Health inspection·July 12, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to notify the resident's emergency contact of an elopement for one of eight sampled residents (Resident 6). This failure resulted in a delay of elopement notification and incomplete information being passed on to the resident's emergency contact, which had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Elopements and Wandering Resident revised 12/2022 showed the DON or designee shall notify the family or legal representative of an elopement. The policy also showed documentation in the medical record will include findings from post elopement assessments, physician and family notification. Closed medical record review for Resident 6 was initiated on 7/6/23. Resident 6 was admitted to the facility on [DATE], and discharged to the community on 7/4/23. Review of Resident 6's admission Record facesheet showed Resident 6's emergency contact was Family Member 2. Review of Resident 6's H&P examination dated 6/5/23, showed the resident could not make their own medical decisions and Family Member 2 was the surrogate decision maker. Review of Resident 6's MDS dated [DATE], showed the resident had severe cognitive impairment. On 7/5/23 at 1148 hours, an interview was conducted with the DON. When asked if the facility had any resident elopement in the past few months, the DON replied there had been none. On 7/6/23 at 0937 hours, a telephone interview was conducted with LVN 3. LVN 3 stated there had been a resident elopement on 6/26/23. LVN 3 stated the local police department notified staff that a person matching the missing resident's description was brought into the ED. LVN 3 stated the facility staff went to the ED and brought the resident back to the facility. On 7/11/23 at 1113 hours, a telephone interview was conducted with the local Police Dispatch. The Police Dispatch stated on 6/26/23, they received the two following calls: - At 0119 hours, a call for a welfare check on a subject found wandering around Motel A. The subject was picked up by the police office and brought to the local ED. (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 6 Event ID: 555021 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 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 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)