Inspection visit

Health inspectionMay 23, 2023

Q: What happened during the May 23, 2023 survey of GARDEN PARK CARE CENTER?

This was a inspection survey of GARDEN PARK CARE CENTER on May 23, 2023. The surveyor cited 27 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Q: Were any deficiencies cited at GARDEN PARK CARE CENTER on May 23, 2023?

Yes, 27 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."

Q: What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

GARDEN PARK CARE CENTERCMS #55566727 citations on this visit

27 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 27 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0558 Reasonably accommodate the needs and preferences of each resident. 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 provide reasonable accommodations to meet the needs of one of 24 final sampled residents (Resident 422). Residents Affected - Few * The facility failed to ensure Resident 422's call light was within the resident's reach. This failure created the potential to negatively impact the resident's psychosocial well-being or result in a delay to provide care. Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response revised 9/2/22 showed the staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light, and staff will ensure the call light is within reach of resident and secured, as needed. On 5/16/23 at 0920 hours, Resident 422 was observed seated in the wheelchair in her room, on the right side of the bed. Resident 422's call light button was observed underneath the pillows on the left side of the bed, which was away from Resident 422 and not within her reach. When asked if she could reach her call light button, Resident 422 answered no. Resident 422 stated it would be nice when they get a resident up, they should also make sure the call light is within reach. When asked if this had happened before, Resident 422 answered yes, and stated she had asked her roommate to press the call light for her. Resident 422 stated her roommate spoke another language so she would do a hand gesture to her roommate to press the call light. On 5/16/23 at 0939 hours, an observation for Resident 422 and concurrent interview was conducted with LVN 7. Resident 422 was observed seated in the wheelchair in her room, on the right side of the bed. Resident 422's call light button was observed underneath the pillows on the left side of the bed, which was away from Resident 422, and not within her reach. LVN 7 verified the above findings. Medical record review for Resident 422 was initiated on 5/16/23. The medical record showed Resident 422 was readmitted to the facility on [DATE]. Resident 422 had moderate cognitive impairment and required limited to extensive assistance from one to two staff members for ADL care. 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 80 Event ID: 555667 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 20 was initiated on 5/16/23. Resident 12 was admitted to the facility on [DATE]. Residents Affected - Few Review of the POLST dated 1/28/21, showed Resident 20 had formulated an advance directive. Review of Resident 20's Progress Notes showing Social Service Assessment - Quarterly dated 4/26/23, showed Resident 20 had a POA (Power of Attorney) for healthcare. However, review of Resident 20's medical record failed to show a copy of the resident's advance directive. On 5/17/23 at 1147 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD was informed and verified the above findings. The SSD stated she asked the residents or the residents' representative regarding an advance directive upon admission. The SSD also stated she tried to follow-up to get a copy of the advance directive within one week. When asked for a copy of Resident 20's advance directive, the SSD verified it was not in the resident's medical record. The SSD was observed going to her office with a pile of copies of advance directives in a folder and could not find a copy of Resident 20's advance directive. On 5/17/23 at 1243 hours, an interview and concurrent medical record review was conducted with the Medical Records Director and the SSD. The SSD asked the Medical Records Director to search the overflow medical records for a copy of Resident 20's advance directive. The Medical Records Director could not find a copy of Resident 20's advance directive. Based on interview, medical record review, and facility P&P review, the facility failed to ensure three of 24 final sampled residents (Residents 20, 54, and 77) had copies of their advance directive (written instruction, recognized under State law, relating to the provision of health care when the individual is incapacitated) in their medical records. This failure had the potential to go against the health care wishes of the Residents 20, 54, and 77. Findings: Review of the facility's P&P titled Advance Directives revised 9/23/20, showed the Social Services staff will place a copy of the completed advance directive in the resident's medical record. 1. Medical record review for Resident 54 was initiated on 5/16/23. Resident 54 was admitted to the facility on [DATE]. Review of Resident 54's H&P Examination dated 1/2/23, showed Resident 54 had the capacity to understand and make decisions. Review of the MDS Quarterly assessment dated [DATE], showed Resident 54 was cognitively intact. Review of the Physician Orders for Life Sustaining Treatment (POLST) form prepared on 4/6/23, showed Resident 54's advance directive was not available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 2 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Social Services Assessments dated 1/4, 3/14, and 3/17/23, showed no documentation showing the facility had reviewed the advance directives with Resident 54. On 5/17/23 at 1147 hours, an interview and concurrent medical review was conducted with the Social Services Director. When asked what the process was for advance directives, the Social Services Director stated they reviewed the status of the resident's advance directive upon admission and quarterly. If a resident had an advance directive, they would ask the resident or family to bring the advance directive to the facility. When asked about their process to monitor the status of advance directives, the Social Services Director stated they would document the resident's advance directive status in the medical record under the Social Worker Assessment and Progress Notes. When asked about Resident 54's advance directive, the Social Services Director stated Resident 54 did not have an advance directive. Upon review of the Social Services Assessments dated 1/4, 3/14, and 3/17/23, the Social Services Director verified there was no documentation to show the advance directives were discussed or offered to Resident 54. On 5/17/23 at 1549 hours, an interview was conducted with Resident 54. When asked if the resident knew what an advance directive was, he stated yes and further stated his advance directive was with his daughter. When asked if the facility had discussed the advance directives with him, he stated the facility never asked him about his advance directive. On 5/17/23 at 1617 hours, an interview was conducted with Resident 54's daughter. When asked regarding the advance directives, she stated her father filled one out years ago. When asked if the facility discussed the resident's advance directives with her, she stated no one from the facility had discussed or asked her about Resident 54's advance directive. On 5/23/23 at 1600 hours, the Administrator, DON, and Consultant 1 were informed and acknowledged the above findings. 2. Medical record review for Resident 77 was initiated on 5/16/23. Resident 77 was admitted to the facility on [DATE]. Review of the POLST form prepared on 12/1/20, showed Resident 77's advance directive was not available. Review of the Social Services assessment dated [DATE], showed Resident 77 had an advance directive. On 5/17/23 at 1147 hours, an interview and concurrent medical record review was conducted with the Social Services Director. When asked about the advance directive process, she stated the Social Services Department would ensure the residents' advance directives and POLST match; the POLST should reflect a resident's healthcare directive. When asked about Resident 77's advance directive, the Social Services Director stated Resident 77 had an advance directive. However, upon concurrent review of Resident 77's documents and electronic medical record, the Social Services Director verified there was no copy of Resident 77's advance directive available in the medical record. The Social Services Director stated she had a copy of Resident 77's advance directive in her office. On 5/17/23 at 1510 hours, an interview was conducted with LVN 4. When asked about the advance directives, she stated the advance directives showed a resident's wish for their care when they were no longer able to make decisions. When asked where she could find the information regarding a resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 3 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0578 advance directive, LVN 4 stated she would look in the resident's paper medical record. Level of Harm - Minimal harm or potential for actual harm On 5/19/23 at 1552 hours, an interview was conducted with LVN 11. When asked where she looked to find information regarding a resident's advance directive, she stated she looked in the paper and electronic medical records. Residents Affected - Few On 5/23/23 at 1600 hours, the Administrator, DON, and Consultant 1 were informed and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 4 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure a significant change of status assessment was completed with 14 days after a significant change in the resident's physical or mental condition had been determined for one of 24 final sampled residents (Resident 101). This had the potential of not providing the appropriate care and services to Resident 101 based on the resident's current status. Residents Affected - Few Findings: According to CMS's RAI 3.0 Manual dated October 2019, Chapter Two: Significant Change in Status Assessment (SCSA), showed the SCSA is a comprehensive assessment for resident that must be completed when the IDT had determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting, 2. Impacts more than one area of the resident's health status, and 3. Requires interdisciplinary review and/or revision of the care plan. According to CMS's RAI 3.0 Manual dated October 2019, Chapter Two: Significant Change in Status Assessment (SCSA), under section Assessment Management Requirements and Tips for SCSA, showed an SCSA is appropriate when there is a determination that a significant change (either improvement or decline) in a resident's condition from his/her baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive assessment and any subsequent quarterly assessment and the resident's condition and the resident's condition is not expected to return to baseline within two weeks. According to CMS's RAI 3.0 Manual dated October 2019, Chapter Two: Significant Change in Status Assessment (SCSA), under the section for Guidelines to Assist in Deciding if a change is significant or not, showed the following: - A condition is defined as self-limiting when the condition will normally resolve itself without further intervention or by staff implementing standard disease-related clinical interventions. If the condition has not resolved within two weeks, staff should begin an Significant Change in Status Assessment. - An Significant Change in Status Assessment is appropriate if there are either two or more areas of decline or two or more areas of improvement. In this example, a resident with a 5% weight loss in 30 days would not generally require an Significant Change in Status Assessment unless a second area of decline accompanies it This situation should be documented in the resident's clinical record along with the plan for subsequent monitoring and, if the problem persist or worsened, an Significant Change in Status Assessment may be warranted. - An Significant Change in Status Assessment is appropriate if there is a consistent pattern of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 5 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0637 changes with either two or more areas of decline or two or more areas of improvement. Level of Harm - Minimal harm or potential for actual harm - Decline in two or more of, but not limited to the following: emergence of unplanned weight loss problem (5% in 30 days or 10% in 180 days), and emergence of new pressure at stage 2 or higher, a new unstageable pressure ulcer/injury, a new deep tissue injury or worsening in pressure ulcer status. Residents Affected - Few According to the National Pressure Injury Advisory Panel (NPIAPI), the pressure ulcer stages are defined as follows: - Stage 1 (one) Pressure Injury: Non-blanchable erythema (redness) of intact skin - Stage 2 (two) Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Review of the facility's P&P titled Weight Management Policy revised on 12/19/22, showed under Section 6. Weight Analysis, the newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in weight in one month (30 days), b. 7.5% change in weight in three months (90 days), and c. 10% change in weight in six months (180 days). The RD will also document weight change notes for residents who have a five pounds weight loss or gain in one week. For weekly weight changes, the RD will complete a weight change note for any resident with a 3% weight loss or gain in one week. Medical record review for Resident 101 was initiated on 5/16/23. Resident 101 was admitted to the facility on [DATE]. Review of Resident 101's Quarterly MDS dated [DATE], showed Resident 101 had no weight loss of 5% or more in the last month or 10% or more in last 6 months, and had no one or more unhealed pressure ulcers(s) at Stage 1 or higher, but Resident 101 had MASD (inflammation or skin erosion caused by prolonged exposure to a source of moisture). Review of the facility document titled Monthly Weights Record for January 2023 showed Resident 101 weighed 100 pounds and had a weight loss of 8.3% in one month and 10.7% in 3 months. The documented weight for Resident 101 in October and December 2022 were 112 pounds and 109 pounds, respectively. Review of the RDN's Weight Changes Progress Note for Resident 101 dated 1/4/23, showed Resident 101's current body weight of 100 pounds (weight loss of nine pounds/8.3% in one month and weight loss of 12 pound/10.7% in three months). Further review of the RDN's Weight Changes Progress Note showed Resident 101 had a sacrococcyx MASD and significant weight loss and unintentional possible related enteral feed meeting lower range of estimated need. The RDN recommended to increase Resident 101's GT feeding rate to 60 ml per hour to run for 20 hours and continue to monitor for significant weight change. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 6 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0637 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 101's medical record did not show the facility conducted an Interdisciplinary Care Conference or Weight Variance Care Conference for Resident 101's significant weight loss in one month and three months. Review of Resident 101's Skin Only Evaluation dated 1/18/23, showed Resident 101 had a new identified Stage 2 pressure ulcer on the sacrococcyx. Review of the RDN's Weight Changes Progress Note for Resident 101 dated 1/20/23, showed Resident 101's current body weight of 98 pounds (weight loss of 5 pounds/4.8% in one week). Review of the RDN's Weight Changes Progress Note further showed Resident 101 had Stage 2 sacrococcyx pressure ulcer and significant unintentional weight loss in one week, unintentional secondary to wound. The RDN recommended to increase Resident 101's GT feeding to 65 ml per hour to run for 20 hours and weekly weights for two weeks. Review of Resident 101's Interdisciplinary Care Conference - Skin Alteration Care Conference record dated 1/20/23, showed a brief description of wound status of Stage 2 sacrococcyx pressure ulcer due to worsening MASD. On 5/22/23 at 0918 hours, an interview and concurrent record review was conducted with the MDS Coordinator. The MDS Coordinator stated significant change in status assessment should be done when there were two significant declines in the resident status. The MDS Coordinator verified Resident 101 had a significant weight loss of 8.3% in one month and an MASD that progressed to Stage 2 pressure ulcer/injury. When asked if the significant change in status assessment was done for Resident 101, the MDS Coordinator stated a significant change in status assessment was not done due to the change was not considered significant when the interventions from the RDN were in-placed and effective. On 5/23/23 at 1330 hours, an interview and a concurrent record review was conducted with the DON. The DON verified Resident 101 had significant changes in January 2023 evidenced by an MASD that progressed to Stage 2 pressure ulcer/injury and a significant weight loss of 8.3% in one month. When asked if the significant change in status assessment should have been done by the MDS Coordinator, the DON further stated the significant change in status assessment should have been done as per the regulation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 7 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Comprehensive Care Plans revised on 9/2/22, showed the comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest, practicable physical, mental, and psychosocial well-being. Medical record review for Resident 18 was initiated on 5/16/23. Resident 18 was readmitted on [DATE], with the diagnosis of End Stage Renal Disease required hemodialysis. Review of Resident 18's Order Summary Report dated May 2023 showed a physician's order dated 5/16/23, for Resident 18's left groin central catheter hemodialysis access dressing site changes at the dialysis center and as needed, and to monitor the access site for signs and symptoms of infection every shift. Review of Resident 18's Plan of Care showed a care plan problem for hemodialysis revised on 10/22/22, showed an intervention to leave AV fistula/graft dressing in place for 48 hours or as indicated by dialysis center after dialysis treatment, unless soiled or if bleeding has occurred; if bleeding excessively, apply direct pressure over shunt site and notify the physician. However, Resident 18's dialysis access site was a left groin central catheter. On 5/19/23 at 0948 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings and stated Resident 18 did not have an AV fistula or graft. RN 1 stated Resident 18's dialysis access site was documented inaccurately in the care plan problem. On 5/19/23 at 0959 hours, the DON was informed and acknowledged the above findings. 