Inspection·September 18, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to verify medications for accuracy and number of dose of each medication being sent home on discharge for 1 of 3 residents (R4) reviewed for discharge medications in the sample of 10. Finding include: 1. On 9/16/2024 9:58 am V8, Clinical Manager stated when R4 seen physician for follow up appointment. R4 care giver brought R4's medication cards from discharge from the facility V8 stated R4 did have all required medications and 7 different medication cards with meds that belonged to R5. V8 stated that R4's care giver had not given R4 any of R5's medications. On 9/16/2024 at 1:10PM V2 Director of Nursing (DON) stated when R4 went to her physician office and took her medications from discharge form the facility she also had some of R5's medication cards with medication. V2 stated this was 3 days after discharge. V2 stated the facility sent a driver out to get the medications and R5 did not miss any medication. V2 stated the nurse that discharged R4 must have accidentally grabbed some of R5's med cards. V2 stated when a resident is discharged their medications are sent with them. V2 stated she spoke to the nurse and informed her to pay more attention with discharge medications. On 9/17/2024 at 10:48AM V6, Registered Nurse (RN) stated when a resident is discharged to make sure there is discharge order in place, review medications, complete discharge sheet and resident takes all of their meds with them. V6 stated it appears she sent some of R5's medications home with R4 R4's discharge plan and instructions dated 9/3/2024 documents follow up/recommendations; follow up with primary regarding medications. R4's discharge plan documents Medication Education/Reconciliation (Has a medication reconciliation been completed? (compare pre-discharge and post-discharge medications to include both prescription and over the counter medication) R4's discharge plan documents yes. R4's discharge plan or clinical record fails to document the number of doses of each medication discharged to R4 or R4's responsible party. R4's clinical record documents in part that R4 has altered mental status. R4's Minimum Data Set (MDS) dated [DATE] documents R4 has severe cognitive impairment. On 9/17/2024 at 11:45AM V2, DON stated when a resident is discharged a discharge packet is sent , the medication cards for resident, V2 stated the nurse is to make a copy of MAR or physician orders (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: 146059 Printed: 05/15/2026 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 146059 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Health & Rehab Ctr, The 873 Grove Street Jacksonville, IL 62650 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)