Health inspection·June 14, 2023

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of clinical records and facility policies and staff and resident interviews, it was determined that the facility failed to ensure water was accessible to one of 54 residents (Resident R1), and failed to ensure the call bell was accessible for resident use for four of 54 residents (Residents R1, R2, R3 and R4). Residents Affected - Some Findings include: Review of the Serving Drinking Water policy, dated 1/04/22 revealed .(11). place the water pitcher and cup within easy reach of the resident . Review of the Call System, Resident policy, dated 1/04/22, stated each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. Review of Resident R1's clinical record revealed an admission date of 2/14/22, with diagnoses that included Alzheimer's disease, high blood pressure, anxiety, and stomach and kidney problems. During observations on 6/13/23 at 9:48 a.m., at 11:07 a.m., and at 11:55 a.m. Resident R1's water cup was sitting on the night stand behind Resident R1. The cup of water was not located in an area that the Resident could reach the water. During an interview at 11:55 with Resident R1 at 11:55 a.m., Resident R1 confirmed that they did not have any water available. When asked if he/she was thirsty, Resident R1 replied yes. During an interview at 11:58 a.m., the Director of Nursing (DON) confirmed that Resident R1's water was not within reach of the resident and the DON provided the resident with the water. Resident R1 took the water provided and began to drink it. During observations on 6/13/23, at 1:22 p.m., Resident R3's call bell was located behind their back while sitting in a chair. At the time of the observation, Resident R3 confirmed they could not reach the call bell. Observation on 6/13/23, at 1:25 p.m. revealed that Resident R1's call bell was on the floor under the wheelchair. At the time of the observation, Resident R1 confirmed they could not reach the call bell. Observation on 6/13/23, at 1: 33 p.m. revealed that Resident R2's call bell was rolled up and placed behind the resident on the bedside table. Resident R2 confirmed they could not reach the call bell. (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 4 Event ID: 395510 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 395510 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grove Manor 435 North Broad Street Grove City, PA 16127 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)