3. On 5/16/23 at 0829 hours, and 5/17/23 at 1103 hours, Resident 107 was observed lying in bed with his bilateral lower extremities covered with a blanket. Resident 107's bed had a metal foot cradle (a frame installed at the foot of the bed to keep sheets/blankets off the legs/feet). However, Resident 107's blanket was not placed over the foot cradle. Medical record review for Resident 107 was initiated on 5/16/23. Resident was admitted to the facility on [DATE]. Review of Resident 107's H&P examination dated 3/24/23, showed Resident 107 had the capacity to understand and make decisions. Review of Resident 107's Order Summary Report for the month of May 2023 showed a physician's order dated 4/23/23, to provide treatment to the open wound status post amputation to the right foot by cleansing with normal saline (salt solution), pat dry, apply Manuka honey (monofloral honey with potential wound repair and antibacterial activities), apply calcium alginate (antimicrobial), apply skin barrier ointment to peri-wound, cover with ABD (a three layer pad with moisture barrier) pad, and secure with Kerlix (used to wrap around wound), then re-evaluate. Review of Resident 107's Comprehensive Plan of Care failed to show documented evidence of using a foot cradle as an intervention for the resident's wound management. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 8 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/17/23 at 1103 hours, an interview was conducted with Resident 107. Resident 107 stated he did not like the foot cradle because the blanket was always a mess. On 5/17/23 at 1112 hours, an observation and concurrent interview was conducted with CNA 2. CNA 2 verified Resident 107's blanket was not over the foot cradle because Resident 107 wanted the blanket to cover his legs and not over the foot cradle. CNA 2 further stated she told the treatment nurse about Resident 107's noncompliance with the use of the foot cradle. On 5/17/23 at 1123 hours, an interview and a concurrent electronic medical record review was conducted with LVN 6. LVN 6 stated the foot cradle was used to take off the pressure from Resident 107's right foot surgical wound. LVN 6 verified he was aware of Resident 107's noncompliance with the use of the foot cradle. In addition, LVN 6 acknowledged the care plan did not include the use of a foot cradle. On 5/17/23 at 1618 hours, an interview and a concurrent electronic medical record review was conducted with the DON. The DON verified the above findings and stated Resident 107's foot cradle was used as a preventative pressure relieving device intervention to promote healing to Resident 107's right foot surgical wound. The DON stated the foot cradle was discussed during the IDT care conference on 4/3/23, to use as a nursing measure. However, the DON was unable to provide documented evidence the foot cradle was discussed during the IDT care conference on 4/3/23. Resident 107's Comprehensive Plan of Care did not include the use of foot cradle, the resident's noncompliance with the use of foot cradle, and any alternatives to the foot cradle for wound management. 4. Medical record review for Resident 45 was initiated on 5/16/23. Resident 45 was initially admitted to the facility on [DATE]. Review of Resident 45's Order Summary Report dated 5/23/23, showed the following orders: - Apiarian (an anticoagulant medication) 5 mg oral tablet one tablet by mouth two times a day - Aspirin (a blood thinner medication) EC Delayed Release 81 mg oral tablet one tablet by mouth one time a day Review of Resident 45's Care Plan initiated on 2/7/22, showed a care plan problem addressing Resident 45's risk for bruising and bleeding. The nursing intervention included for Resident 45 to avoid the use of aspirin. On 5/23/23 at 1110 hours, an interview and concurrent medical record review was conducted with LVN 10. LVN 10 verified Resident 45 had been taking aspirin daily as per the MAR for the month of May 2023. LVN 10 verified Resident 45's care plan intervention showed for the resident to avoid the use of aspirin. On 5/23/23 at 1344 hours, an interview and concurrent medical record review was conducted with the DON. When asked, the DON stated the care plans should be specific to each resident and the staff were to review and update the care plan. The DON verified Resident 45's care plan was not resident centered since Resident 45 was taking aspirin daily. The DON further stated the care plan intervention may have populated from the care plan template. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 9 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm On 5/23/23 at 1600 hours, the Administrator, DON, and Consultant 1 were notified and acknowledged the above findings. Based on interview and medical record review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for four of 24 final sampled residents (Resident 18, 45, 107, and 422). Residents Affected - Few * The facility failed to develop a care plan problem to address Resident 422's use of apixaban (anticoagulant medication) and Melatonin (medication to aid with sleep). * The facility failed to ensure a care plan problem addressing Resident 422's use of lorazepam (antianxiety medication) was accurate to reflect the resident's behavior manifestation as ordered by the physician. * The facility failed to ensure a care plan problem addressing the dialysis access site was accurate to reflect Resident 18's dialysis access site. * The facility failed to ensure a care plan problem to address the use of foot cradle, the resident's noncompliance, and any alternatives to the use of foot cradle for wound management for Resident 107. * The facility failed to ensure a care plan problem addressing Resident 45's use of apixaban and aspirin (blood thinner) was accurate and resident centered. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents. Findings: Review of the facility's P&P titled Comprehensive Care Plans revised 9/2/22, showed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeliness to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Further review of the facility's P&P showed the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well -being, and resident specific interventions that reflect the resident's needs. and preferences and align with the resident's cultural identity, as indicated. 1. Medical record review for Resident 422's was initiated on 5/16/23. Resident 422 was admitted to the facility on [DATE], and readmitted on [DATE]. a. Review of Resident 422's Order Summary Report showed a physician's orders dated 5/8/23, to administer apixaban 5 mg one tablet by mouth two times daily for atrial ibrillation (irregular heart rate) and melatonin 5 mg one tablet by mouth PRN for HS for 14 days for insomnia manifested by inability to sleep. Review of Resident 422's MAR for May 2023 showed melatonin 5 mg was administered on 5/10, 5/22, 5/16, 5/17, and 5/18/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 10 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident 422's plan of care failed to show a care plan problem was developed to address the use of apixaban and melatonin. On 5/17/23 at 1515 hours, an interview and concurrent medical review was conducted with the DON. The DON verified there was no care plan problem developed to address Resident 422's apixaban and melatonin use. b. Medical record review for Resident 422's was initiated on 5/16/23. Resident 422 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 422's Order Summary Report showed a physician's order dated 5/8/23, to administer lorazepam (medication to relieve anxiety) 0.5 mg one tablet by mouth every six hours as needed for anxiety manifested by inability to relax for 14 days. Review of the care plan problem revised on 4/5/22, showed Resident 422 used lorazepam related to anxiety disorder, PTSD, bipolar disorder, schizophrenia manifested by verbalization of nervousness. However, Resident 422's care plan problem was not accurately address Resident 422's target behavior as ordered by the physician. On 5/17/23 at 1515 hours, an interview and concurrent medical review was conducted with the DON. The DON verified the care plan problem did not address Resident 422's anxiety manifested by inability to relax. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 11 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

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 provide the necessary services to attain or maintain the highest practicable well-being for one of 24 final sampled residents (Resident 51). Residents Affected - Few * The facility failed to follow the physician's order to record Resident 51's I&O every shift for 30 days. This failure had the potential risk of not providing the appropriate care for Resident 51. Medical record review for Resident 51 was initiated on 5/16/23. Resident 51 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 51's Order Summary Report showed a physician's order dated 4/26/23, to record I&O every shift for 30 days. However, further review of Resident 51's medical record failed to show documented evidence the resident's I&O was recorded as per the physician's order. On 5/23/23 at 1415 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 51 had a physician's order to record I&O for 30 days; however, there was no documented evidence the resident's I&O was recorded as per the physician's order. On 5/23/23 at 1445 hours, an interview and a concurrent record review was conducted with the Medical Records Director. The Medical Records Director provided paper records of Resident 51's I&O from 4/26 to 5/1/23. When asked to provide documented evidence of Resident 51's I&O after 5/1/23, the Medical Record Director stated Resident 51's I&O was recorded only for seven days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 12 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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 document review, the facility failed to ensure one of 24 final sampled residents (Resident 101) was provided with the appropriate bed to promote the healing of the pressure injury. This failure posed the risk for Resident 101's pressure injury to deteriorate and develop additional pressure injuries. Residents Affected - Few Findings: According to the National Pressure Injury Advisory Panel, Stage 4 pressure injury (ulcer) is defined as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough (non-viable fibrous yellow tissue) and/or eschar (dead tissue) may be visible and undermining and/or tunneling often occur. Review of the Invacare microAir MA600 Alternating Pressure Low Air Loss (LAL) Mattress System User Manual showed MicroAir MA600 Air Mattress Therapy System is recommended for use in the prevention and treatment of decubitus (pressure) ulcer Stage 1 to 3. For higher risk patient, please contact Invacare for additional product offerings to address higher risk patients. On 5/16/23 at 1026 hours, 5/17/23 at 1118 hours, 5/18/23 at 1008 hours, and 5/19/23 at 0911 hours, Resident 101 was observed lying on the Invacare microAir MA600 LAL mattress. Medical record review for Resident 101 was initiated on 5/16/23. Resident 101 was admitted to the facility on [DATE]. Resident 101 had a diagnosis of Stage 4 pressure ulcer to the sacral region. Review of Resident 101's Order Summary Report for May 2023 showed a physician's order dated 1/11/23, to provide low air loss mattress with bilateral wing for skin maintenance, check placement and functioning every shift. Review of Resident 101's Care Plan created 1/18/23, showed a care plan problem addressing pressure ulcer to the sacrococcyx (a bone formed by fusion of the sacrum and coccyx). The intervention included to use a pressure reducing device on the bed. Review of Resident 101's Braden Scale for Predicting Pressure Ulcer Risk dated 3/14/23, showed Resident 101 was a very high risk for pressure injury development. Review of Resident 101's Skin Only Evaluation dated 1/25, 4/26, 5/3, and 5/10/23, showed Resident had a Stage 4 pressure ulcer/injury to the sacrococcyx. On 5/19/23 at 1639 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified Resident 101 had a Stage 4 pressure ulcer/injury to the sacrococcyx and used an Invacare microAir MA600 LAL mattress. On 5/19/23 at 1650 hours, an interview and concurrent medical record review and Invacare microAir MA600 User Manual review was conducted with the DON. The DON verified Resident 101 was a very high risk for pressure ulcer and had a Stage 4 pressure ulcer/injury to the sacrococcyx. When asked if the Invacare microAir MA600 LAL mattress was appropriate, the DON acknowledged the Invacare microAir MA600 LAL mattress was not appropriate for Resident 101's Stage 4 pressure ulcer/injury. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 13 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 5/16/23 at 0911 hours, 5/17/23 at 1109 hours, and 5/18/23 at 1018 hours, Resident 87 was observed with indwelling urinary catheter with the drainage bag hanging on the bed rails. Review of Resident 87's medical record was initiated on 5/16/23. Resident 87 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 87's had diagnoses of ALS and neuromuscular dysfunction of bladder. Review of Resident 87's Indwelling Catheter assessment dated [DATE], showed Resident 87 had an indwelling urinary catheter for neurogenic bladder (lack of bladder control due to brain, spinal cord, or nerve problem). Review of Resident 87's Order Summary Report for May 2023 showed a physician's order dated 4/30/23, to use an indwelling urinary catheter; change for blockage leaking, pulled out excessive sedimentation, and change catheter drainage bag as needed and with every change of indwelling urinary catheter. Review of Resident 87's Care Plan revised on 1/24/23, showed a care plan problem addressing urinary retention, diagnosis of neurogenic bladder, and indwelling urinary catheter in placed. The interventions included to perform indwelling urinary catheter care. However, review of Resident 87's medical record failed to show documented evidence indwelling urinary catheter was performed as per Resident 87's care plan. On 5/19/23 at 1023 hours, an interview was conducted with LVN 6. LVN 6 verified Resident 87 was admitted with an indwelling urinary catheter and indwelling urinary catheter care was provided by the CNAs; however, LVN 6 did not know where the CNAs would document Resident 87's indwelling urinary catheter care. On 5/23/23 at 1330 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 87 was admitted on [DATE], with an indwelling urinary catheter. Review of Resident 87's CNA's Task showed to provide catheter care every shift and PRN. However, further review of Resident 87's CNA's Task showed Resident 87's indwelling urinary catheter care was provided on 5/19/23, during the evening shift (1500 hours to 2300 hours). On 5/23/23 at 1504 hours, an interview was conducted with the Medical Records Director. The Medical Records Director verified there was no documented evidence indwelling urinary catheter care was performed on Resident 87 prior to 5/19/23. