Health inspection·February 12, 2025

F 0676 Level of Harm - Potential for minimal harm Residents Affected - Some Resident 1's dentures this morning. CNA 1 further stated Resident 1's dentures should have been cleaned from the previous evening and submerged in water with the denture cleanser tablet. On 2/12/25 at 1158 hours, Resident 1 was observed sitting in the wheelchair in the dining room, waiting to be served lunch. Resident 1 was observed without her upper and lower dentures inside her mouth. Resident 1 shook her head indicating no, when she asked if she wanted to wear her dentures. When Resident 1 was asked if she had any discomfort when she wore her dentures, the resident shook her head again indicating no. On 2/12/25 at 1205 hours, a follow up observation and concurrent interview was conducted with CNA 1 for Resident 1. Resident 1's upper and lower dentures were observed in a denture cup filled with a very small amount of clear liquid, resembling water. CNA 1 stated she offered to place the dentures in for Resident 1 but Resident 1 refused to wear her dentures. When asked, CNA 1stated she did not clean the dentures when she offered them for Resident 1 to wear. CNA 1 further stated she would clean Resident 1's denturesbefore her shift ended. On 2/12/25 at 1210 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 1 would sometimes refuse to wear her dentures. However, review of Resident 1's plan of care failed to show a care plan problem addressing the resident'srefusal to wear the dentures. 2. Medical record review for Resident 2 was initiated on 2/12/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's H&P examination dated 8/16/24, showed the resident had no capacity to understand and make decisions. Review of Resident 2's MDS dated [DATE], showed Resident 2 required partial to moderate assistance from the staff for oral hygiene. On 2/12/25 at 0840 hours, an observation and concurrent interview was conducted with CNA 1 for Resident 2. Resident 2 was observed lying in bed. Resident 2's upper and lower dentures were observed in a denture cup filled with a very small amount of clear liquid, resembling water. CNA 1 stated Resident 2 usually refused to wear her dentures. CNA 1 further stated the resident's dentures should have been cleaned from the previous evening and submerged in a water with the denture cleanser tablet. CNA 1 verified the above findings. On 2/12/25 at 0855 hours, an interview was conducted with LVN 1. When asked about the facility's policy regarding denture care for the residents, LVN 1 stated the residents' dentures should be cleaned and stored in water at night. LVN 1 further stated the CNAs were expected to clean the dentures and offer them to the residents in the morning before breakfast. On 2/12/25 1220 hours, an interview was conducted with the DSD. The DSD stated the CNAs in the morning shift were expected to clean the residents' dentures every morning, before offering them to the residents. The DSD further stated the CNAs in the evening shift should clean the dentures and store them in water with the denture cleanser tablet. On 2/12/25 at 1552 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated denture care should be provided by the CNAs daily. The DON stated when the residents' dentures were not being used, the dentures should be submerged in water with the denture (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 2 of 3 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 02/12/2025 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)

F 0676 cleanser tablet. The DON verified there was no care plan addressing Resident 1's refusal to wear the dentures. The DON was informed and acknowledged the above findings. Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555021 If continuation sheet Page 3 of 3