Health inspection·September 18, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) and failed to make certain that the necessary resident information was communicated to the receiving health care provider upon transfer to the hospital for three of four residents reviewed for hospitalizations (Residents R1, R12, and R57). Findings include: A facility policy entitled Bed-Holds and Returns dated 1/22/25, indicated that prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Facility policy entitled Transfer / Discharge Documentation dated 1/22/25, indicated that when a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. The policy further stated that should a resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider: basis for the transfer; contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advanced directive information, all special instructions or precautions for ongoing care, comprehensive care plan goals, and all other necessary information including any documentation to ensure a safe and effective transition of care. Resident R1's clinical record revealed an admission date of 7/19/24, with diagnoses that included diabetes (a health condition caused by the body's inability to produce enough insulin), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), and high blood pressure. Resident R1's clinical record revealed a progress note dated 6/9/25, indicating a transfer to the hospital. The clinical record lacked evidence that the resident's necessary clinical information was communicated to the receiving health care provider. Resident R1's clinical record also lacked evidence indicating that Resident R1 and/or their representative were provided with a copy of the facility bed-hold policy upon transfer or within twenty-four hours of transfer. Resident R12's clinical record revealed an admission date of 6/4/21, with diagnoses that included chronic obstructive pulmonary disease (COPD – a condition that prevents airflow to the lungs (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 09/18/2025 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)