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 24 final sampled residents (Residents 87 and 96) were provided with the necessary indwelling urinary catheter care to prevent UTI. This failure had the potential to put Residents 87 and 96 at risk for UTI. Findings: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 14 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0690 Level of Harm - Minimal harm or potential for actual harm Review of the facility's P&P titled Catheter Care revised on 12/19/22, showed it is the policy of the facility to ensure that residents with indwelling urinary catheters received appropriate catheter care and maintain their dignity and privacy when indwelling catheter is in use. Catheter care will be preformed every shift and as needed by nursing personnel. The procedure for catheter care are as follows: Residents Affected - Few - Wipe from front to back with a clean cloth moistened with water and perineal cleaner (soap). - Use new part of the cloth or different cloth for each side. - With new moistened cloth, starting at the urinary meatus moving out. - Document care and report any concerns noted to the nurse on duty and physician. 1. Medical record review for Resident 96 was initiated on 5/16/23. Resident 96 was admitted to the facility on [DATE]. Review of Resident 96's Order Recap Report dated 5/23/23, showed a physician's order dated 3/15/23, to use an indwelling urinary catheter. However, there was no documented evidence an indwelling urinary catheter care had been performed since 3/15/23. During an observation on 5/16/23 at 1145 hours, Resident 96's indwelling urinary catheter tubing was observed with blood. On 5/16/23 at 1223 hours, an interview was conducted with Resident 96's family member. When asked about Resident 96's indwelling urinary catheter, she stated Resident 96 had a UTI in the past. On 5/19/23 at 1007 hours, an interview was conducted with LVN 6. When asked who was responsible for performing indwelling urinary catheter care, LVN 6 stated it was performed by the CNAs. When asked if he knew where would the CNAs document indwelling urinary catheter care, he replied he was not sure. On 5/19/23 at 1350 hours, an interview was conducted with CNA 5. When asked where would they document indwelling urinary catheter care, she stated they would document the catheter care in the resident's medical record; however, not all residents' medical records had a section to document catheter care. CNA 5 further stated they just would not document catheter care. On 5/19/23 at 1445 hours, an interview was conducted with CNA 6. When asked where would the CNAs document catheter care performed, CNA 6 stated they would document in the resident's medical record under PRN Catheter. CNA 6 further stated the PRN Catheter section was new and she had not seen that feature before until today. Further review of the medical record showed the CNA's task for catheter care every shift and PRN. However, there was no documented evidence indwelling urinary catheter care was provided to Resident 96 prior to 5/19/23. On 5/23/23 at 0840 hours, CNA 4 was observed removing linen and towels from a fully stocked linen (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 15 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0690 cart across Resident 96's room. Level of Harm - Minimal harm or potential for actual harm On 5/23/23 at 0845 hours, an observation of indwelling urinary catheter care for Resident 96 and concurrent interview was conducted with CNA 4. CNA 4 cleaned Resident 96's perineal area using one moistened towel with a back and forth motion. CNA 4 proceeded to wipe Resident 96's indwelling urinary catheter tubing. When asked if she was provided with in-service training on indwelling urinary catheter care, CNA 4 replied yes. When asked if she was trained to use multiple towels when performing indwelling urinary catheter care, CNA 4 replied she was instructed to use a lot of towels; however, sometimes, the facility did not have enough towels. Residents Affected - Few Review of the facility's in-service records titled Proper Perineal Care & UTI Prevention for Non-Cath and Residents With Catheters dated 3/28/23, showed CNA 4 was provided with in-service training on the facility's catheter care P&P. On 5/23/23 at 1330 hours, an interview and concurrent medical record review was conducted with the DON. After the DON had reviewed Resident 96's medical record, the DON verified there was no documented evidence catheter care was performed prior to 5/19/23. When asked what the process was for indwelling urinary catheter care, she stated the staff must use soap, water, and a different towel when cleaning the sections of the perineal area and indwelling urinary catheter. On 5/23/23 at 1600 hours, the Administrator, DON, and Consultant 1 were notified and acknowledged the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 16 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **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 the 24 final sampled residents (Resident 99) received the appropriate treatment and services to prevent the occurrences of complications from GT feeding. * The facility failed to ensure Resident 99's head of bed was elevated during GT feeding to reduce the risk of aspiration. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Care and Treatment of Feeding Tubes revised on 9/2/22, showed it is a policy of the facility to utilize feeding tubes in accordance with the current clinical standards of practice, with the interventions to prevent complications to the extent possible. On 5/16/23 at 1606 hours, an observation of CNA 1 performing care to Resident 99 was conducted. CNA 1 was noted to be fixing Resident 99's diaper and bed. However, Resident 99's head of bed was not elevated while the GT feeding was turned on. CNA 1 elevated Resident 99's head only after the care was done. On 5/16/23 at 1612 hours, an interview was conducted with CNA 1. CNA 1 verified Resident 99's head of bed was not elevated when providing care and Resident 99's GT feeding was turned on. When asked if Resident 99's head was supposed to be positioned flat on bed while GT feeding was running, CNA 1 stated being not aware of the resident head's position during the tube feeding. Review of Resident 99's medical record was initiated on 5/16/23. Resident 99 was admitted to the facility on [DATE] and re-admitted on [DATE]. Review of Resident 99's Order Summary report showed a physician's order dated 5/3/23, to administer a continuous enteral feeding formula, Diabetisource at 45 ml/hour to run for 20 hours starting at 12 noon time until the entire volume infused. Review of the facility's Record of In-service training provided to the CNAs dated 12/27 and 12/28/22, showed a lesson plan on the Care of Patient's on GT feeding. The lesson plan included a course content explaining the need to elevate the resident's head of bed at an appropriate angle during feeding to reduce the risk of aspiration. On 5/19/23 at 1416 hours, an interview was conducted with LVN 13. When asked if Resident 99's head of bed had to be positioned a certain way while the GT feeding was running or turned on, LVN 13 stated Resident 99's head of bed should be elevated while the GT feeding was infusing to prevent aspiration. On 5/23/23 at 1507 hours, an interview and concurrent employee record review was conducted with the DSD. The DSD verified CNA 1 had an Initial/Annual Competency Evaluation done 9/27/22, including the care of residents with multiple tubing, ventilator, IV, GT, and oxygen. The DSD further stated the CNAs were aware when the GT feeding was infusing, the head of bed should not be low due to the risk (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 17 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0693 of aspiration. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 18 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Oxygen Administration revised 9/2/22, showed to change the oxygen tubing and mask weekly and as needed if it becomes soiled or contaminated. If applicable, change the nebulizer tubing and delivery devices every 72 hours, per manufacturer's recommendation or per facility policy and as needed if they become soiled or contaminated. Keep the delivery devices covered in plastic bag when not in use. Residents Affected - Some On 5/16/23 at 0920 hours, Resident 422 was observed seated in a wheelchair in her room. Resident 422 was noted to be on room air. An oxygen concentrator was placed near Resident 422's bed, and the oxygen tubing was in a set-up bag dated 5/15/23. A nebulizer machine was also observed on top of Resident 422's bedside table. The nebulizer tubing was attached to the nebulizer and an undated nebulizer mask without a set-up bag was kept inside the bed side table's drawer. When Resident 422 was asked if she was using her nebulizer mask, Resident 422 stated she had started using her nebulizer twice a day. On 5/16/23 at 0939 hours, an observation of Resident 422 and concurrent interview was conducted with LVN 7. LVN 7 verified the nebulizer mask did not have a label with its start used date and was not stored in a set-up bag. Medical record review was initiated on 5/16/23. Resident 422 was readmitted to the facility on [DATE]. Review of Resident 422's Order Summary Report showed the following physician's orders: - dated 5/8/23, to administer oxygen at three liters per minute via nasal cannula continuous to maintain oxygen saturation above 90% every shift; and - dated 5/9/23, to administer albuterol sulfate (bronchodilator) inhalation nebulization solution 0.83 mg/3 ml via nebulizer every six hours for shortness of breath. Review of Resident 422's MAR for May 2023 showed Resident 422's SpO2 level was monitored from 5/8 to 5/18/23, with checkmarks and staff's initials; and it was ranging from 94-98%. Further review of the MAR showed Resident 422 was administered albuterol sulfate via nebulizer on 5/9 at 1200 and 1800 hours; 5/10 to 5/17/23 at 0000, 0600, 1200 and 1800 hours; and 5/18/23 at 0000, 0600, 1200 hours. On 5/17/23 at 1621 hours, Resident 422 was observed inside her room. Resident 422 was noted to be on room air. On 5/18/23 at 0800 hours, Resident 422 was observed in the hallway. Resident 422 was noted to be on room air. On 5/18/23 at 0831 hours, Resident 422 was observed seated in a wheelchair in her room. Resident 422 was noted to be on room air. A nebulizer mask without a set-up bag dated 5/16/23, was seen on top of the bedside table. When Resident 244 was asked if she was being administered with her oxygen, Resident 422 stated she only used the oxygen as needed for an extra boost. On 5/18/23 at 0932 hours, an observation for Resident 422 and concurrent interview and medical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 19 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm record review was conducted with RN 1. RN 1 verified Resident 422's nebulizer mask was not stored in set-up bag and that Resident 422 had a physician's order for administration of oxygen continuously. RN 1 stated Resident 422 was on room air and not receiving her oxygen therapy as per the physician's order. RN 1 checked Resident 422's SpO2 level, and it was 93% on room air. Residents Affected - Some 3. Observation of Resident 85 was initiated on 5/16/23. The following was identified: - On 5/16/23 at 1213 hours, Resident 85 was noted to be in bed at room air. - On 5/17/23 at 1540 hours, Resident 85 was noted to be in bed at room air. - On 5/18/23 at 0808 and 0822 hours, Resident 85 was noted to be in bed at room air. In addition, there was no oxygen concentrator and oxygen tubing seen in Resident 85's room. Medical record review was initiated on 5/16/23. Resident 85 was readmitted to the facility on [DATE]. Review of Resident 85's Order Summary Report showed a physician's order dated 1/5/23, to administer oxygen via nasal cannula at 2 L/minute and may titrate the oxygen dose to maintain the SpO2 level greater or equal to 92% every shift. Review of Resident 85's MAR showed Resident 85's SpO2 level was monitored from 5/1 to 5/17/23, with checkmarks and staff initials and they were ranged from 96-97%. On 5/18/23 at 0930 hours, an observation for Resident 85 and concurrent interview and medical record review was conducted with RN 1. RN 1 verified Resident 85 had a physician's order for the administration of oxygen continuously; however, Resident 85 was on room air and did not receive the oxygen therapy as per physician's order. RN 1 checked Resident 85's SpO2 level that was 97% on room air. 4. On 5/16/23 at 1430 hours, Resident 60 was observed in bed receiving oxygen at 2 L/minute via nasal cannula. An oxygen set-up bag with a label dated 4/24/23, was noted at the bedside. Medical record review for Resident 60 was initiated on 5/16/23. Resident 60 was admitted to the facility on [DATE]. Review of Resident 60's Order Summary Report showed a physician's order dated 4/4/23, to administer oxygen at 2-5 L/minute via nasal cannula to maintain an SpO2 level above 90%. Review of Resident 60's MAR for May 2023 showed Resident 60's SpO2 level was monitored from 5/1 to 5/18/23. On 5/16/23 at 1445 hours, an observation for Resident 60 and concurrent interview and medical record review was conducted with RN 3. RN 3 was informed of Resident 60's oxygen set-up bag with a label dated 4/24/23, at the bedside, RN 3 stated the oxygen set-up bag should be changed weekly by the morning shift nursing staff or the central supply staff. 5. On 5/16/23 at 0908 hours, Resident 52 was observed in the wheelchair. A nebulizer set-up bag with a label dated 5/8/23, was seen on top of the bedside table. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 20 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Medical record review for Resident 52 was initiated on 5/16/23. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's Order Summary Report showed a physician's order dated 3/2/23, to administer ipratropium-albuterol (medication used to treat and prevent symptoms such as wheezing and shortness of breath caused by ongoing lung disease) inhalation solution 0.5 - 2.5 mg/3 ml every four hours. Review of Resident 52's MAR for May 2023 showed the ipratropium-albuterol medication was administered to Resident 52 from 5/1 to 5/18/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours; and 5/19/23 at 0000, 0400, and 0600 hours. On 5/16/23 at 1247 hours, an observation for Resident 52 and concurrent interview was conducted with LVN 8. LVN 8 was informed of Resident 52's oxygen set-up bag noted at bedside with a label dated 5/8/23. LVN 8 stated the nebulizer set-up bag was usually changed weekly, every Monday. On 5/18/23 at 1437 hours, an interview was conducted with the Central Supply staff. The Central Supply staff stated he was responsible for changing the oxygen tubing and nebulizer mask weekly, every Monday morning. The Central Supply staff stated if a resident came after Monday, then it would be the responsibility of the nurses to set-up the oxygen tubing, nebulizer mask, and equipment. The Central Supply staff stated the oxygen tubing and nebulizer mask should be in a set-up bag with date. The Central Supply staff stated in the subacute unit, the RTs and nurses should change the oxygen tubing and nebulizer masks; however, he was not sure if these were being changed weekly. 6. Review of the facility's P&P titled Changing the Yankauer undated showed to minimize the risk of infection to the resident and the resident's Yankauer shall be changed on a regular schedule and as needed. Under the section for procedure showed to gather the Yankauer, and label with the date and resident's initials. On 5/16/23 at 1606 hours, an observation of Resident 99 was conducted in the resident's room. Resident 99's Yankauer with a label dated 5/12/23, and a suction tubing dated 5/14/23, were noted inside the suction set-up bag in the bedside table's drawer. However, Resident 99's suction set-up bag was dated 5/2023. On 5/16/23 at 1622 hours, an observation and concurrent interview was conducted with RT 1. RT 1 verified Resident 99's Yankauer was dated 5/12/23, and the suction tubing was dated 5/14/23. However, the suction set-up bag was dated 5/2023 and RT 1 verified he could not tell the date when it was changed. Review of Resident 99's medical record was initiated on 5/16/23. Resident 99 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 99's Care Plan initiated on 9/19/22, showed a care plan problem addressing Resident 99's dependence on tracheostomy related to impaired breathing mechanics with interventions to assess tracheostomy for excessive tracheal and/or oral secretions frequently and as needed for suction and suctioning as necessary. Review of Resident 99's Tracheostomy Daily Notes dated 5/16/23, showed Resident 99 was suctioned at 0720, 0920, and 1320 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 21 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 5/22/23 at 1410 hours, an interview was conducted with the DON. When asked how often the facility staff should change the suction supplies, the DON stated Resident 99's suction supplies including the suction set-up bag should be dated and changed once a week. 7. On 5/16/23 at 1559 hours, an observation of Resident 67 was conducted in the resident's room. Resident 67's Yankauer was dated 5/12/23 and the suction tubing dated 5/14/23 were noted to be inside the suction set-up bag. However, the suction set-up bag was dated May 2023. On 5/16/23 at 1623 hours, an observation and concurrent interview was conducted with RT 1. RT 1 verified Resident 67's Yankauer was dated 5/12/23, and the suction tubing was dated 5/14/23. However, the suction set-up bag was dated 5/2023 and RT 1 verified he could not tell the date when it was changed. Review of Resident 67's medical record was initiated on 5/16/23. Resident 67 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 67's Care Plan revised on 4/26/23, showed a care plan problem addressing Resident 67's dependence on the tracheostomy related to impaired breathing mechanics with an intervention to assess tracheostomy for excessive tracheal and/or oral secretions frequently and as needed for suctioning and suction as necessary. Review of Resident 67's Continuous Ventilator Flow Sheet dated 5/16/23, showed Resident 67 was suctioned at 0830, 1230, and 1430 hours. On 5/22/23 at 1410 hours, an interview was conducted with the DON. When asked how often the facility staff should change the suction supplies, the DON stated Resident 67's suction supplies including the suction set-up bag should be dated and changed once a week. