Health inspection·November 19, 2024

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 interview and medical record review, the facility failed to ensure the necessary care and services were provided to meet the needs for one of two final sampled residents (Resident 1). Residents Affected - Few * The facility failed to ensure Resident 1's levothyroxine medication was continued upon his discharge from the acute care hospital. This failure had the potential to affect Resident 1's health and wellbeing. Findings: Closed medical record review for Resident 1 was initiated on 11/19/24. Resident 1 was admitted to the facility on [DATE], from the acute care hospital and discharged on 11/9/24. Review of Resident 1's acute care hospital H&P examination dated 10/22/24, showed Resident 1 [NAME] history of hypothyroidism. Review of Resident 1's ED Patient Education and Visit Summary from the acute care hospital dated 10/22/24, the section for Final Active Medication List showed an order for levothyroxine (a medicine used to treat an underactive thyroid gland) 100 mcg orally one tablet daily before breakfast on an empty stomach. Further review of the closed medical record showed no documented evidence levothyroxine was ordered for the resident upon admission to the facility. There was no documented evidence as to why the levothyroxine medication was not continued when it was included in the active medications list from the acute care hospital. Review of Resident 1's Order Summary Report showed a physician's order dated 10/31/24, to administer levothyroxine 100 mcg by mouth in the morning for hypothyroidism, starting on 11/1/24, six days after Resident 1 had been admitted to the facility. On 11/19/24 at 1615 hours, an interview and concurrent closedmedical record review for Resident 1 was conducted with the ADON. The ADON acknowledged the findings. The ADON further stated the admitting nurse failed to reconcile the discharge medications thoroughly on 10/25/24 (admission date). Resident 1 should have continued his levothyroxine medication as directed in the acute care hospital's discharge medication list for the treatment of hypothyroidism. The ADON verified Resident 1 was not provided with the levothyroxine medication until 11/1/24. 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 11/19/2024 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)