The Grove Post-acute Care Center
THE GROVE POST-ACUTE CARE CENTER in SYLMAR, CA — inspection on August 13, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 6/13/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/24/2025, the MDS indicated Resident 1's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact.
During a review of the facility-provided Grievance/Complaint Resolution Report, dated 7/3/2025, the Grievance/Complaint Resolution Report indicated Resident 1 reported to the SSD about the allegation that happened on 7/2/2025 at 2 p.m. to 3 p.m., where the transportation company personnel inappropriately touched her face and called the resident beautiful.
During an interview on 8/13/2025 at 9:41 a.m. with the Social Services Director (SSD), the SSD stated Resident 1 reported to her on 7/3/2025 that the transportation company personnel allegedly touched the resident's face and had unspecified inappropriate actions towards Resident 1.
The SSD stated she notified the Director of Nursing (DON) and the Administrator (ADM) about Resident 1's allegations.
During an interview on 8/13/2025 at 2:23 p.m. with the DON and a concurrent record review of the facility's policy and procedure (PnP) titled, Prevention, Reporting, and correction of Inappropriate Conduct Including Abuse, neglect, and Mistreatment of Residents and Investigations of Injuries of Unknown Origin, last reviewed on 1/2/2025, the PnP indicated .all personnel, vendors, and volunteers do not abuse or neglect any resident in the facility at any time for any reason.
The PnP indicated The Administrator in coordination with General Counsel will.verify that any allegation of abuse is reported.to the California Department of Public Health Licensing and Certification.within two hours.
The DON stated the ADM was the facility's Abuse Coordinator.
The DON stated Resident 1's allegation of being inappropriately touched by the transportation company personnel should be reported within two hours to the SSA, Ombudsman, and law enforcement.
The DON stated Resident 1 had the potential to experience distress and cause harm to other residents.
The DON stated the facility failed to report the allegation of abuse within two hours.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
056382 08/13/2025
The Grove Post-Acute Care Center 14122 Hubbard Street Sylmar, CA 91342
During a review of Resident 1's History and Physical (H&P - a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 6/13/2025, the H&P indicated the resident had the capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/24/2025, the MDS indicated Resident 1's cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact.
During a review of the facility-provided Grievance/Complaint Resolution Report, dated 7/3/2025, the Grievance/Complaint Resolution Report indicated Resident 1 reported to the SSD about the allegation that happened on 7/2/2025 at 2 p.m. to 3 p.m., where the transportation company personnel inappropriately touched her face and called the resident beautiful.
During an interview on 8/13/2025 at 9:41 a.m. and a concurrent record review of Resident 1's Progress Notes, reviewed with the Social Services Director (SSD), the SSD stated Resident 1 reported to her on 7/3/2025 that the transportation company personnel allegedly touched the resident's face and had unspecified inappropriate actions towards Resident 1.
The SSD stated there was no documented evidence in Resident 1's Progress Notes, dated 7/2/2025 to 8/13/2025, that the resident was monitored after the reported allegation of being inappropriately touched.
The SSD stated she did not document her follow-up visits to Resident 1.
The SSD stated that if the monitoring was not documented, it did not happen.
The SSD stated Resident 1 had the potential to experience depression.
During an interview on 8/13/2025 at 2:23 p.m. with the Director of Nursing (DON), the DON stated the licensed nurses, and the social services did not document the monitoring of Resident 1's psychological and psychosocial well-being after the resident reported the allegation of being inappropriately touched.
The DON stated Resident 1's depression and anxiety had the potential to worsen if the resident's psychological and psychosocial health were not monitored.
The DON stated the facility failed to monitor the psychological and psychosocial effects of the reported allegation on Resident 1.
During a review of the facility's policy and procedure (PnP) titled, Prevention, Reporting, and correction of Inappropriate Conduct Including Abuse, neglect, and Mistreatment of Residents and Investigations of Injuries of Unknown Origin, last reviewed on 1/2/2025, the PnP indicated Evaluation of facts as deemed appropriate based on a case -by-case analysis, which may include. the assessment, care planning, and monitoring of residents with needs and behaviors that might lead to conflict or neglect.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.