Grove Health & Rehab Ctr, The
GROVE HEALTH & REHAB CTR, THE in JACKSONVILLE, IL — inspection on March 26, 2026.
Found 2 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
Investigation as completed on 6/6/2025, unable to determine who or where the card of hydrocodone went.The facility's policy, Abuse Policy, revised 12/2025 documents, This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment.
This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.
The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents and in correspondence with the Elder Justice Act of 2010 that strengthens elder abuse protections and the Illinois Administrative Code.
146059 03/26/2026
Grove Health & Rehab Ctr, The 873 Grove Street Jacksonville, IL 62650
with R16's death until today ([DATE]). V19 stated he assumed R16 was a no code (no CPR) by the
jeopardy to resident health or took her last breath. V19 then stated, I only received 2 days of orientation, I did not look at her (R16's) safety paperwork to see if she was a code.On [DATE] at 10:38 AM V30 CNA stated she found R16 unresponsive on [DATE] and she went to get the nurse (V19), and he (V19) told her to get the other
V2 DON stated she expects the facility nurses to follow facility protocols.On [DATE] at 11:26 AM V1 Administrator stated he would have expected the nurses to administer CPR.The facility's CPR Policy dated [DATE] documents Emergency Procedure - Cardiopulmonary Resuscitation. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR.
Instruct a staff member to activate the emergency response system (code) and call
- Instruct a staff member to retrieve the automatic external defibrillator (if applicable).
Verify or instruct a staff member to verify the DNR or code status of the individual.
Initiate the basic life support (BLS) sequence of events.
The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy:Immediate re-education of all licensed and direct care staff on CPR requirement, including initiation unless a valid DNR order is present [DATE] prior to working the floor.Facility staff educated in-serviced all staff on the code status of facility residents and where to check for code status of resident on [DATE] or prior to working the floor on their next scheduled shift.All agency staff will be checked off on knowledge of CPR and knowledge of code status prior to working the floor on their next scheduled shift.Verification of all residents' code status to ensure accuracy and accessibility [DATE].Removal of any staff involved from resident care pending re-education and competency validation [DATE].Hands-on CPR return demonstrations completed for all staff [DATE] and prior to working the floor.Emergency equipment (crash cart, oxygen) checked and confirmed functional [DATE].Policy reviewed that it clearly requires initiation of CPR unless a valid DNR order is verified [DATE].Code status verification added to shift report and electronic medical record review [DATE].HR (Human Resource) assigned responsibility for CPR compliance and education [DATE].Routine mock code drills scheduled weekly for 4 weeks then monthly x 3 months [DATE] and ongoing.CPR requirements incorporated into orientation for all new hires [DATE].This alleged deficient practice has potential to affect all residents in the facility.R16 no longer resides in the facility.Monitoring:All staff will complete CPR competency validation immediately on [DATE] and ongoing.Weekly audits of code status starting on [DATE] and ongoing verification x4 weeks, new admissions verified upon admission.Monthly mock code drills with documentation starting on [DATE].Quarterly audits of emergency response documentation starting on [DATE].Results will be reviewed in QAPI meetings.
The facility's Census Room Roster dated [DATE] documents there are 138 residents residing at the facility.