Other·March 26, 2019

F609 Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/26/2019 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(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 long-term care facilities) in accordance with State law through established procedures. §483.12(c)(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. This REQUIREMENT is not met as evidenced by: Based on staff interview and document review, the facility failed to report evidence of an alleged report of neglect of (Resident 1) within 24 hours of learning of the incident. This failure could have potentially caused a 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: QLKD11 Facility ID: CA030000030 If continuation sheet 1 of 3 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 03/19/2019 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 delay in the Department's investigation of the alleged event. Findings: Resident 1's "Record of Admission" confirmed Resident 1 was admitted to the facility in November 2006. On 1/31/19 at 5:36 p.m., the Department received a FAX with documentation of a "suspected abuse investigation follow up" report from the facility. Per the report the incident occurred on 1/26/19 at about 1:30 p.m. On 2/1/19 the Departmemt received a Facility Reported Incident (FRI) that described an alleged allegation of abuse/neglect of Resident 1. The report indicated on 1/26/19 at 1:30 p.m. (6 days prior to receipt of the FRI), the Charge Nurse received a report that Resident 1 was found with her gown, brief, sheet and mattress saturated with urine. On 2/4/19 at 4:59 p.m., the Department received a FAX from the facility's Director of Social Services (DSS) that indicated, "Only proof of the FAX transmission made by reporting party to CDPH (Department of Public Health). Unfortunately Ombudsman's Fax number was used mistakenly...(sic)." During an interview with the Director of Nursing (DON) on 2/25/19 at 11:30 a.m., the DON expressed a search for the FAX confirmation for the original report intended to be sent to the Department by 1/27/19, failed to support the facility's claim the ERI was submitted to the Department on time. The DON agreed with the DSS statement and confirmed the FRI was not submitted to the Department on time. Review of the facility's policy titled "Abuse, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QLKD11 Facility ID: CA030000030 If continuation sheet 2 of 3 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 03/19/2019 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 Prevention Of", with a revised date 12/2011, confirmed "...Reporting: ...Administrator shall report all incidents of alleged abuse or suspected abuse to DHS (Department of Health Services) [now under CDPH jursidiction] within 24 hours..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QLKD11 Facility ID: CA030000030 If continuation sheet 3 of 3