Health inspection·February 27, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 allegation of staff-to-resident abuse within two hours to the State Survey Agency (SSA- the agency that inspects long-term care facilities for the purposes of survey and certification) for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for abuse. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 2/16/2025, with diagnoses that included unspecified (unconfirmed) fracture of right femur (broken thigh bone), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and essential hypertension (also known as primary hypertension, is a type of high blood pressure that has no identifiable cause). During a record review of Resident 1 ' s admission / readmission Screening, dated 2/16/2025, timed at 8:17 p.m., the admission / readmission Screening indicated Resident 1 was oriented to person, place, time, and situation. During a record review of Resident 1 ' s Progress Notes, dated 2/16/2025, timed at 8:25 p.m., the Progress Notes indicated Resident 1 was alert. During a record review of facility ' s Report addressed to SSA, dated 2/18/2025, the Report indicated on 2/17/2025, at approximately 4:45 p.m., Resident 1 informed Family Member 1 (FM 1) that Certified Nursing Assistant 1 (CNA 1) had grabbed Resident 1 in the forearm and verbalized inappropriate words. The Report indicated CNA 1 tried to grabbed Resident 1 for no apparent reason. The Report indicated local law enforcement was notified on 2/17/2025 and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) on 2/18/2025. During a record review of Licensed Vocational Nurse 1 (LVN 1) ' s written statement, dated 2/17/2025, LVN 1 ' s written statement indicated on 2/17/2025, at 4:30 p.m., FM 1 notified LVN 1 that CNA 1 had verbally abused Resident 1 and CNA 1 had grabbed Resident 1 ' s forearms and verbalized inappropriate words. LVN 1 ' s written statement indicated at 4:40 p.m., FM 1 requested Resident 1 to be transferred to the General Acute Care Hospital (GACH) and FM 1 had called 911 (emergency medical response) and the local law enforcement. LVN 1 ' s written statement indicated the Administrator (ADM) and the physician were notified, paramedics (healthcare professionals who respond to emergencies and provide advanced medical care to patients) arrived at 5:15 p.m., and local law enforcement arrived at (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: 056382 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 056382 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342 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)