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure seven of 24 final sampled residents (Residents 52, 54, 60, 67, 85, 99, and 422) were provided with the appropriate respiratory care when: * The facility failed to administer the oxygen therapy as ordered and failed to ensure the titration oxygen order included the parameters as to how to titrate the oxygen flow rate. * The facility failed to ensure Residents 85 and 422 were provided with continuous oxygen therapy per the physician's order. In addition, the facility failed to ensure Resident 422's nebulizer mask was changed weekly and stored properly per the facility's P&P. * The facility failed to ensure Resident 60's oxygen therapy tubing was changed weekly per the facility's P&P. * The facility failed to ensure Resident 52's nebulizer mask was changed weekly per the facility's P&P. * The facility failed to ensure Residents 67 and 99's suction set-up bag showed the date when it was changed. These failures had the potential to effect the respiratory health and well being of the residents (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 22 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0695 in the facility. Level of Harm - Minimal harm or potential for actual harm Findings: Residents Affected - Some 1. Review of the facility's P&P titled Oxygen Administration revised 9/2/22, showed the oxygen therapy must be administered under the orders of a physician, and the staff must document the ongoing assessment of a resident's condition warranting the oxygen administration and the response to oxygen therapy. Medical record review for Resident 54 was initiated on 5/16/23. Resident 54 was initially admitted to the facility on [DATE]. Review of the Order Summary Report showed an order dated 5/23/23, to administer oxygen via T-Mask at 2 L/minute and may titrate oxygen to maintain SpO2 (oxygen saturation level) greater or equal to 92%. * However, the order did not include the parameter as to how to titrate the oxygen flow rate. Review of the Weights and Vitals Summary dated 5/23/23, showed the following documentation of Resident 54's SpO2 levels: - On 5/17/23, Resident 54's SpO2 level was 97% at 0409 hours, 96% at 1700 hours, and 100% at 2028 hours. - On 5/19/23 at 2109 hours, Resident 54's SpO2 level was at 96%. - On 5/23/23, Resident 54's SpO2 level was 99% at 0048 hours, and 96% at 1530 hours. Review of the rounding reports was initiated on 5/16/23. The following was identified: - On 5/17/23 at 1051 hours, Resident 54 received oxygen at 7 L/minute. - On 5/19/23 at 1548 hours, Resident 54 received oxygen at 6 L/minute. - On 5/23/23 at 1026 hours, Resident 54 received oxygen at 4 L/minute. On 5/23/23 at 1028 hours, an interview was conducted with LVN 5 in Resident 54's room. LVN 5 verified that Resident 54 received 4 L/minute of oxygen. When asked when Resident 54's oxygen flow rate (amount being administered) and SpO2 level were last checked, LVN 5 stated the resident's oxygen flow rate should be checked once for every shift; however, at this time, she had not checked for her shift yet. On 5/23/23 at 1043 hours, LVN 5 was observed checking the Resident 54's oxygen flow rate and SPO2 level. LVN 5 stated Resident 54's SpO2 level was at 100% and LVN 5 proceeded to decrease Resident 54's oxygen flow rate from 4 to 2 L/minute. On 5/23/23 at 1330 hours, an interview and concurrent medical record review was conducted with the DON. When asked, the DON stated the oxygen therapy orders should have a titration parameters. Upon review of Resident 54's oxygen therapy order, the DON verified Resident 54's oxygen therapy order did (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 23 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete not have a titration parameters to guide the staff as to the appropriate flow rate of oxygen the resident should be receiving. When asked how often the nurses should reassess the resident after titrating up on a resident's oxygen flow rate, the DON stated the staff should reassess a resident five minutes after increasing a resident's oxygen flow rate. On 5/23/23 at 1600 hours, the Administrator, DON, and Consultant 1 were notified and acknowledged the above findings. Event ID: Facility ID: 555667 If continuation sheet Page 24 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided to one of 24 final sampled residents (Resident 20). Residents Affected - Few * The licensed nurse failed to clarify with the physician regarding two different orders for pain scale for Resident 20. In addition, the medication prescribed for moderate pain was administered for a severe pain, and there were no documented non-pharmacological interventions provided to Resident 20 prior to the administration of the pain medication. These failures posed the risk of Resident 20's pain not being managed appropriately. Findings: Review of the facility's P&P titled Pain Management revised on 2/2022 showed the following steps for the staff to complete: - Following the implementation of non-pharmacological intervention, the licensed nurse may administer pharmacological interventions as ordered and document medication administered on the MAR; - The licensed nurse will complete the Pain Flow Sheet for residents receiving PRN pain medication to evaluate the effectiveness of the medication regimen; - Each shift the licensed nurse will assess the resident for pain and document the results on the MAR using the 0-10 pain scale. The shift pain score will indicate the highest pain level that occurred on that shift; - If there is a new onset of pain, worsening of pain, new pain medication, pain medication change, and/ or other, the licensed nurse will complete the COMS - Vitals and Pain Only Evaluation and notify the attending physician and IDT for further recommendations; and - The facility staff will utilize non-pharmacological interventions to help reduce pain level as much as possible. Medical record review for Resident 20 was initiated on 5/16/23. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's MDS dated [DATE], showed Resident 20 was cognitively intact. a. Review of Resident 20's Order Summary Report showed the following physician's orders: - dated 4/2/21, to monitor for the resident's pain intensity before, during, and after the treatment using the following pain scale rating: 0 = no pain, 1 to 4 = mild, 5 to 7 = moderate, 8 to 9 = severe, and 10 = very severe pain, every shift; - dated 1/18/22, to monitor for the resident's pain intensity before, during, and after the treatment using the following pain scale rating: 0 = no pain, 1 to 4 = mild, 5 to 7 = moderate, 8 to 9 = severe, and 10 = very severe pain, every 24 hours as needed; and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 25 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - dated 11/21/22, to administer Ultram (narcotic opioid medication used to treat moderate to severe pain) 50 mg one tablet every six hours as needed for moderate pain levels 4 to 7. However, Resident 20's pain scale rating in the above orders on 4/2/21 and 1/18/22 were inconsistent with the order dated 11/21/22, for moderate pain. Further review of Resident 20's medical record failed to show documented evidence the pain scale rating orders were clarified with the physician. b. Review of Resident 20's MAR for May 2023 showed Resident 20 was administered Ultram for the pain level above 7. Further review the MAR showed Resident 20 was administered Ultram on 5/1, 5/2, 5/9, 5/10, 5/15, 5/16, and 5/19/23, and the documented pain level ranged from 4 to 9 or mild to severe pain using the pain scale rating above; however, the physician order to administer Ultram was for moderate pain only. c. Review of Resident 20's Progress Notes showing a late entry for COMS - Vitals and Pain Only Evaluation dated 1/24/22, showed the resident complained of back pain daily and non-pharmacological interventions did not provide relief. However, the notes including the evaluation did not show what non-pharmacological interventions were provided to Resident 20. Review of Resident 20's plan of care showed a care plan problem dated 9/15/22, to address acute pain/chronic pain. The interventions included to medicate with PRN medications if non-medication interventions were ineffective and to utilize non-pharmacological interventions for pain relief. Review of Resident 20's Progress Notes dated 5/2/23, showed the resident had pain or was hurting anytime in the last five days, and the pain intensity level was moderate. However, the documentation failed to include any non-pharmacological interventions that were provided to Resident 20. Further review of Resident 20's medical record failed to show documented evidence any non-pharmacological interventions being implemented by the staff before administering the pharmacological interventions to the resident. On 5/19/23 at 0956 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified there were two different pain scale rating used for moderate pain per the physician's orders. LVN 7 verified the Ultram medication was for moderate pain of 4 to 7 pain rating scale; however, the Ultram medication was given for 8 to 9 pain rating scale. LVN 7 stated she needed to clarify the pain rating scale in the physician's order for Ultram medication. On 5/19/23 at 1039 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was informed and verified the above findings. RN 1 stated non-pharmacological interventions were initiated during the pain assessment upon admission and implemented prior to the administration of the pain medication. RN 1 verified there was no non-pharmacological interventions provided for Resident 20. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 26 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 the licensed nurse coordinated with the physician regarding the sevelamer carbonate (a medication that can lower the amount of phosphorus in the blood of residents receiving kidney dialysis) scheduled at the time when the resident was out to the dialysis center for one of 24 final sampled residents (Resident 18). Resident 18 did not receive the medication as ordered by the physician on the dialysis days. This failure posed the risk for Resident 18 to not be provided with the appropriate care and treatment and sustained possible medical complications that could had been avoided when the physician's order was followed. Residents Affected - Few Findings: Review of the facility's P&P titled Hemodialysis revised on 9/2/22, showed the licensed nurse will communicate to the dialysis facility via telephone communication or written format, such as the used of the dialysis communication record or other forms that will include, but not limited to the timely medication administration (initiated, held, or discontinued) by the nursing home. Medical record review for Resident 18 was initiated on 5/16/23. Resident 18 was readmitted on [DATE], with the diagnosis of End Stage Renal Disease requiring hemodialysis. Review of Resident 18's Order Summary Report for May 2023 showed a physician's order dated 12/10/22, for Resident 18 to receive hemodialysis treatment on Tuesdays, Thursdays, and Saturdays, with a chair time of 1300 hours; and to be picked up by transportation from the facility at 1130 hours. In addition, there was a physician's order dated 4/14/23, for Resident 18 be administered sevelamer carbonate 800 mg by mouth three times a day with meals. Review of Resident 18's MAR for May of 2023 showed the sevelamer carbonate medication scheduled at 1300 hours, was not administered during dialysis days on 5/4, 5/6, 5/11, 5/13, and 5/18/23. There was no documented evidence the nursing staff had coordinated with the physician on what to do for the sevelamer carbonate medication scheduled at 1300 hours on those dialysis days. On 5/19/23 at 0945 hours, an interview and a concurrent electronic medical record review was conducted with LVN 1. LVN 1 stated Resident 18 was out of the facility on Tuesdays, Thursdays, and Saturdays for dialysis. LVN 1 stated Resident 18 had left the facility for dialysis at around 1130 hours. LVN 1 was informed and verified the above findings and stated there was no physician's order to hold Resident 18's sevelamer carbonate medication when she was out for dialysis, nor did LVN 1 notify the physician of the sevelamer carbonate not being given to Resident 18. LVN 1 stated he did not know he had to notify the physician if he did not administer the sevelamer carbonate to Resident 18 when the resident was out of the facility receiving her dialysis treatment. On 5/19/23 at 0959 hours, an interview and a concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings and stated it was important for Resident 18 to receive all her scheduled medications to prevent complications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 27 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical records review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of one of 24 final sampled residents (Resident 5) and three nonsampled residents (Residents 22, 90, and 822). * The facility failed to ensure Resident 22's Lactulose (medication to treat constipation) was administered as ordered. * The facility failed to ensure the Norco (controlled pain medication) for Resident 5 was documented in MAR when administered. * The facility failed to ensure the Norco for Resident 90 was documented in the MAR when administered. * The facility failed to ensure the medications were not left unattended by a licensed nurse during medication administration. * The facility failed to ensure the wasting of controlled medication was performed by two licensed nurses. These failures posed the risk for possible complications, delay in interventions and treatments, and risk for diversion of controlled medication. Findings: Review of the facility's P&P titled Medication Administration-General Guidelines dated 10/2017 showed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Review of the facility's P&P titled Preparation and General Guidelines: Controlled Medications dated 8/2014 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: date and time of administration; amount administered; signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply; and the initials of the nurse administering the dose on the MAR after the medication is administered. Review of the facility's P&P titled Medication Storage in the Facility: Storage of Medications dated 4/2008, showed only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 1. Medical record review for Resident 22 was initiated on 5/16/23. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Order Summary Report showed a physician's order dated 6/29/22, to administer Lactulose Solution 20 gm/30 ml via GT one time for bowel management and to hold for loose stool. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 28 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/16/23 at 0817 hours, a medication administration observation and concurrent interview for Resident 22 was conducted with LVN 8. LVN 8 did not administer the Lactulose as ordered. LVN 8 verified she did not administer the Lactulose because the facility did not have the medication available at the time of medication administration. 