Groves Center
Inspection Findings
F-Tag F0585
F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0600
F 0600
resident were on 9/1/25, 9/2/25, and 9/3/25. The resident received three doses of the five ordered doses.
Level of Harm - Actual harm
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.
Residents Affected - Few
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.
- 8. 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.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0609
F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0610
F 0610
possible re-enactment of the event.
Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0684
F 0684
no reason not to provide the pain medication and stated, it's kind of cut and dry, right?
Level of Harm - Actual harm
On 10/28/2025 at 1:48 p.m., an interview was conducted with the Director of Rehab, (DOR). The DOR stated Resident #12 verbalized having constant aching pain in the abdomen at a level of 6 out of 10 with both movement and while at rest.
Residents Affected - Few
On 10/29/2025 at 2:07 p.m., an interview was conducted with the Director of Nursing, (DON). The DON stated if a resident's primary care provider was contacted, it should have been documented in the resident's medical record. The DON stated if a resident's primary care provider was unreachable, the Medical Director should have been contacted, and if unreachable, the DON should have been contacted. The DON stated a resident's primary care provider should have been contacted for level 6 out of 10 pain. The DON stated pain medication should have been provided for Resident #12's colostomy care. The DON reviewed Resident #12's medical record and confirmed the resident had a pain level of 6 out of 10, on 10/23/2025 and no pain medication was provided until 10/25/2025. The DON confirmed acetaminophen was ordered on 10/23/2025 and was not provided on 10/23/205 and 10/24/2025. The DON confirmed Percocet was ordered on 10/24/2025 and it was not given until 10/25/2025. The DON stated her expectation was something would have been ordered by then.
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
- 1. Collect data on the intensity of the resident/patient's pain.
- 2. Identify the current analgesic regimen (i.e., analgesic usage covering a 24-hour period for several days
- 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
- 8. Obtain an order for around-the-cl
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.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0690
F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0697
F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
stated residents admitted from the hospital with pain and without orders for pain medication, had primary care providers, who would be contacted. If the primary care provider contact attempt was ineffective, then
the Medical Director would be contacted. Staff C stated any level of pain, such as level 6 out of 10, warranted a call to the provider. Staff C reviewed Resident #12's medical record and confirmed the resident's pain level was documented at a six out of 10 on the pain scale and Acetaminophen was not administered. Resident #12 had no additional orders for pain medication on 10/23/2025. Staff C stated there was no reason not to provide the pain medication and stated, it's kind of cut and dry, right? On 10/28/2025 at 1:48 p.m., an interview was conducted with the Director of Rehab, (DOR). The DOR stated Resident #12 verbalized having constant aching pain in the abdomen at a level of 6 out of 10 with both movement and while at rest. On 10/29/2025 at 2:07 p.m., an interview was conducted with the Director of Nursing, (DON). The DON stated if a resident's primary care provider was contacted, it should have been documented in the resident's medical record. The DON stated if a resident's primary care provider was unreachable, the Medical Director should have been contacted, and if unreachable, the DON should have been contacted. The DON stated a resident's primary care provider should have been contacted for level 6 out of 10 pain. The DON stated pain medication should have been provided for Resident #12's colostomy care. The DON reviewed Resident #12's medical record and confirmed the resident had a pain level of 6 out of 10, on 10/23/2025 and no pain medication was provided until 10/25/2025. The DON confirmed acetaminophen was ordered on 10/23/2025 and was not provided on 10/23/205 and 10/24/2025. The DON confirmed Percocet was ordered on 10/24/2025 and it was not given until 10/25/2025. The DON stated her expectation was something would have been ordered by then. 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.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/29/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Groves Center
512 S 11th St Lake Wales, FL 33853
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0777
F 0777 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
(immediate) labs for a complete blood count (CBC) and comprehensive metabolic panel (CMP) on 9/28/25 related to tremors and feeling cold. 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.
Event ID:
Facility ID:
If continuation sheet
GROVES CENTER in LAKE WALES, FL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LAKE WALES, FL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from GROVES CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.