Health inspection·May 8, 2025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident1) was free from the unnecessary medications. Residents Affected - Few * Resident 1 was administered Ozempic (medication used to manage type 2 diabetes) one mg subcutaneously (beneath the skin) for DM. However, Resident 1 had no diagnosis of DM. In addition, the facility failed to ensure Resident 1's plan of care addressed the use of the Ozempic medication and monitored the side effects of the medication. * Resident 1 was administered oxycodone (used to relieve severe pain) 10 mg medication when Resident 1's pain level was below the parameters ordered for the medication. These failures had the potential for Resident 1 to receive unnecessary medications and experience adverse effects from the medications. Findings: Review of the facility's P&P titled Medication Administration revised 4/2025 showed it is the policy of the facility that medications for residents be administrated in a safe manner and as prescribed. Medical record review for Resident 1 was initiated on 5/7/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. a. Review of Resident 1's H&P examination dated 1/5/21, showed the resident had no diagnosis of diabetes mellitus (DM). Review of Resident 1's Order Summary Report showed a physician's order dated 1/24/25, to administer Ozempic one mg/dose subcutaneously every evening shift on Wednesdays for DM. Review of Resident 1's MAR for April 2025 showed Resident 1 was administered the Ozempic medication on 4/2, 4/9, 4/16, 4/23, and 4/30/25. Review of Resident 1's General Lab Work dated 4/14/25, showed Resident 1's hemoglobin A1c level was 5.2, indicating normal or non-diabetic range. Further review of Resident 1's medical record failed to show a care plan problem addressing Resident 1's use of the Ozempic medication and the monitoring of the side effects for the use of the (continued on next page) 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 Page 1 of 3 Event ID: 056145 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 056145 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Grove Post Acute 12882 Shackelford Lane Garden Grove, CA 92841 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)