Inspection·May 15, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were free from physical abuse when Resident 1 and Resident 2 were in a physical altercation that resulted in Resident 1 sustaining a skin tear on her right forearm and discoloration on her right upper arm. This failure had the potential to result in serious physical injuries for Resident 1 and Resident 2. Findings: A review of a facility document titled admission Record, indicated Resident 1 was admitted to the facility in 2023 with diagnoses including depression and anxiety disorders. Review of Resident 1 ' s Minimum Data Set (MDS, an assessment tool), dated 2/6/24, indicated Resident 1 had a Brief Interview of Mental Status (BIMS) score of 11 out of 15, which indicated moderate cognitive impairment. Review of Resident 1 ' s medical record titled, SBAR [Situation, Background, Assessment, Recommendation] and Initial COC [Change of Condition]/Alert charting and Skilled Documentation, dated 5/1/24, indicated Resident 1 had a skin tear on her right arm approximately 3 inches long on 5/1/24 at 9 p.m. Review of Resident 1 ' s Nurses Notes, dated 5/2/24, indicated Resident 1 had a resident altercation with roommate and, .Sustained a skin tear on her [right] forearm and discoloration on her [right] upper arm. Review of Resident 1 ' s note titled, IDT [Interdisplinary Team] – Grievance Investigation, intervention/s and Resolution, dated 5/2/24, indicated Resident 1 reported on 5/1/24 around 8 p.m. that her roommate struck the front of her right arm causing a skin tear and discoloration, as well as discoloration on her right upper arm. Review of Resident 1 ' s Nurse Practitioner (NP) note titled, Skilled Nursing/ Rehab Office/ Clinic Note, dated 5/2/24, indicated Resident 1 had a physical altercation with roommate resulting in trauma. The NP note further wrote, Per resident she was trying to open the balcony door last night but her roommate hit her right arm with a hard object. She had a large discoloration with skin tear on her forearm as a result of the trauma. She also has a new bruising on her deltoid region. (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 3 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 05/15/2024 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)