2.a. Medical Record review for Resident 5 was initiated on 5/16/23. Resident 5 was admitted to the facility on [DATE]. Review of the Order Summary report showed a physician's order dated 5/06/23, to administer Norco Oral Tablet 5-325 mg (hydrocodone- acetaminophen) one tablet via GT every 6 hours as needed for moderate pain to severe pain NTE 3 gm/24 hrs of APAP (acetaminophen) from all sources. Review of Resident 5's Antibiotic or Controlled Drug Record for the use of Norco (hydrocodone-acetaminophen)showed Norco 5-325 mg one tablet on 5/12/23 at 2030 hours, and one tablet on 5/13/23 at 0300 hours, were signed out on the narcotic count sheet. Review of Resident 5's MAR for May 2023 failed to show documentation of Norco 5-325 being administered to Resident 5 on 5/12/23 at 2020 hours, and 5/13/23 at 0300 hours. On 5/17/23 at 0922 hours, an interview and concurrent medical record review was conducted with LVN 12. LVN 12 verified Resident 5's Antibiotic or Controlled Drug Record showed the Norco was signed out on 5/12/23 at 2030 hours, and 5/13/23 at 0300 hours. However, the Norco 5-325 was not documented as administered in Resident 5's MAR. b. Medical Record review for Resident 90 was initiated on 5/16/23. Resident was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 90's Order Summary Report showed a physician's order dated 5/5/23, to administer hydrocodone-acetaminophen (Norco) 5-325 one tablet via GT every 6 hours as needed for moderate pain to severe pain, NTE 3 gm/24 hrs of APAP from all sources. Review of Resident 90's Antibiotic or Controlled Drug Record for Norco showed Norco 5-325 was signed out on 5/10/23 at 2200 hours. Review of Resident 90's MAR for May 2023 failed to show documentation of Norco 5-325 being administered to Resident 90 on 5/10/23 at 2200 hours. On 5/17/23 at 0922 hours, and interview and concurrent medical record review was conducted with LVN 12. LVN 12 verified Resident 90's Antibiotic or Controlled Drug Record showed the Norco was signed out on 5/10/23 at 2200 hours. However, it was not documented as administered in Resident 90's MAR. 3. Medical record review for Resident 22 was initiated on 5/16/23. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's Order Summary report showed the physician's orders for the following medications: - Symmetrel 50 mg/5 ml 20 ml via GT for Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 29 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0755 - amlodipine 10 mg one tablet via GT for hypertension (high blood pressure) Level of Harm - Minimal harm or potential for actual harm - Folic Acid 400 mcg via GT as supplement - Lansoprazole (medication to help reduce high levels of acid in the stomach) 30 mg one capsule via GT Residents Affected - Few - Keppra (levetiracetam) 100 mg/ml 5 ml via GT for seizure (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements and state of awareness) - Lisinopril (to treat high blood pressure) 5 mg one table via GT - Metformin (to treat high sugar level in the blood) 500 mg one tablet via GT - MVI + minerals 5 ml (multivitamins with minerals) via GT as supplement - metoprolol tartrate (to treat high blood pressure) 25 mg via GT - Ultra B-100 complex one tablet via GT as supplement - Oyster shell Calcium 500 mg and Vitamin D 5 mcg via GT as supplement On 5/16/23 at 0817 hours, a medication administration observation for Resident 22 was conducted with LVN 8. LVN 8 prepared the liquid medication and crushed tablet medications to administer to Resident 22. LVN 8 was observed to have turned her back three times away from the medications, to get gloves, stethoscope, and spoons, leaving the prepared medication in the cups on top of the over bed table and unattended. On 5/16/23 at 1448 hours, an interview was conducted with LVN 8. LVN 8 acknowledged the findings and stated she should not have left the medications unattended. 4. Medical record review for Resident 822 was initiated on 5/19/23. Resident 822 was admitted to the facility on [DATE], and discharged on 2/28/23. Review of Resident 822's Antibiotic or Controlled Drug Record for alprazolam (medication to treat anxiety) 0.25 mg tablet showed on 2/28/23, with no time documented, one alprazolam tablet was signed as wasted by one licensed nurse. On 5/19/23 at 1109 hours, an interview and concurrent medical record review was conducted with the DON. The DON verifed one tablet of alprazolam 0.25 mg was signed and wasted by one licensed nurse, but it should have been signed by two licensed nurses. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 30 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility P&P review, and facility document review, the Pharmacy Consultant failed to identify and recommend for monitoring of the side effects for enoxaparin (anticoagulant medication which reduces the chance of getting blood clots) for one of 24 final sampled residents (Resident 92). This failure had the potential risk of providing Resident 92 unnecessary medication and the potential for the development of significant side effects. Findings: Review of the facility's P&P titled Consultant Pharmacist Reports IIIA1: Medication Regimen Review (Monthly Report) dated 6/2021 showed the consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly. The MRR includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and prevents or minimized adverse consequences relation to medication therapy. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing and/or prescriber as appropriate. If no irregularities are found, the consultant pharmacist will provide documentation. According to Lexicomp (online drug reference), enoxaparin sodium is an anticoagulant medication. The adverse effects section showed the list of adverse effects including major bleeding. The Warning/Cautions section showed concerns related to adverse effects which include bleeding. Medical record review for Resident 92 was initiated on 5/17/23. Resident 92 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 92's Order Summary Report for May 2023 showed a physician's order dated 2/22/23, to administer enoxaparin sodium injection solution prefilled syringe 40 mg/0.4 ml 0.4 ml subcutaneously one time a day for DVT prophylaxis. The physician's order for enoxaparin sodium did not include the monitoring of side effects. Review of Resident 92's Pharmacy Consultant's Medication Regimen Review for 2/15, 3/15, and 4/20/23, did not show the recommendations for Resident 92 to be monitored for the side effects of enoxaparin sodium. On 5/18/23 at 1508 hours, a telephone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant verified he conducted a medication regimen review for Resident 92. The Pharmacy Consultant was asked if he had recommendations for Resident 92's enoxaparin sodium order. The Pharmacy Consultant reviewed his data and stated he did not see documentation of recommendations for the resident's enoxaparin sodium medication. The Pharmacy Consultant stated he would initially assess the residents and their medications before providing recommendations, but he would normally recommend side effects monitoring for anticoagulant medications. Cross reference to F757. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 31 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Lexicomp, an online reference for clinical drug information, showed precautions and concerns related to the adverse effects of enoxaparin sodium included bleeding and residents should be monitored closely for signs and symptoms of bleeding. Residents Affected - Few Review of the facility's P&P titled High Risk Medication-Anticoagulants revised 9/2/22, showed the resident's plan of care shall alert staff to monitor for adverse consequences. Risks associated with anticoagulants include bleeding and hemorrhage (bleeding gums, nosebleed, unusual bruising, blood in urine or stool), fall in hematocrit or blood pressure, and thromboembolism. Medical record review for Resident 92 was initiated on 5/17/23. Resident 92 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 92's Order Summary Report for May 2023 showed a physician's order dated 2/22/23, to administer enoxaparin sodium injection solution prefilled syringe 40 mg/0.4 ml inject 0.4 ml subcutaneously one time a day for DVT prophylaxis. The physician's order for enoxaparin sodium did not include monitoring for side effects. Review of Resident 92's MAR dated April and May 2023 failed to show documentation the signs and symptoms of bleeding related to the use of enoxaparin sodium were being monitored. Review of Resident 92's plan of care failed to show a care plan problem was developed for the use enoxaparin sodium medication. On 5/17/23 at 1545 hours, an interview and concurrent electronic medical record review was conducted with LVN 9. LVN 9 stated there should be monitoring for the signs and symptoms of bleeding related to the use of enoxaparin for Resident 92. LVN 9 verified he could not find the monitoring of the adverse effects for the use of enoxaparin sodium medication in the MAR or the care plan. On 5/17/23 at 1618 hours, an interview and a concurrent electronic medical record review was conducted with the DON. The DON acknowledged the above findings and stated the facility did not need an order for monitoring of the adverse effects for enoxaparin, but it needed to be included in the care plan problem. The DON confirmed Resident 92 did not have a care plan problem for the use of enoxaparin sodium. Cross reference to F756. Based on interview and medical record review, the facility failed to ensure three of 24 final sampled residents (Residents 77, 92, and 422) were free from unnecessary medications. * The facility failed to monitor for signs and symptoms of bleeding related to Residents 422 and 77's use of apixaban (anticoagulant medication used to prevent blood clots). * The facility failed to monitor for signs and symptoms of side effects related to Resident 422's use of Reglan (medication used to treat nausea and vomiting). * The facility failed to monitor for signs and symptoms of bleeding related to Resident 92's use of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 32 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0757 enoxaparin (anticoagulant medication used to prevent blood clots). Level of Harm - Minimal harm or potential for actual harm * The facility failed to ensure Resident 422's anti-bacterial medication order had a stop date. Residents Affected - Few These failures had the potential for residents to receive unnecessary medications and develop significant adverse effects, and risk of adverse effects from prolonged use of the medication. Findings: 1. According the Lexicomp, Apixaban is an anticoagulant and may increase the risk of bleeding (hemorrhage), including severe and potentially fatal major bleeding. a. Medical record review for Resident 422 was initiated on 5/16/23. Resident 422 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 422's Order Summary Report showed a physician's order dated 5/8/23, to administer apixaban oral tablet 5 mg one tablet by mouth two times a day related to unspecified atrial fibrillation. The Order Summary Report did not include a physician's order to monitor for the side effects of the apixaban. b. Medical Record Review for Resident 77 was initiated on 5/16/23. Resident 77 was admitted to the facility on [DATE], and readmitted on 3/16 and 11/23/22. Review of Resident 77's Order Summary report showed a physician's order dated 2/4/23, to administer Eliquis (brand name for apixaban) tablet 5 mg one tablet enterally one time a day for atrial fibrillation. The Order Summary Report did not include a physician's order to monitor for the side effects of the Eliquis. On 5/19/23 at 0835 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified there was no physician's order to monitor Resident 77 for the adverse effects of the Eliquis. On 5/19/23 at 1012 hours, a telephone interview and concurrent medical record review was conducted with the facility's Pharmacy Consultant. The Pharmacy Consultant acknowledged and verified that the facility did not have a physician's order to monitor for the adverse effects of the blood thinners ordered for for Residents 422 and 77. 2. Medical record review for Resident 422 was initiated on 5/16/23. Resident 422 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the drug information sheet from Lexicomp showed Reglan can cause tardive dyskinesia, a serious movement disorder that is often irreversible, which include trouble controlling body movements or problems with tongue, face, mouth, or jaw-like tongue sticking out, puffing cheeks, mouth puckering or chewing, extrapyramidal symptoms (trouble controlling body movements, twitching, change in balance, trouble swallowing or speaking), neuroleptic malignant syndrome (fever, muscle cramps or stiffness, dizziness, very bad headache, confusion, change in thinking, fast hearbeat, heartbeat that does not feel normal, or are seating a lot). Review of Resident 422's Order Summary Report showed an order dated 5/8/23, to administer Reglan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 33 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Oral 5 mg tablet (metoclopramide HCl) one tablet by mouth every 6 hours as needed for nausea and vomiting. The Order Summary Report for Resident 422 did not include the monitoring of adverse effects of the medication. On 5/18/23 at 1329 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the facility did not monitor for the adverse effects of Reglan. 3. Medical record review for Resident 422 was initiated on 5/16/23. Resident 422 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 422's Order Summary Report showed a physician's order dated 5/8/23, to administer rifaximin (antibiotic) oral tablet 550 mg one tablet by mouth two times a day for SIBO-Small Bowel intestinal Bacterial Overgrowth. The Order Summary Report did not include a stop date for Resident 422's rifaximin. Review of the drug information sheet from Lexicomp showed rifaximin for small intestinal bacterial overgrowth (off label use) is administered by mouth, 550 mg three times daily for 14 days. A concern for potential risk of development of antimicrobial resistance with prolonged rifaximin use or repeated courses of treatment. On 518/23 at 1105 hours, an interview and concurrent medical record review was conducted with LVN 7. When asked if an antibiotic used to treat bacterial infection needed to have a duration, LVN 7 stated yes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 34 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview, medical record review, and facility P&P review, the facility failed to ensure two of 24 final sampled residents (Residents 77 and 422) were free from unnecessary psychotropic medications (any drug which afftects brain activities associated with mental processes and behavior). * The facility failed to ensure the non-pharmacological interventions were provided to Resident 422 for the use of lorazepam PRN and melatonin. In addition, the facility failed to ensure a rationale was documented for extending the duration of the use of lorazepam for Resident 422. * The facility failed to ensure non-pharmacological interventions were provided to Resident 77 for the use of clonazepam (antianxiety medication). These failures had the potential for residents to develop significant adverse effects from the medications and had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Use of Psychotropic Medication revised on 9/2/22, showed residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Further review of the P&P showed non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. 1.a. Medical Record review for Resident 422 was initiated on 5/16/23. Resident 422 was admitted to facility on 10/15/19, and readmitted on [DATE] and 5/8/23. Review of Resident 422's Order Summary Report showed a physician;s order dated 4/4/23, Ativan (brand name for lorazepam) 0.5 mg one tablet by mouth every six hours PRN for anxiety manifested by verbalization of nervousness for 14 days. Review of Resident 422's Order Summary report showed a physician's order dated 5/8/23, to administer lorazepam oral tablet 0.5 mg one tablet by mouth every six hours PRN for anxiety manifested by inability to relax for 14 days. Review of Resident 422's MAR showed on 4/7, 4/12, 4/13, 5/2, 5/3 , 5/9, 5/10, 5/11 , 5/15, and 5/16/23, the lorazepam 0.5 mg one tablet was documented as administered. The MAR failed to show non-pharmacological interventions were implemented prior to the administration of the lorazepam medication. b. Medical Record review for Resident 422 was initiated on 5/16/23. Resident 422 was admitted to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 35 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0758 facility on 10/15/19, and readmitted on [DATE] and 5/8/23. Level of Harm - Minimal harm or potential for actual harm Review of Resident 422's Order Summary Report showed a physician's order dated 5/8/23, to administer melatonin oral tablet 5 mg one tablet by mouth PRN for HS for 14 days for insomnia manifested by inability to sleep. Residents Affected - Few Review of Resident 422's MAR showed on 5/10, 5/11, and 5/16/23, melatonin oral tablet 5 mg was administered to the resident. The MAR failed to show non-pharmacological interventions were implemented prior to the administration of the medication. On 5/19/23 at 0825 hours an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified non-pharmacological interventions were not being implemented prior to administering the medication. 