Other·November 9, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated survey for the investigation of entity reported incident #CA00546223. Representing the Department of Public Health: HFEN, 38518 HFEN, 38223 The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility.

F225 SS=D INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS CFR(s): 483.12(a)(3)(4)(c)(1)-(4)

F225 11/02/2017 483.12(a) The facility must(3) Not employ or otherwise engage individuals who(i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or (iii) Have a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PNUX11 Facility ID: CA030000030 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055438 (X3) DATE SURVEY COMPLETED 10/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE GROVE POST-ACUTE 124 Walnut Street Woodland, CA 95695 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in longterm care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PNUX11 Facility ID: CA030000030 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055438 (X3) DATE SURVEY COMPLETED 10/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE GROVE POST-ACUTE 124 Walnut Street Woodland, CA 95695 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to report an allegation of abuse timely, and failed to protect one of three sampled residents (Resident 1) from potential physical and verbal abuse when an allegation of abuse was not reported for three days and the alleged abuser was not identified for the same period of time. This failure had the potential to expose residents to potential abuse by a facility staff member. Findings: Resident 1 was admitted to the facility in late 2006 with multiple diagnoses that included schizoaffective disorder (a mood disorder). Review of the clinical record for Resident 1 included: A Minimum Data Set (MDS - an assessment tool), dated 5/5/17, indicated Resident 1 had a BIMS (a brief interview of mental status) score of 8 out of 15, indicating moderate short-term and long-term memory problems. A Plan of Care dated 7/15/16 for Alteration in Mood/Behavior indicated not to rush or show impatience with Resident 1 and approach in calm manner. A Short term Care Plan dated 7/28/17, indicated Resident 1 had a potential for mood distress due to alleged abuse by staff. A Progress Note dated 7/28/17 at 1:10 p.m., indicated RN 2 did a skin assessment with a scratch noted to right upper arm. Progress Notes indicated no pain, bleeding or other skin issues. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PNUX11 Facility ID: CA030000030 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055438 (X3) DATE SURVEY COMPLETED 10/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE GROVE POST-ACUTE 124 Walnut Street Woodland, CA 95695 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's documents included: An abuse report dated 7/28/17 stated CNA 1 saw CNA 2 pushing Resident 1 into bed and raising his voice. A handwritten letter dated 7/28/17, written by CNA 1 stated CNA 2 "...Used bad words and push [sic] into bed". A follow up report dated 8/3/17, written by the SSD (Social Service Director) stated alleged incident happened on 7/24/17 in the evening. CNA 1 met with the DON (Director of Nurses) and SSD on 7/28/17. CNA 1 stated CNA 2 was "In abuse [sic]" of Resident 1. When asked what she meant by "Abuse", CNA 1 said CNA 2 was raising his voice, speaking to her in his native tongue, and then "pushed Resident 1 into bed". CNA 1 also stated it bothered her the next couple of days so she felt she had to report it. In a review of the facility's staffing records, CNA 2 continued to work two days after the alleged abuse occurred (7/26/17 and 7/27/17). In an interview on 8/10/17 at 1:35 p.m., LN 1 stated Resident 1 was usually "Pretty alert, knows names and faces but forgets dates." LN 1 (Licensed Nurse) also stated Resident 1 was sleepy due to recent medication for restlessness, so was unable to hold a conversation. In an interview on 8/10/17 at 2:50 p.m., the DON stated CNA 1 was hesitant to report issue due to "being related" to CNA 2. The DON stated she could not "unsubstantiate" the abuse complaint so they terminated CNA 2 on 8/1/17. In an interview on 8/10/17 at 3:05 p.m., CNA 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PNUX11 Facility ID: CA030000030 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055438 (X3) DATE SURVEY COMPLETED 10/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE GROVE POST-ACUTE 124 Walnut Street Woodland, CA 95695 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated it was an afternoon shift and CNA 2 was working with her at around 8:30 p.m. when they usually put residents to bed. CNA 2 was talking to Resident 1 about going to bed. He stated, "If you don't want to go to bed, I will push you." Resident 1 tried to scratch CNA 2. CNA 2 got mad and started to talk to Resident 1 in his own language (non-English). CNA 1 indicated she spoke the same language as CNA 2. CNA 2 stated, "She never wants to go to bed," so he lifted her from the wheelchair and threw her in the bed. CNA 2 raised his voice as if he was mad at Resident 1 and made a comment that he was "the man". CNA 1 was afraid to say anything at first because she has a family relationship to CNA 2 but she felt "bad" so she told her charge nurse on her next day back at work, 7/27/17. In an interview on 8/10/17 at 3:50 p.m., LN 2 stated CNA 1 notified her of the incident on 7/27/17 in the evening. LN 2 came in the following morning and reported it to the DON. LN 2 stated she was aware of the abuse reporting timelines and knew she should have reported when she was aware of the abuse. LN 2 assessed Resident 1 on the evening shift of 7/27/17 after she learned of the incident. LN 1 asked if Resident 1 was "ok." but did not note assessment on progress note. LN 2 was not aware of the short -term care plan that stated to monitor Resident 1 for 72 hours. LN 2 also stated she had heard of other residents commenting about CNA 2 being "rough," and CNA 2's assignment would be changed so he would not have those residents In an interview on 8/10/17 at 4:40 p.m., the DON acknowledged that the report of abuse was not made with 24 hours as required. In a phone interview on 8/22/17 at 2:20 p.m., the DON verified they had suspended CNA 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PNUX11 Facility ID: CA030000030 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055438 (X3) DATE SURVEY COMPLETED 10/26/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE GROVE POST-ACUTE 124 Walnut Street Woodland, CA 95695 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE on 7/28/17, but CNA 2 continued to work two more days after incident (7/26/17 and 7/27/17) before they were aware of the alleged allegation of abuse. In a phone interview on 8/22/17 at 2:25 p.m., the SSD stated he was the Director of the Abuse Committee. He confirmed his expectations of abuse reporting would be "all staff will follow policy and procedure of abuse reporting and report immediately to supervisor" and verified his expectations were "residents will be free from abuse from all staff and other residents". SSD also confirmed that the allegation of abuse was reported late per facility policy. A facility policy titled "ABUSE, PREVENTION OF," dated 12/2012, indicated the following: 1. Abuse, neglect, mistreatment...will not be tolerated at this facility." 2. All mandated reporters are required by law to report incidents of known or suspected abuse. 3. First responder or first staff member informed will be responsible for informing immediate supervisor and initiating incident report. 4. Administrator or designee shall report all incidents of alleged abuse or suspected abuse to DHS within 24 hours. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PNUX11 Facility ID: CA030000030 If continuation sheet 6 of 6