Inspection·July 3, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to report an incident of an injury of unknown origin timely for one of three sampled residents (Resident 1) as required by the regulations. Residents Affected - Few This failure resulted in a delay in the investigation process and decreased the facility's potential to protect patients from physical and psychosocial harm. Findings: During a review of Resident 1's admission records, the records indicated Resident 1 was admitted in October 2023 with diagnoses that included pathological fracture (broken bone caused by disease) of right humerus (upper arm bone), displaced oblique fracture (diagonal break in the bone) of shaft of humerus (long middle portion of the upper arm bone) of right arm, and dementia (group of symptoms affecting memory, thinking and social abilities). Residents 1's Minimum Data Set (MDS, an assessment tool) indicated Resident 1 had severe cognitive impairment. During a review of Resident 1's nurses notes, dated 6/19/24 at 1:05 p.m., the notes indicated, CNA [Certified Nursing Assistant] reported that res [resident] has R [right] arm pain before transferring the res from bed to shower chair. @ [at] around 07:30 [am] I assessed, and no swelling noted but res complains of pain and unable to lift the R arm. During a review of Resident 1's nurses notes, dated 6/22/24 at 1:01 p.m., the notes indicated, .Resident is on day 2 of 7 po [by mouth] atb [antibiotic] .for R arm cellulitis [deep infection of the skin] .R arm still swollen but now color is dark purple to area .[family member] in facility requesting resident to get an xray to resident's R elbow and arm .Received orders from NP [Nurse Practitioner] .Stat [immediately] xray to R elbow and arm .Orders carried out. During a review of Resident 1's Radiology Results Report, reported on 6/22/24 at 3:53 p.m., the report indicated, Reason for Study: .PAIN IN RIGHT ELBOW .CONCLUSION: Acute transverse distal humerus supracondylar fracture [break in the lower end of the arm bone just above the elbow joint]. During a review of Resident 1's nurses notes, dated 6/23/24 at 7:16 a.m., the notes indicated, Message received from PCP to send resident to ED [emergency department] d/t [due to] x-ray results regarding right elbow x-ray results. During a review of Resident 1's nurses notes, dated 6/23/24 at 2:14 p.m., the notes indicated, Resident returned back from [acute hospital] at approx. 1345 [1:45 p.m.] .R arm is on a splint. (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: 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 07/03/2024 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)