2. Medical Record review for Resident 422 was initiated on 5/16/23. Resident 422 was admitted to facility on 10/15/19, and readmitted on [DATE] and 5/8/23. Review of Resident 422's Order Summary Report showed a physician's order dated 2/20/23 to administer lorazepam tablet 0.5 mg one tablet by mouth every 6 hours as needed for anxiety for 14 days manifested by verbalization of nervousness. Further review of the Order Summary Report showed the lorazepam was ordered again for 14 days on 3/22, 4/4, and 5/8/22. Further review of Resident 422's medical record failed to show documentation from the physician for the rationale for extending the use of lorazepam PRN beyond 14 days. On 5/8/23 at 1329 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was no physician's documentation of the rationale to extend/renew the order for the use of antianxiety medication. 3. Medical Record review for Resident 77 was initiated on 5/18/23. Resident 77 was admitted to facility on 12/1/20, and readmitted on 3/16 and 11/23/22. Review of Resident 77's Order Summary Report showed a physician's order dated 2/3/23, to administer clonazepam tablet 0.5 mg one tablet two times a day for anxiety manifested by restlessness. Review of Resident 77's MAR showed on 3/1 to 3/31, 4/1 to 4/30, and 5/1 to 5/16/23, clonazepam tablet 0.5 mg one tablet was administered twice a day to the resident. The MAR failed to show non-pharmacological interventions were implemented prior to the administration of the medication. On 5/19/23 at 0825 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 verified non-pharmacological interventions were not being implemented prior to administering the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 36 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 23.33%. Two of two licensed nurses (LVNs 7 and 8) were found to have made errors during the medication administration. Residents Affected - Few * Resident 22 had the physician's order to mix lanzoprazole (a medication which reduces the amount of acid in the stomach) with apple sauce/apple juice; however, LVN 8 mixed the medication with water instead of apple juice as ordered. * Resident 22 had the physician's order for lactulose (medication to treat constipation); however, LVN 8 did not administer the medication as ordered. * Resident 22 had the physician's order for Oscal and D3 500/200 (supplement); however, LVN 8 did not administer the correct dose as ordered. * Resident 422 had the physician's orders for diltiazem ER (an extended release antihypertensive medication) and potassium chloride ER (an extended release potassium supplement); however LVN 7 crushed these extended release medications to administer to the resident. * Resident 422 was administered with the crushed medications; however, LVN 7 left the crushed medication residue in the medication cup. * Resident 422 had the physician's order for diclofenac sodium gel (medication ointment to relieve pain); however, LVN 7 did not administer the medication as ordered. These failures resulted in the residents not receiving the prescribed medications as ordered by the physician, posed the risk of adverse effects, and had the potential to negatively affect the residents' health. Findings: Review of the facility's P&P titled Preparation and General Guidelines: Medication Adinistration-General Guidelines dated 10/2017, showed medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Further review of the facility's P&P also showed long-acting or enteric coated dosage forms should generally not be crushed; an alternative should be sought. 1. On 5/16/23 at 0817 hours, a medication administration observation for Resident 22 was conducted with LVN 8. LVN 8 administered Resident 22's Lanzoprazole via GT mixed with water. However, review of the Order Summary Report showed a physician's order dated 10/13/22, for Lansoprazole Capsule Delayed Release 30 mg one capsule via GT, to mix with applesauce/apple juice. According to Lexicomp, lanzoprazole capsule can be opened and the granules mixed with 40 ml of apple juice and administered through the nasogastric tube into the stomach, then flush tube with additional apple juice. Do not mix with other liquids. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 37 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 5/16/23 at 1428 hours, an interview was conducted with LVN 8. LVN acknowledged that lansoprazole was mixed/dissolved in water instead of mixing with apple juice or apple sauce as ordered by physician. 2. On 5/16/23 at 0817 hours, a medication administration observation for Resident 22 and concurrent review of the medical record was conducted with LVN 8. Review of the Order Summary Report showed a physician's order dated 6/29/22, to administer Lactulose Solution 20 gm/30 ml 30 ml via GT one time a day for bowel management and to hold for loose stools. However, LVN 8 did not administer the Lactulose as ordered to Resident 22 during the medication administration observation. On 5/16/23 at 0930 hours, an interview and concurrent medical record review was conducted with LVN 8. LVN 8 stated she did not administer the Lactulose because it was not available in the facility during the medication administration. 3. On 5/16/23 at 0817 hours, a medication administration observation for Resident 22 was conducted with LVN 8, LVN 8 administered a crushed Oyster Shell Calcium 500 mg with Vitamin D 5 mg via GT. However, review of the Order Summary Report showed a physician's order dated 6/30/22, to administer Oscal with vitamin D3 tablet 500/200 MG-UNIT one tablet via GT two times a day for supplement. On 5/16/23 at 0930 hours, an interview and concurrent medical record review was conducted with LVN 8. LVN 8 acknowledged vitamin D 200 IU should have been given to Resident 22. 4. On 5/16/23 at 0931 hours, a medication administration observation for Resident 422 was conducted with LVN 7. LVN 7 crushed diltiazem (drug that can treat high blood pressure and chest pain) 300 mg ER (extended release tablet, medication designed to make it last longer in the body) and KCl ER tablet (potassium chloride extended release, this medication is a mineral supplement used to treat or prevent low amounts of potassium in the blood) and administered to Resident 422. Review of the Order Summary Report showed a physician's order dated 5/8/23, to administer diltiazem HCL ER 24 Hour 300 mg one tablet by mouth one time a day, HOLD IF SBP less than 100 mmHg, and another physician's order dated 5/8/23, to administer potassium chloride ER tablet 40 mEq by mouth one time a day for supplement. On 5/16/23 at 1242 hours, an interview and concurrent medical record review was conducted with LVN 7. LVN 7 was asked if the dializem HCL ER and Potassium Chloride ER should have been crushed. LVN 7 stated it should not have been crushed; however, she crushed the medications because Resident 422 requested for the medications to be crushed. 5. On 5/16/23 at 0931 hours, a medication administration observation for Resident 422 was conducted with LVN 7. LVN 7 had crushed Xifaxan (brand name for rifaximin- antibiotics that can treat traveler's diarrhea and intestinal infection) 550 mg as per the resident's request, mixed it with apple sauce, and placed in a plastic medicine cup. After administering Xifaxan, it was observed moderate amount of residue was left inside the medication cup. Resident 422 did not receive a full dose of the medication as ordered. Review of the Order Summary Report for Resident 422 showed a physician's order dated 5/8/23, to administer rifaximin 550 mg one tablet by mouth two times a day for SIBO-Small Bowel intestinal Bacterial Overgrowth. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 38 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0759 Level of Harm - Minimal harm or potential for actual harm On 5/16/23 at 1242 hours, an interview was conducted with LVN 7. LVN 7 acknowledged and verified Resident 422 did not receive the full dose as ordered. 6. On 5/16/23 at 0931 hours, a medication administration observation and concurrent medical review for Resident 422 was conducted with LVN 7. Residents Affected - Few Review of the Order Summary Report for Resident 422 showed a physician's order dated 5/8/23, to administer diclofenac sodium External Gel 1% 4 gm to both BLE joints topically two times a day for pain management. During the medication administration observation, LVN 7 did not apply diclofenac to the resident's BLE joints. However, review of Resident 422's MAR showed diclofenac was documented as administered to the resident On 5/16/23 at 1242 hours, an interview was conducted with LVN 7. LVN 7 verified the medication was signed for in the MAR as administered; however the medication was not administered to Resident 422. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 39 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Review of the facility's P&P titled Medication Storage in the Facility dated April 2008 showed the medications and biologicals are stored safely, and properly, following manufacturer's recommendation or those of supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff member lawfully authorized. Review of the facility's P&P titled Self-Administration of Medication dated April 2008 showed bedside medication storage is permitted only when it does not present a risk to confused residents who wander into rooms of, or room with, residents who self-administer, the manner of storage prevents access by other residents, and all nurses and aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage and to give unauthorized medications to the change nurse for return to the family or responsible party. On 5/16/23 at 0924 hours, an observation of Resident 53's room was conducted. Two bottles of [NAME] pain relieving oil was observed on top of Resident 53's bedside table. Review of Resident 53's medical record was initiated on 5/16/23. Resident 53 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 53's Order Summary Report did not show an order for the pain reliving oil. Review of Resident 53's Care Plan showed a care plan problem dated 8/27/21, to address the resident's risk for pain secondary to arthritis. Review of Resident 53's Self-Administration of Medication assessment dated [DATE], showed Resident 53 was not capable of the following: - storing medications in a secure location, - opening/closing the medication containers, - administering medication by various routes, - correctly state/read name of medication and its prescribed use, - identify common side effects of medication(s), - correctly state what time medication(s) are to be taken, - correctly state and dispense the proper dosage for medication(s), - accurately document self-administration of medication(s), and - safe self-administration of medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 40 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0761 The [NAME] Loong pail relieving medication was labeled with, but not limited to the following: Level of Harm - Minimal harm or potential for actual harm - Active Ingredients: Methyl Salicylate 35% external analgesic (pain medication) and Menthol 16% external analgesic (pain medication), Residents Affected - Few - Warnings: for external use only, use only as directed, avoid contact with eye and mucous membranes, do not apply on open wounds, damaged or irritated skin, do not bandage or cover with any type of wrap except clothing, do not use with heating pad or apply with external heat and do not use one hour prior to bathing or within 30 minutes of bathing. - Stop use and ask a doctor if: condition worsens, pain persist for more than seven days, pain clears up then recurs few days later and sever skin irritation occurs. - Keep out of reach of children, if swallowed get medical help or contact a Poison Control Center immediately. - Directions: adults and children [AGE] years of age or older, apply to the affected areas no more than 3-4 times daily - Other information: This product may cause allergic reaction on some individuals. Test on small areas before use. On 5/16/23 at 1649 hours, an observation and concurrent interview was conducted with LVN 3. LVN 3 verified Resident 53 had two bottles of [NAME] Loong pain relieving oil on the bedside table. When asked, LVN 3 stated Resident 53 was not supposed to have [NAME] Loong pain relieving oil medication at the bedside. On 5/17/23 at 1529 hours, an interview was conducted with Resident 53. When asked where Resident 53 used the [NAME] Loong pain relieving oil, Resident 53 pointed at his fingers and knees and Resident 53 stated, arthritis. On 5/18/23 at 1044 hours, a follow-up interview with a Vietnamese translator was conducted with Resident 53. When asked if Resident 53 used the [NAME] Loong pain relieving oil, Resident 53 stated he had the medication at the bedside and used the medication as needed when achy. On 5/22/23 at 1410 hours, an interview and concurrent record review was conducted with the DON. The DON verified Resident 53 was not capable of safe self-administration and storing medication in a secure location. When asked if Resident 53 was supposed to have [NAME] Loong pain relieving oil at bedside, the DON acknowledged Resident 53 was not supposed to have the medication at the bedside. When asked regarding the facility's process to ensure the resident's rooms did not have unauthorized medications for bedside storage, the DON stated the facility conducted weekly Guardian Angel Rounds to check each resident's room and the reports were submitted to the Administrator. Review of the facility's form titled Guardian Angel - Action Rounds dated 3/2022, showed to observe the following and correct if needed that includes no medication/creams on the bedside/over-bed table. On 5/22/23 at 1513 hours, an interview and concurrent review of the facility document was conducted with the Administrator. When asked to review the facility's weekly Guardian Angel records, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 41 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Administrator was unable to show the weekly reports of Guardian Angel-Action Rounds for Resident 53's room. Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. Residents Affected - Few * The facility failed to ensure the expired medications were removed from Treatment Cart A and Medication Room B. * The facility failed to ensure Resident 45's medication requiring refrigeration was stored in the medication refrigerator. * The facility failed to ensure the discontinued eye drop medication was removed from Refrigerator A. * The facility failed to ensure the opened insulin pens and medication vial labeled with open date more than 30 days for Residents 25, 56, and 100) were removed from stock or Medication Cart A. * Two bottles of pain-relieving oil were observed on Resident 53's bedside table. These failures had the potential to negatively impact the residents' well-being; had the potential for the medications to lose the stability and effectiveness; and had the potential for residents, staff, and visitors to have an access to the medications. Findings: Review of the facility's P&P titled Medication Storage in the Facility: Storage of Medications dated 4/2008 showed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if current order exists. Further review of the facility's P&P showed medications requiring refrigeration or temperatures between 2 degrees C (36 degrees F) and 8 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Review of the Drug Pharmacology Information from Lexicomp (drug reference developed to provide drug reference solutions for hospital wide or community pharmacist ) for Insulin Lispro, under Storage/Stability section showed store unopened vials, cartridges and prefilled pens under refrigeration between 2 and 8 degrees C (36 degrees F and 46 degrees F) until the expiration date or at room temperature < 30 degrees C (<86 degrees F) for 28 days; do not freeze; keep away from the heat and light. Store in in-use vials under refrigeration between 2 degrees C and 8 degrees C (36 degrees F and 46 degrees F) or at room temperature <30 degrees C (<86 degrees F) and use within 28 days. Store in-use cartridges and prefilled pens at room temp <30 degrees C (<86 degrees F) and use within 28 days; do not freeze. 1. On 5/17/23 at 0900 hours, an inspection of Medication Room B and concurrent interview was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 42 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm conducted with the DSD. One bottle of Earwax Softener drop was found with an expiration date of 4/2023. The DSD verified and acknowledged the finding. On 5/17/23 at 1043 hours, an inspection of Treatment Cart A and concurrent interview was conducted with LVN 6. Residents Affected - Few A Pluro Gel Wound and Burn Dressing (no specific resident name) was found with an expiration date of 3/2023. LVN 6 verified the finding. 2. On 5/17/23 at 1057 hours, an inspection of Medication Cart B and concurrent interview was conducted with LVN 5. Resident 45's arformoterol (medication to treat breathing problems caused by chronic obstructive pulonary disease) 15 mcg/2 ml solution/nebulizer labeled as REFRIGERATE was found inside Medication Cart B. LVN 5 acknowledged and verified the finding and stated the medication should have been kept in the refrigerator. 