The Grove Post-Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards for food service safety was maintained for a census of 123, when:Inside the walk-in refrigerator and reach-in freezer were unlabeled and undated food; Multiple food spices containers had cracked lids and with whitish-brownish-dust-like substances; and, Spoiled bananas were found inside the dry storage area. Two kitchen trash bin lids had scattered brownish-sticky-substances; The can opener blades had orange-color-substances; Inside the walk-in refrigerator: the floor and the metal food shelves had brownish-blackish-sticky-substances;The juice dispenser spouts and connection tubing had scattered sticky-brownish-substances;Several pots and pans were stored under the working table and were exposed to kitchen dusts and debris particles; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were maintained for a census of 123, when: The staff failed to remove PPE (Personal Protective Equipment) inside an enhanced barrier precaution (EBP - a patient's room where staff must take extra steps to prevent the spread of hard-to-treat germs) and after handling dirty laundry;Staff reused contaminated PPE and touched clean items after contact with soiled equipment;The CK, with her gloved hands, kept pulling the lower back portion of her clothes, touched the side rim of the food tray-line area; touched the moving trays parked near her; side-touched her apron to remove food dripped on her gloves; and, The outside dumpster side-mounted opening was uncovered, garbage were dumped inside and flies flew around the dumpster. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a comfortable room temperature for one out of 30 sampled residents (Resident 57) when Resident 57's room temperature was below 71 degrees Fahrenheit (*F). This failure negatively impacted Resident 57's comfort, and created an environment that was not homelike.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure a safe and appropriate discharge for one of three sampled residents (Resident 58) when Resident 58 was discharged from the facility while an application for Medi-Cal (state run Medicaid program under federal guidelines) was still in process and without a discharge plan .This failure resulted in Resident 58's discharge to a hotel without appropriate resources or discharge instructions.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure two out of nine sampled Certified Nurse Assistant (CNA) employee personnel records were current in their annual Resident Abuse Prevention and Department of Justice (DOJ) trainings. This failure had the potential to result in staff not recognizing, preventing, and reporting any possible resident abuse for a census of 123 residents.

Inspectors wroteBased on interview and record review the facility failed to protect one of three sampled residents (Resident 1) from verbal abuse when Resident 2 made derogatory remarks toward Resident 1. This failure had the potential to negatively affect Residents 1's mental health. During a review of Resident 1's Minimum Data Set (MDS: federally mandated assessment) Section C dated 3/16/26, MDS-C indicated Resident 1 had a Brief Interview for Mental status (BIMS: a standardized assessment used by healthcare professionals to evaluate cognitive function, with a score 13-15: indicating Intact cognition) score of 13. This indicated Resident 1's cognition (ability to think and rationalize) was intact. During a review of Resident 1's Order Review History Report dated 3/2/26-4/2/26, report indicated, Resident 1 had an order indicating Resident is capable of making her own health decisions. [...]

Inspectors wroteBased on interview and record review the facility failed to identify and to report an allegation of verbal abuse to the California Department of Public Health (CDPH) when: an incident between Resident 1 and Resident 2 was not identified as a verbal abuse allegation or reported timely per Federal regulations. This failure resulted in the Department being unaware of the abuse allegation between Resident 1 and Resident 2 and, had the potential for Resident 1 to be continually subjected to verbal abuse by Resident 2, who was not separated from Resident 1. During a review of Resident 1's Minimum Data Set (MDS: federally mandated assessment) Section C dated 3/16/26, MDS-C indicated Resident 1 had a Brief Interview for Mental status (BIMS: a standardized assessment used by healthcare professionals to evaluate cognitive function, with a score 13-15: indicating Intact cognition) score of 13. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect one of five sampled residents' (Resident 1) right to be free from physical/mental abuse by Resident 2 when Resident 2 shoved a walker into Resident 1's legs. As a result of this failure, Resident 1 experienced a skin tear in the left knee.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the kitchen for a census of 132 when: 1. Unsanitary conditions were observed in the kitchen's dry storage area; and, 2. Expired items were found in the walk-in refrigerator. These failures had the potential to cause food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were accessible and in good repair for three of 32 sampled residents (Resident 16, Resident 24, and Resident 1). This failure had the potential to jeopardize the safety of these residents and limited accessibility for them to call for help.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the RP (Responsible Party) of the transfer and the reason for the transfer for one resident (Resident 132) out of 32 sampled residents. This failure increased the risk for Resident 132's RP not be informed of the resident's discharge rights.

Inspectors wroteBased on interview and record review, the facility failed to timely submit a Minimum Data Set (MDS, a federally mandated resident assessment tool) for one of 32 sampled residents (Resident 119) when the discharge assessment was not completed and transmitted according to the required regulatory time frame. This failure had the potential to result in incomplete information being submitted to Centers for Medicare and Medicaid Services (CMS).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 32 sampled residents (Resident 125) had a PASARR (Pre admission Screening and Resident Review, a federal requirement to ensure individuals with serious mental illness, intellectual disability, or other related conditions are not inappropriately placed in nursing homes for long term care and receive services in the most integrated setting) completed. This failure had the potential for the facility not to provide or seek appropriate mental health services for Resident 125.

Inspectors wrote3b. A review of the admission Record indicated Resident 115 was initially admitted [DATE] and recently admitted [DATE]. with diagnoses including Diabetes mellitus with diabetic neuropathy (nerve damage caused by high blood sugar levels). A review of Resident 115's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 1/17/25 indicated Resident 115 had moderate cognitive impairment with a score of 12 out of 15 in the Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident). A review of Resident 115's physician order dated 1/13/25 indicated, COMPRESSION SOCKS: CNA [Certified Nursing Assistant] to apply COMPRESSION SOCKS to BLE [bilateral lower extremities] during the day and remove at bedtime as tolerated . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote safety measures for one of 32 sampled residents (Resident 50) when Resident 50's order for the use of wander guard (a device that allows sensors on doors to alarm to keep track of wandering residents) was not followed as ordered. This failure increased Resident 50's risk for elopement.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacy recommendations for one of 32 sampled residents (Resident 54) during a Medication Regimen Review (MRR) was communicated to the physician. This failure had the potential for Resident 54 to experience adverse effects from the medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication error rate was less than five percent (5%) for a census of 132 when: 1. Licensed Nurse 1 (LN 1) did not follow the physician's order in administering Resident 13's prescribed medication; 2. Resident 115 was given another resident's supply of insulin glargine (long-acting insulin); and 3. Three of Resident 83's morning medication were combined and administered at the same time through the feeding tube with no regard for medication reactions (therapeutic response). These failures resulted in a medication error rate of 23.08% for the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (Resident 115) for a census of 132 was free from significant medication error when Resident 115 was administered another resident's insulin. This failure increased Resident 115's risk for receiving the wrong medication and complications of diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) including diabetic coma.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the medication label for one (Resident 115) out of a census of 132 when Resident 115's insulin glargine (long-acting insulin) order was changed. This failure increased the potential for unsafe administration of medication to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure services furnished by outside resources had written agreements when two of 32 sampled residents' (Resident 56 and Resident 96) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) services were provided without existing agreements with dialysis clinic. This failure had the potential to result in the lack of responsibility and accountability in the dialysis services received by Resident 56 and Resident 96.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program, for a census of 132, when: 1. Personal Protective Equipment (PPE-clothing and equipment that is worn or used for for protection against hazardous substances and or environments) was not contained properly in the trash for Resident 15; 2. The Licensed Nurse 2 (LN 2) did not perform safe administration of insulin for Resident 115; and, 3. Resident 46's nebulizer (machine that turns liquid medication into an inhalable mist through a connected mouthpiece that allows the medication to enter the lungs directly) tubing was not changed as scheduled and the incentive spirometer (a handheld plastic device that helps exercise the lungs and breathe deeply) was not stored appropriately. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a homelike environment for one of 32 sampled residents (Resident 99) when a patio door was in disrepair. This failure had the potential to minimize Resident 99's psychosocial well-being and made the resident feel uncomfortable.

Inspectors wroteBased on interview and record review, the facility failed to report an incident of an injury of unknown origin timely for one of three sampled residents (Resident 1) as required by the regulations. This failure resulted in a delay in the investigation process and decreased the facility's potential to protect patients from physical and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) for one of three sampled residents (Resident 1) accurately reflected Resident 1 ' s behavioral symptoms when her MDS Section E Behavior was not accurately documented. This failure had the potential to result in Resident 1 not receiving interventions to improve behavioral symptoms and placed Resident 1 at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were free from physical abuse when Resident 1 and Resident 2 were in a physical altercation that resulted in Resident 1 sustaining a skin tear on her right forearm and discoloration on her right upper arm. This failure had the potential to result in serious physical injuries for Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to report immediately to officials an alleged violation involving physical abuse between two residents (Resident 1 and Resident 2) of three sampled residents, when the Department received the report of alleged violation greater than two hours after the incident's occurrence. This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and homelike environment was provided when: 1. One of 32 sampled residents (Resident 106) low air loss mattress (LAL, a pressure relieving and redistribution device to help prevent skin breakdown) was not in good working condition; and 2. Five of 12 sampled rooms had holes and peeling paint on the walls. This failure increased the risk for Resident 106 to develop skin breakdown and the disrepair in the rooms may negatively impact the well being of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer appropriate treatment and services to maintain continence for one of 32 sampled residents (Resident 47), who was assessed as a candidate for bladder retraining and the bladder retraining was not provided. This failure resulted in Resident 47 not receiving the services and assistance to maintain her continence and resulted in decline of resident's continence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its pharmaceutical policies and procedures for a census of 120, when: 1. Two used and unsealed E-Kit boxes (Emergency-Kit, storage box containing emergency supplies of medication) were not removed and replaced with the potential for not having all the emergency medications available to the residents and increased risk of drug diversion; and 2. Resident 433's intravenous (IV, medication given through the vein) antibiotics (medication that treat bacterial infections) was not administered per physician's order with the potential for his infection not to be resolved.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 32 sampled residents (Resident 107), was free from unnecessary drugs when Resident 107 did not have adequate indication for the use of Seroquel (a psychotropic medication indicated for psychosis; affects the mind, emotions, and behavior). This failure resulted in Resident 107 receiving unnecessary medication for an excessive duration and placed the resident at risk for adverse (unwanted) effects and further decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly store medications for a census of 120, when: 1. Two expired medications were found in the medication refrigerator, which could lead to the resident receiving expired or ineffective medication; 2. Three loose pills were found in a medication cart, which could result in diversion of the loose medication; and 3. Two prescription blister packs were found displaced and stuck in the back of the medication cart, which could result in drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare foods that conserved nutritive value, flavor, and palatability when vegetables and pureed meals were prepared without following the recipe with measured ingredients. This failure had the potential of leading to poor intake, malnutrition, and weight loss for the 117 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 117 residents who received facility prepared foods when: 1. Food labeling not followed; 2. Expired foods not discarded; 3. Egg and tuna salad not kept in safe food temperature range; 4. Freezer door frame had ice build-up suggesting temperature fluctuations; 5. Ice build-up on food items stored in reach-in freezer; 6. Can opener had missing metal from the cutting tip; 7. Dust, dirt, and food debris in kitchen areas including dry food storage, refrigerator and under the stove; 8. Box of lentils was left open to air; 9. Improper use of thermometer during food temperature check; and 10. Wet pans on storage, and wet, stained blender container. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide rehabilitation services for one of 32 sampled residents (Resident 4), when Resident 4 did not receive physical therapy (PT) evaluation and treatment as ordered by the resident's physician. This failure prevented Resident 4 from attaining and maintaining the highest practicable functional level and had the potential to result in further decline of Resident 4's mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed when, 1. A blood pressure monitor (device used to measure blood pressure) was not disinfected according to manufacturer's instructions after being used during medication pass observation, and 2. A laundry room exhaust fan located above the clean linen area was coated with thick, sticky substance. These failures had the potential to transmit pathogens or bodily fluids for 120 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge MDS (Minimum Data Set, an assessment tool) assessment was completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) System within the required time frame for one resident (Resident 112), for a census of 120. This failure resulted in the most recent MDS resident assessment not being reported to CMS as required.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool used to guide care) for one of 32 sampled residents (Resident 52) accurately reflected Resident 52's Physician's Order for Life Sustaining Treatment (POLST) when her MDS Section S RESIDENT ASSESSMENT AND CARE SCREENING was not accurately documented. This failure had the potential to result in Resident 52 receiving interventions that were contrary to his own choices.

Inspectors wroteBased on interview and record review, the facility failed to refer one (Resident 22) of 32 sampled residents for Pre-admission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) when the resident received a new mental illness diagnosis. This failure had the potential for Resident 22 to not receive necessary services to meet his mental and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive care plan for refusing nail care was developed for one of 32 sampled residents (Resident 20). This failure had the potential for Resident 20 to spread infection and inflict injury to self due to long fingernails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 32 sampled residents (Resident 20) who was dependent on staff to perform activities of daily living (ADLs, daily activity such as self care including personal hygiene) received the necessary nail care. This failure had the potential for Resident 20 to spread infection and self inflicted injury due to long fingernails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision and assistive devices were provided for 2 of 32 sampled residents (Resident 87 and Resident 90) when: 1. Resident 87 had a fall with a facility staff present; and 2. Resident 90 had an unwitnessed fall. These failures had the potential for Resident 87 and Resident 90 to have increased incidences of fall and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of 32 sampled residents (Resident 97), who was identified at risk for dehydration with sufficient fluids to maintain proper hydration, when Resident 97 did not meet her estimated fluid needs as assessed by the Registered Dietitian. This failure placed Resident 97 at further risk for dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen therapy in accordance with the physician's order and the resident's care plan for one of 32 sampled residents (Resident 80), when Resident 80 did not receive the prescribed amount of oxygen. This failure resulted in Resident 80 receiving more oxygen than ordered by the physician and had the potential for the resident to experience serious health complications related to too much supplemental oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when the garbage dumpster was found open, for a census of 120. This failure had the potential to attract pests to the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to ensure the safety for one of four residents identified at risk for wandering (Resident 1) when he left the facility unsupervised, wandered to a busy street, was found by fire department, and the resident was brought back to the facility. This failure had the risk potential to jeopardize Resident 1's health and safety.