Inspection·September 26, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to provide adequate supervision to ensure the safety for one of four residents identified at risk for wandering (Resident 1) when he left the facility unsupervised, wandered to a busy street, was found by fire department, and the resident was brought back to the facility. This failure had the risk potential to jeopardize Resident 1's health and safety. Findings: According to Resident 1's 'admission Record,' he was admitted by the facility recently with multiple diagnoses which included Neurocognitive disorders with Lewy bodies( Lewy body dementia is a disease which can lead to problems with thinking, movement, behavior, and mood) , Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) and bipolar disorder (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). Resident 1 scored 13 out of 15 in a Brief Interview for Mental Status (BIMS, a tool that tests memory and recall) contained in his MDS (Minimum Data Set, an assessment tool) assessment, dated 8/4/23, indicated Resident 1 was cognitively intact. A review of Resident 1's ' Elopement Risk,' dated 7/28/23, indicated that he was at risk for elopement. A review of Resident 1's ' Nurses Notes,' dated 9/4/23, indicated that staff was looking for the resident at breakfast time. The assigned Certified Nursing Assistant (CNA) for Resident 1's care was looking for him in the whole building before reporting it to the nursing supervisor. Around 8:00 am, the fire department was called and notified that they found the resident on the corner of two streets. A paramedic, who was on the scene, informed the staff involved with the search of the resident that they will only release the Resident when a nurse or a supervisor will identify and speak to them. Licensed Nurse (LN) 1 talked to the paramedics and came back to the facility with Resident 1 and other staff. During an interview conducted with LN 1 on 9/20/23, at 12:05 p.m., LN 1 stated that on the day of the elopement, he first saw Resident 1 around 6:30 a.m. during the bed side report with the night nurse. Around 7 a.m. LN 1 stated he was standing by the med cart in the hallway when he saw Resident 1 come towards him with his walker and passed by him. That was the last time LN 1 saw him before his elopement. Around 7:15 a.m., when passing Resident 1's tray, one of the CNAs asked him where Resident 1 was as she did not see him in his room. LN 1 told her to check the living room, as Resident 1 usually likes to sit down in the living room to watch television. When the CNA said that she did not (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: 055438 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 055438 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute 124 Walnut Street Woodland, CA 95695 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)