Inspection·June 28, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff used appropriate PPE (Personal Protective Equipment) while providing direct care for 1 of 5 residents on transmission-based precautions, Resident #2, to help prevent the possible spread of infection and communicable diseases (Photographic evidence obtained). Residents Affected - Few Findings include: During an observation on 6/28/2024 at 9:28 AM, there was a sign on the door of Resident #2 and Resident #3's room that read, STOP: Contact Precautions: In addition to standard precautions . Everyone MUST: Perform hand hygiene with alcohol-based hand rub (ABHR) or soap and water before entering and exiting, wear gown before entering and remove upon exiting, wear gloves before entering and remove upon exiting. Staff A, Certified Nursing Assistant (CNA) lifted Resident #2's right arm and placed an automatic blood pressure cuff around the upper arm and placed a pulse oximeter device (device that measures the pulse and the oxygen level in the body) on the resident's finger and began measuring the vital signs with the machine. Staff A did not have a gown or gloves. Staff B, CNA, entered the room without wearing a gown or gloves, briefly spoke to Staff A and proceeded to Resident #3's bedside and began making her bed, folded some linen and placed Resident #3's linen on her dresser against the wall at the foot of the bed. Staff B then walked over to where Staff A was standing with Resident #2. Staff B touched the foot board of Resident #2's bed, spoke with Staff A and Resident #2 briefly without wearing gloves or a gown, and then left Resident #2 and Resident #3's room. Staff A finished taking the vital signs, wrote them on a piece of paper on top of the vital signs machine with a pen, and disconnected the blood pressure cuff from Resident #2's arm and pulse oximeter device from Resident #2's finger without wearing a gown or gloves and exited Resident #2 and Resident #3's room. Review of Resident #2's admission record showed the resident was admitted on [DATE] with diagnoses including MRSA (Methicillin-Resistant Staphylococcus Aureus) to right foot, Alzheimer's disease, metabolic encephalopathy, cognitive communication deficit, chronic kidney disease (stage 3), dysphagia, and peripheral vascular disease. Review of Resident #2's physician order dated 6/23/2024 read, Contact precautions: MRSA to right foot, every shift until 07/01/2024 23:59 [11:59 PM]. During an interview on 6/28/2024 at 9:32 AM, Staff A, CNA, stated, I am an agency CNA. I don't know which resident [Resident #2 or Resident #3] is on contact precautions in that room [pointing to Contact Precautions sign on the door]. I took her vital signs including her blood pressure on her arm and I used a pulse oximeter on her finger. I should have worn a gown and gloves when entering the room with a contact precautions sign on the door. (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: 106036 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 106036 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Healthcare and Rehabilitation Center and Reh 124 W Norvell Bryant Hwy Hernando, FL 34442 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)