Health inspection·April 4, 2025

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **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 four sampled residents' (Resident 1) medical record was accurate and complete. * The facility failed to ensure there was nursing documentation for 72 hours each shift for a COC. This failure posed the risk for changes in Resident 1's health condition to go undetected and possibly delay necessary care and treatment. Findings: Review of the facility's P&P titled Change of Condition Notification revised 4/2015 showed a licensed nurse will document each shift for at least 72 hours for a change of condition. Review of the facility's P&P titled Fall Management Program revised 3/2021 showed documentation of the fall incident in the medical record may include the resident's condition. Medical record review for Resident 1 was initiated on 4/4/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 12/28/24, showed Resident 1 could make needs known but could not make medical decisions. Review of Resident 1's medical record titled eINTERACT Change in Condition Evaluation – V 5.1 dated 2/21/25, showed Resident 1 had an unwitnessed fall on 2/20/25. Review of Resident 1's Post Fall Evaluation dated 2/2025 showed Resident 1 had an unwitnessed fall on 2/20/25 at 2331 hours, with no evidence of an injury. Further review of Resident 1's medical record failed to show the nursing staff had documented in each shift for 72 hours post the unwitnessed fall on 2/20/25. On 4/4/25 at 1007 hours, a concurrent interview and medical record review was conducted with LVN 4. LVN 4 verified Resident 1 had a history of an unwitnessed fall on 2/20/25. LVN 4 further verified the above findings. LVN 4 stated Resident 4 was transferred to the acute care hospital on 2/22/25. LVN 4 verified there should have been a COC documentation done every shift until the time of the transfer to the acute care hospital. LVN 4 stated a change of condition including falls required 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: 055206 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 055206 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/04/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Healthcare Center 1209 Hemlock Way Santa Ana, CA 92707 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)