3. On 5/17/23 at 0830 hours, an inspection of Refrigerator A and concurrent interview was conducted with RN 4. A bottle of latanoprost .005% (medication to treat glaucoma, an eye condition which can cause blindness) with a refilled date of 7/1/22, was discontinued on 8/2/22; however, the medication was still inside Refrigerator A. RN 4 verified the finding and stated the medication should have been removed from Refrigerator A. 4. On 5/16/23 at 1447 hours, an inspection of Medication Cart A and concurrent interview was conducted with LVN 4. The following medications were observed inside Medication Cart A: - Insulin (hormones which regulates the amount of sugar in the blood. Lack of insulin causes a form of diabetes) Lispropen 100 u/ml, with an open date of 4/8/23, for Resident 56 - Insulin Lispro pen 100 u/ml, with an open date of 4/2/23, for Resident 26 - Regular insulin -Humulin 100 u/ml vial, with an open date of 3/30/23, for Resident 100 The insulin vials were opened for more than 30 days at room temperature and stored inside Medication Cart A. When LVN 4 was asked how long should the insulin should be kept at room temperature and used once opened, LVN 4 stated for 28 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 43 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure an adequate oversight of the kitchen was provided when multiple issues were identified in regard to the kitchen safety and sanitation, following the facility's recipes, and monitoring of the kitchen staff' competency. This failure had the potential to result in food not being served in a safe and sanitary manner which could lead to foodborne illness and resident nutritional needs not being met for the 115 facility residents who received food prepared in the kitchen. Findings: According to the USDA Food Code 2022 Annex 4 Management of Food Practices-Achieving Active Managerial Control of Foodborne Illness Risk Factors showed under section G. Assess Active Managerial Control of Foodborne Illness Risk Factors and Implementation of Food Code Interventions, the Demonstration of Knowledge: it is the responsibility of the person in charge to ensure compliance with the Code. The knowledge and application of Food Code provisions are vital to preventing foodborne illness and injury. The data collected by FDA suggest that having a certified food manager on-site has a positive effect on the occurrence of certain foodborne illness risk factors in the industry. Review of the facility's Director of Food Services job description signed and dated by the DSS on 1/22/20, showed the primary purpose of this job position is to assist the Dietitian in planning, organizing, developing and directing the overall operation of the Food Service Department in accordance with current federal, state, and local standards, guidelines and regulations governing the facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner. Review of the facility document titled Employee Performance Appraisal signed and dated by the DSS on 2/16/21, showed the DSS was excellent in knowledge and quality of work. During the multiple observations at the kitchen and facility conducted from 5/16 to 5/23/23 at various times, the following was identified related to food safety and sanitation: 1. The Potential for cross contamination during food preparation, Time Temperature Control for Safety Foods were not handled safely, lack of proper hand hygiene, food preparation equipment was not sanitized when washed manually, kitchen surfaces were not sanitized, refrigerated and frozen foods were not stored properly, hair restraints were not worn appropriately, food preparation equipment was not clean, non-food contact surfaces in the kitchen were not clean, an ice storage chest with soiled wheels was stored on a food preparation counter, and employee's food was not stored appropriately. On 5/17/23 at 1454 hours, an interview was conducted with the RD. The RD was asked how she had communicated her concerns from the Sanitation Audit Report (SAR) she completed monthly. The RD stated she discussed her concerns from the SAR verbally to the DSS. The RD added the DSS handled most of the issues in the SAR. When asked how the RD knew her concerns had been resolved, the RD stated she addressed any concerns on the spot or reminded the DSS if she had sanitation concerns. On 5/18/23 at 1448 hours, an interview was conducted with the DSS. The DSS was asked how the RD communicated the findings from the monthly SAR. The DSS stated the RD emailed a copy of the SAR to him, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 44 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the RD verbally explained the SAR to the DSS, then the DSS would talk to his staff regarding the findings. The DSS acknowledged he did not have documented evidence to show when he had spoken to the kitchen staff regarding the RD's SAR. The DSS was asked if he performed an audit of the kitchen. The DSS stated he conducted a kitchen walk through but did not document the findings. The DSS was asked how he confirmed the kitchen staff completed the required cleaning or sanitation of the kitchen. The DSS stated the kitchen staff were assigned cleaning schedules. The DSS acknowledged that oftentimes, he did not have the opportunity to check the cleaning schedule being completed. The DSS added he was not involved with Quality Assurance and Performance Improvement for the Food and Nutrition Department. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD stated she was not involved with the kitchen cleaning schedules but expected the cleaning schedules to be completed and the kitchen was kept clean. Cross reference to F812. 2. The facility's recipes were not followed for the American and Vietnamese menu puree vegetable, puree meats, and puree dessert; and the Vietnamese puree starch were not followed. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all recipes must be followed to ensure the residents nutritional needs were met. The RD acknowledged adding unmeasured quantities of liquid to puree foods prior to blending the food, then adding an unmeasured quantity of stabilizer was not ideal. Cross reference to F803. 3. The kitchen staff were not competent in completing and implementation of the daily kitchen tasks, including prevention of cross contamination, proper hand hygiene, sanitization of food preparation equipment and food preparation surfaces, following recipes, knowledge of final cooking temperature for poultry, and manual dishwashing procedures. On 5/17/23 at 1454 hours, an interview was conducted with the RD regarding employee training. The RD stated she was available to do in-service training but the DSS handled in-service training of the kitchen employees. The RD stated if she saw something as a problem she would provide the in-service training on the spot, but it was a verbal without documentation. The RD stated she was not involved in assessing the kitchen employees' competency. The RD added she was not involved in assessing the DSS's competency either as they were coworkers. During an interview conducted with the DSS regarding the kitchen employees' competency and employees' in-service training on 5/18/23 at 1448 hours, the DSS stated he assessed his employees' competency with an annual competency evaluation that was based on knowledge and demonstration. Review of the facility documents titled Verification of Job Competency Demonstration for Cooks 1, 4, and Diet Aide 1 failed to show documentation from the DSS that these employees' competency had been verified. The DSS was asked regarding the kitchen employees in-service training, the DSS stated he tried to have a monthly in-service training. The DSS stated he decided on the topic/subject for the training based on findings he observed and mandatory for all the kitchen staff. The DSS was asked how he determined the employee's comprehension of the in-service, the DSS stated he provided a question and answer about the in-service topic. A request was made for in-service training related to the following topics: cross contamination, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 45 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sanitization of food preparation equipment and food preparation surfaces, following resident recipes, knowledge of final cooking temperature for poultry, and manual dishwashing procedures. However, the DSS was not able to provide any documented evidence for the above in-services training topics provided to the kitchen staff. During an interview conducted with the DSS on 5/19/23 at 0950 hours, the DSS was asked regarding the new employee training, the DSS confirmed DA 2 was newly hired on 3/31/23, and stated the new employees were trained for one to two weeks by the senior employees who did the same job, then the DSS allowed the new employee to work alone. The DSS stated DA 2's first day alone was on 5/18/23. The DSS was asked how did he ensure the new employee would be competent prior to working alone. The DSS stated there was a competency form that he filled out but had not completed the competency form for DA 2. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed any new employee should be deemed competent prior to working alone. The RD stated she would do a walk through with new employees but had not completed a walk through with DA 2 because she was too busy. Cross reference to F802. On 5/18/23 at 1034 hours, an interview was conducted with the Administrator. The Administrator was asked how he did ensure that his managers were competent in running their departments. The Administrator stated he is over all the department managers. The managers were evaluated annually. The DSS's last annual evaluation was completed by the previous Administrator. The Administrator stated he ensured the managers had dealt with compliance issues. The Administrator added the RD did a sanitation report and the DSS received a copy. The DSS attended quarterly corporate in-service training. The Administrator provided an email dated 5/18/23, from the Corporate [NAME] President of nutrition showing the DSS had attended all the training. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 46 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the kitchen staff were competent in the position related duties when: Residents Affected - Many 1. Two of four cooks (Cooks 1 and 4) failed to perform the following: a. Failed to prevent cross contamination, b. Failed to perform proper hand hygiene during food preparation, c. Failed to sanitize food preparation equipment when washed manually, d. Failed to sanitize food preparation surfaces, and e. Failed to follow the recipes. 2. One of four cooks (Cook 1) failed to know the final cooking temperature of chicken. 3. One of seven DA (DA 1) failed to know the manual dish washing procedure. 4. One of seven DA (DA 2) failed to follow the resident menu. These failures had the potential to cause food borne illness and not meet the resident's nutritional needs for the 115 residents who received food prepared in the kitchen. Findings: 1.a. Review of the facility's P&P titled Food Storage revised 4/6/23, showed in part, Dry Storage 7. Any opened products should be placed in seamless plastic or glass containers with tight-fitting lids and labeled and dated .8. Remove food stored in bins from their original packaging. Label and date all storage containers or bins. Keep free of scoops. Lids need to be tight fitting and in good condition .Clean and sanitize insides of food bins when product is changed out or is outdated. On 5/17/23 at 1026 hours, an observation of the puree meal preparation and concurrent interview was conducted with [NAME] 1 with the DSS as an interpreter . An unlabeled, undated white plastic container with a cracked red plastic lid was used to store instant mashed potatoes. A metal four-ounce measuring cup covered with old, dried instant mashed potatoes was observed stored inside the white plastic container. The white plastic container was almost empty. [NAME] 1 filled the white plastic container with instant mashed potatoes from a new instant mashed potato plastic container, put the scoop inside, and placed the red cracked lid on top. The DSS confirmed the scoop should not be stored inside the plastic container. On 5/18/23 at 0905 hours, an observation of the Vietnamese menu puree preparation and concurrent interview was conducted with [NAME] 4 and the DSS. [NAME] 4 obtained the white plastic container with a cracked red plastic lid containing the instant mashed potatoes. The DSS was asked if the original plastic food containers with a cracked lid was appropriate for storage, the DSS stated, No. The DSS asked [NAME] 4 to change the storage container for the instant mashed potatoes. [NAME] 4 obtained a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 47 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many clear plastic container, labeled and dated the container, then transferred the instant mashed potatoes into the container. Once the Vietnamese menu puree preparation was completed, [NAME] 4 stored the metal four-ounce measuring cup used for the instant mashed potatoes inside the clear plastic container containing the instant mashed potatoes. On 5/19/23 at 1014 hours, a telephone interview was conducted the RD. The RD confirmed the original plastic food containers should be discarded and not used for food storage. The scoops should not be stored inside the bins. Review of the facility's P&P titled Food Storage revised 4/6/23, showed in part, Raw Meat . 3. Wash and sanitize all the surfaces, equipment, and utensils that have come in contact with raw meats before using for any other food to prevent cross-contamination. Review of the facility's P&P titled Dish and Utensil Procedure revised 3/3/20, showed in part, under number 10, cutting boards need to be washed and sanitized between each use . Color-coded cutting boards are desirable designating boards for raw products versus cooked products. On 5/18/23 at 0821 hours, an observation of the Vietnamese menu lunch meal preparation and concurrent interview was conducted with [NAME] 4 and the DSS. [NAME] 4 prepared chicken curry for the Vietnamese menu lunch meal. Wearing gloves, [NAME] 4 cut raw chicken on a brown cutting board. The DSS confirmed a brown cutting board was to be used for cooked meats only. The DSS added [NAME] 4 should use a yellow cutting board which was for raw chicken. [NAME] 4 obtained a yellow cutting board and transferred the raw chicken to the yellow cutting board. [NAME] 4 completed cutting the raw chicken on the yellow cutting board. [NAME] 4 went to the refrigerator walk in, opened the door with the same gloved hands she touched the raw chicken with, and obtained a raw onion. [NAME] 4 placed the raw onion on the yellow cutting board and proceeded to cut the raw onion. The DSS stated [NAME] 4 should have used a green cutting board to cut the onion, which was designated for fruits and vegetables only. On 5/19/23 at 1014 hours, a telephone interview was conducted the RD. The RD confirmed using different colored cutting boards avoided the potential for cross contamination. The RD confirmed using the same cutting board for the raw chicken and raw vegetables posed the risk for cross contamination and could lead to food borne illness. The DSS was unable to provide in-service education training regarding cross contamination for the kitchen employees. Cross reference to F812, example #1. b. Review of the facility's P&P titled Personal Hygiene/Safety/Food Handling/Infection Control revised 11/30/22, showed in part, under number 2, Clean hands, fingernails, and Gloves b. Hands must always be washed after . handling any unsanitary items. Review of the facility's P&P titled Food Storage revised 4/6/23, showed in part, Raw Meat .2. Wash hands before and after handling raw meat to prevent the transmission of bacteria to food from the hands and from objects that have been touched by hands. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed appropriate hand washing and glove use. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 48 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 5/17/23 at 1020 hours, an observation was conducted of [NAME] 1 in the kitchen. [NAME] 1 put soiled dishes in the dish machine, then proceeded to put plastic wrap on the residents' food bowls without washing his hands. On 5/17/23 at 1037 hours, [NAME] 1 was observed to wash the soiled Robot Coupe (RC, a machine used to puree food) in the dish machine, placed prepared vegetables on the steam table, obtained a pen from his pocket and labeled the instant mashed potato container, then began to puree sweet potatoes without washing his hands. On 5/17/23 at 1200 hours, [NAME] 1 was observed to touch his cell phone from his pocket then proceeded to prepare the resident food for lunch tray line without washing his hands. On 5/18/23 at 0821 hours during the Vietnamese food preparation, an observation of [NAME] 4 was conducted. [NAME] 4 obtained spices from the storage without wearing gloves. [NAME] 4 donned gloves without washing her hands, then proceeded to touch multiple unclean surfaces: the water faucet handle, counter, knife handle, then [NAME] 4 touched raw chicken. [NAME] 4 opened the walk-in door using the same gloved hands she touched the raw chicken, then proceeded to touch a raw onion without changing gloves or washing her hands. On 5/18/23 at 0830 hours, an observation was conducted of [NAME] 4. [NAME] 4 changed her gloves to puree the resident food but failed to wash her hands between glove change. On 5/18/23 at 0844 hours, an observation of [NAME] 4 was continued . [NAME] 4 changed her gloves prior to cutting raw chicken for mechanically altered diets but failed to wash her hands between glove change. