Inspection·June 15, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to maintain a safe and homelike environment by failing to ensure properly functioning toilets in 2 of 4 halls observed (100 and 200 halls). Toilets were observed to be backed up, overflowing and slow to drain resulting in flooding in two rooms on the 100 hall (105 and 107). The findings include: On 6/15/23 at approximately 9:00 AM, an interview was conducted with resident #4 during which he stated that the toilet in his room was slow to drain and would at times become clogged requiring the maintenance main to use a plunger to unclog it. At this time the toilet in his room was flushed and found that it was slow to drain and did not completely empty during the flush cycle. He stated this happens about once a week. On 6/15/23 at approximately 9:15 AM, an observation was made of room [ROOM NUMBER] in which the water in the bathroom toilet was observed to be at the rim of the toilet, the water was dark brown and there were feces noted with toilet paper. At this time an interview was conducted with the staff member F, Certified Nursing Assistant (CNA) who was providing one on one care to the resident in the room. She stated that the toilet has been backing up but that maintenance would be in to clear it when he has time. She stated that this occurs from time to time, but they can usually unplug it with a plunger. On 6/15/23 at approximately 9:25 AM an observation was made of room [ROOM NUMBER], staff member I, a floor tech, was observed placing towels down on the floor around the toilet and around the 4 resident's beds. Employee I, a floor tech, said that the toilet overflowed to the point that the water was coming out into the resident's room and under the wall into room [ROOM NUMBER]. Housekeeping staff were observed in room [ROOM NUMBER] with towels noted on the floor and a mop was being used to clean up the water in the room. At this time staff member I, stated that this is the first time this had happened on this hall, it usually happens on the 300 hall. Photographic evidence obtained. On 6/15/23 at approximately 10:20 AM an interview was conducted with the administrator during which she stated that she was aware of the issue in rooms [ROOM NUMBERS] with the toilet backing up and flooding the room. She stated that she feels it is the result of someone using too much toilet paper when using the bathroom or they flushed something they should not have down the toilet. She was not aware of the clogged toilet in room [ROOM NUMBER]. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 105269 Printed: 05/28/2026 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 105269 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/15/2023 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)