Health inspection·May 2, 2024

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review, interviews, and facility policy reviews, the facility failed to ensure an assessment was completed before they applied a bolster mattress to 1 (Resident #292) of 1 sampled resident reviewed for physical restraints to determine whether the bolster mattress was a physical restraint. Residents Affected - Few Findings included: A review of the facility policy titled, Restraint Free Environment, implemented on 12/19/2022, revealed Policy: It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. Definitions: Physical Restraint refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. According to the policy, 5. Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine: a. How the use of restraints would treat the medical symptom. b. The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released. c. The type of direct monitoring and supervision that will be provided during the use of the restraint. d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place. e. How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being. A review of the facility policy titled, Use of Assistive Devices implemented on 12/19/2022, revealed Policy: The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. Per the policy, 2. The use of assistive devices will be based on the resident's comprehensive assessment, in accordance with the resident's plan of care. A review of Resident #292's admission Record revealed the facility originally admitted the resident on 03/28/2023, with diagnoses to include paroxysmal atrial fibrillation, osteoarthritis of the left hip, hypertensive heart disease, and orthostatic hypotension. Per the admission Record, the resident had a medical history to include diagnoses of reduced mobility, lack of coordination, dizziness and giddiness, and history of falling. A review of Resident #292's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 (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 3 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 05/02/2024 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)