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 Page 1 of 4 056382 056382 02/27/2025 The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5:30 p.m. LVN 1 ' s written statement indicated local law enforcement spoke to Resident 1 and CNA 1, and local law enforcement left without providing contact information. During an interview on 2/27/2025 at 9:54 a.m., with the Director of Nursing (DON), the DON stated the allegation of abuse happened on 2/17/2025, between 4 p.m. to 4:30 p.m. The DON stated the reports to SSA and Ombudsman were sent on 2/18/2025 at 1:20 p.m., more than two hours from the time allegation was made. The DON stated because Resident 1 had no injury and if no injury they can send the report within 24 hours. During an interview on 2/27/2025, at 10:16 a.m., with the Administrator (ADM), the ADM stated the facility ' s policy and procedure for reporting allegation of abuse with no bodily injury was to report within 24 hours and to local law enforcement immediately and within two hours. The ADM stated the facility reports within two hours to SSA and Ombudsman if allegation involves bodily injury. The ADM stated the facility last reviewed the policy for abuse on 1/2/2025. During a concurrent interview and record review on 2/27/2025, at 10:25 a.m., with the ADM, facility ' s policy and procedure (P&P) titled, Prevention, Reporting and Correction of Inappropriate Conduct including Abuse, Neglect, and Mistreatment of Residents and Investigations of Injuries of Unknown Origin dated 7/1/2011 and last reviewed on 1/2/2025, the P&P indicated, It is the policy of this facility that all personnel, vendors and volunteers do no abuse or neglect any resident in the facility at any time for any reason. Abuse includes, but is not limited to physical, mental, verbal, sexual, or financial abuse or misappropriation of resident property. The facility maintains a zero tolerance to any abuse to residents from anyone including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies, serving the resident, family members or legal guardians, friends, or other individuals. The Administrator in coordination with General Counsel will . 2. Verify that any allegation of abuse is reported, to the California Department of Public Health Licensing and Certification (SSA), Local Law Enforcement and the Ombudsman within two (2) hours that does not involve serious bodily injury. The ADM stated their policy was wrong and should be updated. The ADM stated he (ADM) thought reporting two hours was to local law enforcement and reporting to SSA and Ombudsman with no injury within 24 hours. 056382 Page 2 of 4 056382 02/27/2025 The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342

F 0842 Level of Harm - Minimal harm or potential for actual harm Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to maintain accurate and complete medical record for one of four sampled residents (Resident 1). Residents Affected - Few This deficient practices had the potential to cause confusion in care and the medical records containing inaccurate documentation. 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 Resident 1 ' s Change of Condition (COC-communication between members of the health care team about a resident ' s condition), dated 2/17/2025, timed at 4 pm to 4:30 pm, the COC did not indicate any allegation of abuse. During a record review of Resident 1 ' s Progress Notes, dated 2/17/2025, the Progress Notes indicated no documentation that Resident 1 made an allegation of abuse against Certified Nursing Assistant 1 (CNA 1). During a record review of facility ' s Report addressed to State Survey Agency (SSA- agency that inspects long-term care facilities for the purposes of survey and certification), 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 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 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 was 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 5:30 p.m. LVN 1 ' s written statement indicated local law enforcement spoke to Resident 1 and CNA 1, and local law enforcement left without providing contact information. 056382 Page 3 of 4 056382 02/27/2025 The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 2/27/2025, at 9:54 a.m., with the Director of Nursing (DON), Resident 1 ' s COC, dated 2/17/2025, and Progress Notes, dated 2/17/2025, were reviewed. The DON stated LVN 1 did not document in COC and Progress Notes that Resident 1 had an allegation of abuse towards CNA 1. The DON stated LVN 1 should have documented. The DON stated the importance of documentation was for communication process and to make sure whatever in the medical record is what had happened. During a record review of facility ' s policy and procedure (P&P) titled, Charting and Documentation, dated 7/2017 and last reviewed on 1/2/2025, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident' condition and response to care. 2. The following information is to be documented in the resident medical record: a. Objective observations. b. Medications administered. c. Treatments or services performed. d. Changes in the resident's condition. e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 056382 Page 4 of 4