Health inspection·December 23, 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 interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medical record was accurate and complete for one of four sampled residents (Resident 3). * Resident 3's assessments for the bed rails, bowel and bladder, elopement, falls, lift and transfer, self-administration of medications, smoking, vital signs and pain, Braden (skin assessment and risk factors), GG (section in the MDS (a standardized assessment tool) to address the residents functional abilities) were not completed quarterly. These failures had the potential for negative effects and had the potential to not receive the appropriate care and services.Findings: Review of the facility's P&P titled Fall Management Program dated 11/11/25, showed a licensed nurse will conduct a new fall risk evaluation quarterly, annually, upon identification of a significant change of condition, pos-fall, and as needed. Medical record review for Resident 3 was initiated on 12/22/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Quarterly Nursing Assessments showed the following with their respective dates of completion: - Bed rails: 7/21/25- Bowel and Bladder: 7/21/25- Elopement: 7/21/25- Falls: 7/21/25- Lift and Transfer: 7/21/25- Self- administration of medications: 7/21/25- Smoking: 7/21/25- Vital signs and Pain: 7/21/25- Braden: 8/20/25- Section GG of the MDS: 8/25/25 Review of Resident 3's H&P examination dated 9/2/25, showed Resident 3 had no mental capacity to make decisions. On 12/22/25, an interview and concurrent medical record review for Resident 3 was conducted with the MDS Coordinator. The MDS Coordinator stated the Nursing Assessments were completed on admission, quarterly, significant change, or as needed i.e. post fall. On 12/22/25 at 1023 hours, an interview and concurrent medical record review for Resident 3 was conducted with the MDS Nurse. The MDS Nurse stated nursing assessments were completed on admission, quarterly, during significant change, and after a specific occurrence like post- fall. The nursing assessments included the AIMS, Bedrails, Bowel and Bladder, Braden, Elopement, Fall, GG interim, Lift/ Transfer, Orthostatic Hypotension, Self Administration of Meds, Smoking, and Vital signs/ Pain. Resident 3's nursing assessments were reviewed with the MDS Nurse. The MDS Nurse verified Resident 3's assessments showed no current Bedrails, Bowel and bladder, Braden, Elopement, Section GG of the MDS, Lift/ Transfer, Self Administration of Meds, Smoking, and Vital signs/ Pain. The MDS Nurse stated, I have a lot of assessments to complete and I could still transmit the quarterly MDS. The MDS Nurse further stated these assessments were only for the facility. On 12/23/25 at 0925 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator stated the MDS assessments were based on the information gathered from the residents and medical records then coded in the MDS, then the nursing assessments to follow. The MDS Coordinator further stated the policy was to do the MDS assessments and the nursing assessments together and was aware the Bedrails, Bowel and bladder, Braden, Elopement, Section GG interim of the MDS, Lift/ Transfer, Self Administration of Meds, Smoking, and Vital signs/ Pain assessments (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 12/23/2025 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)