicable.)3.
Analyze the reported pain severity on the current regimen.4.
Include the resident/patient and family in development of the Plan of Care. 6.
Develop individualized comfort interventions using collaborative proactive, not reactive, interdisciplinary approach.
Obtain physician's orders as needed. d.
Identify the sources of pain. e.
Maintain prescribed levels.8.
Obtain an order for around-the-clock dosing if the following occurs: Duration of pain relief/control is consistently less than the dosing interval.
Pain is not well controlled Pain management requires three or more doses for breakthrough pain per day.9.
Utilize adjuvant medications for pain control, when appropriate, including, but not limited to: Anticonvulsant for pain associated with neuropathy Muscle relaxants for treatment of skeletal muscle pain11.
Keep resident/patient and family informed, knowledgeable, and in control of pain management.12.
Re-evaluate pain status frequently.13.
Review and revise the Plan of Care as needed to relieve /control pain.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/29/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
SUMMARY STATEMENT OF DEFICIENCIES
Review of Resident #4's lab results showed the labs ordered were completed on 9/28/25 and results were printed on 9/28/25 at 7:10 p.m.
The results showed Resident #4 had abnormal lab results including low red blood cells (RBC), hemoglobin, hematocrit, platelet count, lymphocytes, lymphocyte absolute and had high neutrophils.
Review of Resident #4's progress notes did not show any documentation a provider was notified of the abnormal Stat lab results on 9/28/25. An interview was conducted on 10/28/25 at 2:41 p.m. with Resident #4's PCP's assistant.
The assistant stated she was returning the phone call on behalf of the PCP.
She said the provider would expect to be notified of any abnormal lab results.
She said she and the provider did not recall if they were notified on 9/29/25, but the facility would be expected to document that information.
She said the PCP did not document every time he received a phone call. An interview was conducted on 10/29/25 at 2:09 p.m. with the Director of Nursing (DON) and the Regional Nurse Consultant (RNC).
They said abnormal lab results were faxed to the facility and the nurse called the provider and let them know the results.
They stated they expect this to happen within a couple of hours or receiving notification of abnormal lab results, and documentation of the contact should be in the progress notes or on the lab results sheet.
They said if there were no new orders from the provider it should have been documented as well.
They stated being aware of discrepancies with physician notifications.
The RNC and DON reviewed Resident #1's medical record and confirmed there was no documentation prior to her discharge that a provider was notified of abnormal labs.
They also reviewed Resident #4's medical record and confirmed there was no documentation a provider was notified of the abnormal Stat lab results.
Review of a facility policy titled Lab/Radiology Process Guidelines, undated, showed:5.
Upon receiving the results, notify the physician and resident/resident representative of the results, and file the results in the medical record under Labs/Radiology tab.6.
Document in a progress note the labs/radiology tests you received and who the results were reported to.
Include any additional follow up or new physician orders received in the progress.8.
Stat and critical labs must be called to the physician as soon as they have resulted, with the nurse documenting the communication and follow-up in the electronic medical record.
Facility ID: