The Grove Post Acute
Inspection Findings
F-Tag F0919
F 0919
Make sure that a working call system is available in each resident's bathroom and bathing area.
Level of Harm - Potential for minimal harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, medical record review, and facility P&P review, the facility failed to ensure the call light system was functioning for one of six sampled residents (Resident 2). * Resident 2's call light was not working when it was pressed. This failure had the potential for delayed provision of assistance to the resident.Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response dated 12/19/22, showed the facility was to assure it was adequately equipped with a call light. The staff will report problems with a call light or the call system to the supervisor and/or maintenance director. On 12/30/25 at 1142 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was lying
in bed with the call light within reach. Resident 2 appeared upset and stated he had been waiting for the facility staff to provide incontinence care for almost an hour, but no staff had assisted him. Resident 2 stated
he had pressed the call light several times. Resident 2 pressed the call light, however the call light system was observed to be non-functional. On 12/30/25 at 1143 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 2's call light was not functioning. LVN 1 stated Resident 2 used the call light and was dependent on staff for the ADL care. LVN 1 further stated the staff should have ensured Resident 2's call light was functioning before leaving the room. LVN 1 stated she would notify the maintenance department to resolve the issue. Medical record review for Resident 2 was initiated on 12/30/25. Resident 2 was admitted to the facility on [DATE REDACTED]. Review of Resident 2's MDS assessment dated [DATE REDACTED], showed Resident 2 had severe cognitive impairment and was dependent on staff for his ADL care.
On 12/31/25 at 1006 hours, an interview was conducted with the DON and the Administrator. The DON stated the call light system for the residents should be functional. The DON and Administrator were informed and acknowledged the above findings.
Residents Affected - Some
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
Event ID:
THE GROVE POST ACUTE in GARDEN GROVE, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GARDEN GROVE, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from THE GROVE POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.