The Grove Post-acute Care Center
Inspection Findings
F-Tag F0609
F 0609
harm to other residents. The DON stated the facility failed to report the allegation of abuse within two hours.
Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/13/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
The Grove Post-Acute Care Center
14122 Hubbard Street Sylmar, CA 91342
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-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure licensed nurses and social services monitored Resident 1's psychological (anything concerning the mind, mental processes, or emotions) and psychosocial (a person's mental, emotional, social, and spiritual health) health after Resident 1's reported allegation of being inappropriately touched by the transportation company personnel. This deficient practice placed Resident 1 at risk of not being provided necessary care and services.Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 8/3/2024 with diagnoses including aftercare following joint replacement surgery, major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy), and anxiety disorder (persistent and excessive worry that interferes with daily activities).
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.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
THE GROVE POST-ACUTE CARE CENTER in SYLMAR, 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 SYLMAR, 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 CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.