Health inspection·November 20, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based on interview and record review, the facility failed to notify a resident's guardian of a change in medications in 1 of 5 residents (R2) reviewed for notification of changes in the sample of 6. Residents Affected - Few Findings include: On 11/20/24 at 8:38 AM, V6, RN (Registered Nurse) stated (R2) has had some changes with her Gabapentin because it was causing her to be sleepy, so the physician lowered the dosage. V6 stated she did not notify (V15), (R2's) Daughter/Guardian, of the order for Gabapentin, but should've. On 11/20/24 at 8:50 AM, R2 stated (V15) went through the court and got custody of her because at that time, she needed someone to make decisions for her, but now she is improving and doesn't necessarily need both she and (V15) to be notified of everything. R2 stated if there has been an addition of a medication or change in a medication, she would like to consent from her and (V15). On 11/20/24 at 9:40 AM, V15, stated she was not notified of (R2's) order for Gabapentin. R2's Face Sheet, undated, documents V15 as R2's Daughter and legal guardian. R2's Order for Appointment of Guardian, dated 9/25/23, documents V15 was appointed as R2's legal guardian by the Seventh Court of the Seventh Judicial Circuit of the county where R2 resides. R2's MDS (Minimum Data Set) dated, 9/5/24, documents R2 has a BIMS (Brief Interview of Mental Status) score of 11, which indicates R2 moderate cognitive impairment. R2's Care Plan, dated 9/6/24, documents R2 has impaired cognitive function or thought processes related to impaired decision making. R2's POS (Physician Order Sheet) documents an order, dated 10/17/24, for Gabapentin 100 mg three times per day for Neuropathy. R2's Progress Note, dated 10/15/24 at 2:10 PM by V18, R2's Physician, documents in part Back pain with leg pain - likely neuropathy related pain- start Neurontin (Gabapentin) 100 mg TID (Three Times Daily) monitor mentation closely. There is no documentation in R2's progress notes that V15 was notified of the addition of the Neurontin. The Charting & Documentation Policy, dated 7/1/24, documents All services provided to the resident, progress toward the care plan goals or any changes in the resident's medical, physical, functional, (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 11/20/2024 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)