Health inspection·March 5, 2024

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to protect the resident's rights to be free from the physical abuse by the staff. * Resident 3 was hit on the right of the head by CNA 1 with an open hand, which was witnessed by another staff. This failure had the potential to cause injury and physical and/or psychosocial harm to the resident. Findings: Review of the facility's P&P titled Abuse Reporting and Prevention revised January 2023 showed the Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, or mental anguish, or deprivation of an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain, or mental anguish. Physical Abuse means a willful physical action that is meant to inflict physical harm, pain, or mental anguish. Review of the facility's SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 2/24/24, the document showed an abuse allegation reported by Housekeeping 1. Housekeeping 1 observed CNA 1 hit Resident 3 in the head. Medical record review for Resident 3 was initiated on 2/29/24. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's MDS dated [DATE], showed Resident 3 had moderate cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life) and was dependent on staff for feeding, mobility (the ability of a patient to change and control their body position) and their activities of daily living (a term used to refer to an individual's daily self-care activities). Review of Resident 3's Progress Note completed by the physician on 1/27/24, showed Resident 3 was alert and oriented to person, place, and time, able to comprehend questions, able to converse and answer basic questions appropriately, and able to make needs know. On 2/29/24 at1030 hours, an interview with the aid of a Vietnamese speaking interpreter was conducted with Resident 3. Resident 3 stated a female staff member had hit him on the right side 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: 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 03/05/2024 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)