Health inspection·July 19, 2023

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 **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 one of two sampled residents' (Resident 1) physician was notified of a change in Resident 1's skin condition. This failure had the potential to negatively impact Resident 1's well-being. Residents Affected - Few Findings: Review of the facility's P&P titled Wound Treatment Management dated 12/19/22, showed to promote wound healing of various types of wounds, it is the policy of the facility to provide evidence-based treatment in accordance with the current standards of practice and physician order. The P&P further showed in the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. On 7/18/23 at 1032 hours, a telephone interview was conducted with the Resident Representative. The Resident Representativestated when he visited Resident 1 around the end of May 2023, and noticed Resident 1's fingers on the right hand were white in color and looked like it had a fungal infection. The Resident Representative stated another family member visited Resident 1 on 7/11/23, and noticed the fingers of the Resident 1 ' s right hand were worse and sent a picture of the wound to the Resident Representative. The Resident Representativestated the picture showed Resident 1's nails looked long and had thick yellow whitish substance. The Resident Representative stated the facility did not take care of the Resident 1's right hand fingers. Medical record review for Resident 1 was initiated on 7/18/23. Resident 1 was admitted to the facility on [DATE],and was readmitted to the facility on [DATE]. Review of Resident 1's History and Physical Examination dated 2/17/23, showed Resident 1 did not have the capacity to understand and make decisions. Review of Resident 1's MDS dated [DATE], showed Resident 1 had cognitive impairment and required extensive assistance for her ADL care. Review of Resident 1's Progress Notes dated 7/18/23 at 1147 hours, showed Resident 1 had a change in skin color and condition. The progress notes further showed Resident 1 was assessed to have hard thick fingernails. Resident 1's physician was notified and ordered to apply ciclopirox (medication to treat fungal skin infection) external solution 8% daily. Review of Resident 1's Surgical Note dated 7/18/23, showed Resident 1 was assessed with a lesion on Resident 1's right fourth and fifth fingernails. The physician described the condition 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 2 Event ID: 555021 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 555021 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Grove Post Acute 12332 Garden Grove Blvd. Garden Grove, CA 92843 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)