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD was asked when hand washing was necessary. The RD stated hand washing was necessary to prevent cross contamination between dirty and clean tasks and between glove changes. Review of the facility's document titled Lesson Plan: Infection Prevention dated 7/25/22, showed [NAME] 1 was in attendance, but [NAME] 4 was not in attendance. Cross reference to F812, example #3. c. Review of the facility's P&P titled Pots and Pans- Sanitizing Solution revised 8/31/18 showed in part, .2. Fill all tanks 2/3 full. a. Fill first tank with water and an effective concentration of detergent. b. Fill second tank with clean rinse water. c. Fill third tank with tepid water for sanitizing to fill line. If third sink is not available or is not used, pots and pans are run through the dish machine to sanitize as an alternate method. 3. Add sanitizing agent to third tank according to EPA-registered label use directions. a .200 ppm or 150-400 ppm (depending on which kind you use) is the required concentration of sanitizer-to-water ratio using a quaternary ammonia-base sanitizer .5. Scrub pots and pans in first tank using a scouring pad or appropriate cleaning tool, 6. Rinse pots and pans free of detergent in second tank. 7. Sanitize pots and pans in third tank by immersing in water with sanitizing agent for at least two minutes or per manufacturer guidelines. On 5/18/23 at 0841 hours, an observation of [NAME] 1 was conducted in the kitchen. [NAME] 1 manually washed the steam table pans by scrubbing the pans with water, then rinsed the pans off with water. The DSS confirmed all the items washed manually should be washed and sanitized. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 49 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 5/18/23 at 0902 hours, an observation of [NAME] 4 was conducted in the kitchen. [NAME] 4 manually washed the Robot Coupe (RC). [NAME] 4 sprayed soap on the RC through the soap dispenser, scrubbed the top and bottom of the RC, rinsed the RC with water, then placed the RC to drain at the side of sink. On 5/18/23 at 0921 hours, an interview was conducted with the DSS. The DSS confirmed all pots and pans should be sanitized in the dish machine or the three-sink method could be utilized to wash, rinse, and sanitize the pots and pans. The DSS further stated the cook was in a rush to wash the RC, therefore, the cook did not sanitize the RC in the dish machine and should have given the RC to the dishwasher to sanitize it. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD stated she believed the pots and pans were washed and sanitized in the dish machine. The RD added all the food preparation equipment and utensils must be sanitized. The DSS was unable to provide documentation of in-service education training regarding manual dish washing for the kitchen employees. Cross reference to F812, example #4. d. Review of the facility's P&P titled Sanitizer Use Concentrations for Food Services and Food Production Facilities revised 4/30/20 showed in part, c. A quaternary ammonium compound solution shall have a minimum temperature and contact time based on the concentration as listed in the following chart: Concentration Range: 200 ppm (part per million) or 150-400 ppm .3. All surfaces and equipment should be washed with a sanitizing solution. On 5/18/23 at 0844 hours, an observation of [NAME] 4 in the kitchen was conducted. [NAME] 4 was preparing the chicken curry for the lunch meal. [NAME] 4 picked up a large, soiled spoon from the food preparation counter. [NAME] 4 wiped the food preparation counter with a paper towel then continued food preparation activities for the lunch meal. On 5/18/23 at 0905 hours, an observation of [NAME] 1 in the kitchen was conducted. [NAME] 1 obtained a cleaning cloth from the sanitation bucket. [NAME] 1 rinsed and wrung the cleaning cloth out three times with water in the food preparation sink. [NAME] 1 proceeded to wipe the stove top with the cleaning cloth. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed that all kitchen surfaces should be cleaned with a cleaning cloth stored in the sanitizing solution. The RD confirmed cleaning the food production surfaces with a paper towel or cleaning cloth that had been rinsed out with water was not appropriate. The DSS was unable to provide documentation of in-service education training regarding sanitation of food production surfaces for the kitchen employees. Cross reference to F812, example #5. e. Review of the facility's document titled Recipe: Pureed Vegetables, undated, showed six, 12, 24, and 48 serving options. For 24 servings, use 24 servings of regular vegetables. Warm fluid such as milk, or low sodium broth ½ cup to 1 ½ cups. If needed: Stabilizer: instant potatoes ¾ cup to 1 ½ cup. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 50 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0802 Directions: Level of Harm - Minimal harm or potential for actual harm 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a paste consistency before adding any liquid. Residents Affected - Many 3. Gradually add warm liquid (low sodium broth or milk) if needed. See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. 4. Puree on low speed, adding stabilizer where needed. See above for amounts. Review of the facility's document titled Daily Spreadsheet dated 5/17/23, showed the spring blend vegetables serving size was four ounces. On 5/17/23 at 1026 hours, an observation of the spring blend vegetable puree preparation for the American lunch menu and concurrent interview was conducted with [NAME] 1 with the DSS as a translator. [NAME] 1 stated he was preparing 20 puree portions. Using a four-ounce scoop, [NAME] 1 placed ten scoops of vegetables that included water the vegetables were cooked in, into the Robot Coupe (RC, an equipment used to puree foods). [NAME] 1 stated he wanted honey consistency for the pureed vegetables. [NAME] 1 then added an unmeasured quantity of instant mashed potatoes to the RC and blended the mixture. [NAME] 1 added an unmeasured quantity of instant mashed potatoes to the RC, a total of four additional times; and blended the mixture after adding each quantity of instant mashed potatoes. [NAME] 1 was asked if he added a certain amount of instant mashed potatoes to the vegetables. [NAME] 1 stated it depended on the type of vegetable. The DSS confirmed a consistency of mashed potatoes was the goal for pureed foods. No recipe was referred to during the vegetable puree preparation for the American lunch menu. Review of the facility's document titled Garlic [NAME] Beans undated showed the portion size was four ounces. On 5/18/23 at 0905 hours, an observation of the vegetable puree preparation for the Vietnamese lunch menu and concurrent interview was conducted with [NAME] 4. It was noted [NAME] 4 prepared green peas rather than garlic green beans. [NAME] 4 stated she substituted green peas for green beans for lunch today. [NAME] 4 stated she was preparing about 18 puree servings. [NAME] 4 stated she used 2.5 pounds (equivalent to 10 four-ounce servings) of frozen peas cooked in water. [NAME] 4 placed an unmeasured quantity of the pea and water mixture into the RC and added one-four ounce of instant mashed potatoes. The mixture was blended. [NAME] 4 added another unmeasured quantity of the pea and water mixture to the RC. The pea and water mixture was blended again. The final product had a liquid consistency. [NAME] 4 stated the mixture would thicken over time and placed the pureed peas on top of the steam table. No recipe was referred to during the vegetable puree preparation for the Vietnamese lunch menu. Review of the facility's document titled Recipe: Puree Meats dated 4/17, showed six, 12, 24, and 48 serving options. For six servings, use six serving of regular meat recipe, warm fluid such as gravy, or low sodium broth. If the meat is moist, you can start with only a few ounces of liquid. These amounts are only an average and may vary, ¾ to 1 ½ cups of liquid. Stabilizer: instant potato 0-6 Tablespoons. Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 51 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Gradually add warm liquid (low sodium broth or gravy). See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. 4. Puree should reach a consistency slightly softer than whipped topping. May add more liquid if needed to reach this consistency. 5. Add stabilizer to increase the density of the pureed food if needed. On 5/17/23 at 1133 hours, an observation of the puree meat preparation for the American lunch menu and concurrent interview was conducted with [NAME] 1. [NAME] 1 stated he was preparing five puree meat portions, three ounces each. Using the three-ounce scoop, [NAME] 1 measured five meat portions into the RC. [NAME] 1 then added an unmeasured quantity of chicken broth to the RC. The meat and broth mixture was blended. After blending, the meat and broth mixture had a liquid consistency. [NAME] 1 then added an unmeasured quantity of instant mashed potatoes to the RC and blended the mixture. The meat and broth mixture was too thick so [NAME] 1 added an additional three 3-ounce scoops of chicken broth to the RC to achieve mashed potato consistency. Review of the facility's document titled Chicken Curry and Sweet Potatoes undated showed Ingredients: for 50 servings included 6 2/3 pounds of boneless, skinless chicken thigh meat, fresh yellow onion, fresh garlic clove peeled, fresh ginger root, fresh herb lemon grass, fresh carrots, fresh sweet potato, fresh red chili pepper paste, Thai curry paste, light brown sugar, coconut milk, fish sauce, hot water, and chicken soup base. Review of the facility's document titled Recipe: Puree Meats dated 4/17 showed six, 12, 24, and 48 serving options. For 24 servings, use 24 serving of regular meat recipe, warm fluid such as gravy, or low sodium broth. If the meat is moist, you can start with only a few ounces of liquid. These amounts are only an average and may vary, three cups to 1 ½ quarts of liquid. Stabilizer: instant potato ¾- 1 ½ cups. Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or gravy). See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. 4. Puree should reach a consistency slightly softer than whipped topping. May add more liquid if needed to reach this consistency. 5. Add stabilizer to increase the density of the pureed food if needed. On 5/18/23 at 0821 hours, an observation of the puree meat preparation for the Vietnamese lunch menu and concurrent interview was conducted with [NAME] 4. [NAME] 4 stated she was preparing about 18 servings of chicken curry for the puree diet. After cutting an unmeasured quantity of raw chicken and onion, [NAME] 4 added the chicken, onion and unmeasured quantities directly from the packages of curry powder, turmeric powder, and white mushroom seasoning salt to a cooking pot. [NAME] 4 then added unmeasured quantities of coconut milk and water to the chicken mixture and boiled it on the stove. No recipe was referred to during the preparation of the chicken curry. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 52 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 5/18/23 at 0925 hours, [NAME] 4 poured the chicken mixture from the pot into the RC and blended the mixture. Review of the facility's document titled Recipe: Puree Breads, Cakes, Cookies, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and Other Bread Products dated 3/17 showed for 24 servings to add warm milk or cold milk three cups to 1 ½ quarts, thickener ¾- 1 ½ cups. Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed adding milk gradually. See above for recommended amounts of milk, starting with the smaller amount and adding in more as needed to achieve desired consistency. 3. Puree should reach a consistency of applesauce. 4. Add stabilizer to increase density of the pureed food if needed. Review of the facility's document titled Daily Spreadsheet dated 5/17/23, showed puree diets received a #10 scoop of pureed strawberry shortcake. On 5/17/23 at 1054 hours, an observation of the puree strawberry shortcake preparation for the lunch meal was conducted with [NAME] 1. [NAME] 1 stated he was preparing 20 portions of puree cake. [NAME] 1 added 12 pieces of strawberry shortcake to the RC. [NAME] 1 then poured an unmeasured quantity of milk directly from the milk carton into the RC. The cake and milk mixture was blended. [NAME] 1 added four more pieces of strawberry shortcake and added an unmeasured quantity of milk directly from the milk carton to the RC, blended the mixture again. [NAME] 1 added two more pieces (total of 18 pieces) of strawberry shortcake to the RC and blended the mixture. [NAME] 1 added a #16 scoop (two ounces) of thickener to the RC and blended the mixture. The puree cake was placed in a pan. No recipes were referred to during the strawberry shortcake puree preparation. Review of the facility's document titled pureed starch undated showed six, 12, 24, and 48 serving options. For 24 servings, prepare 24 starch servings, warm milk 3 cups to 1 ½ quarts, if needed: stabilizer instant potato ¾ - 1 ½ cups. Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm milk. See above for recommended amounts of liquids, starting with the smaller amount and adding in more as needed to achieve consistency. If starch is already moist after being pureed, you may not need much added milk. 4. Puree should reach a consistency slight softer than whipped topping. May add more liquid if needed to reach this consistency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 53 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0802 5. Add stabilizer to increase the density of the pureed food if needed. Level of Harm - Minimal harm or potential for actual harm On 5/18/23 at 0830 hours, an observation of the puree rice preparation for the Vietnamese lunch menu was conducted with [NAME] 4 and the DSS present. [NAME] 4 stated she was pureeing about 18 servings. When asked how she measured the 18 servings she stated she used the scoop located in the rice bin. [NAME] 4 asked the DSS how big the scoop was that was stored in the rice bin. The DSS replied it was a large scoop. [NAME] 4 added an unmeasured quantity of cooked rice to the RC followed by an unmeasured quantity of water. The mixture was blended. When asked how much water she added, [NAME] 4 stated she just watched the mixture and added more water as needed. [NAME] 4 then added more unmeasured quantity of water to the rice mixture and blended the mixture. [NAME] 4 stated the product was too runny and added an unmeasured quantity of instant mashed potatoes. No recipe was referred to during the puree rice preparation. Residents Affected - Many On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all recipes must be followed to ensure the residents' nutritional needs are met. The RD acknowledged adding unmeasured quantities of liquid to the puree foods prior to blending the food then adding an unmeasured quantity of stabilizer is not ideal. The DSS was unable to provide documentation of in-service education training regarding following resident menus for the kitchen employees. Cross reference to F803, examples #1, #2, #3, and #4. 2. Review of the professional reference FoodSafety.gov titled Safe Minimum Cooking Temperatures Charts revised 4/12/19, showed the minimum internal temperature for poultry should be 165 degrees Fahrenheit (F). An interview was conducted with [NAME] 1 with the DSS as a translator on 5/17/23 at 1138 hours, in the kitchen. [NAME] 1 was asked if he took the final cooking temperatures of meats. [NAME] 1 stated he did take the final cooking temperatures of meats but did not record the temperatures. During the lunch meal tray line observation and concurrent interview with [NAME] 1 using the DSS as an interpreter, on 5/17/23 at 1203 hours, [NAME] 1 took the tray line temperature of the BBQ chicken. The temperature of the BBQ chicken was 140 degrees F using the surveyor's thermometer. [NAME] 1 was asked if 140 degrees F was ok for chicken. [NAME] 1 did not answer. [NAME] 1 was then asked what the final cooking temperature of chicken should be. [NAME] 1 stated 135-140 degrees F. The DSS agreed that the final cooking temperature of chicken should be 135-140 degrees F. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed the facility took final cooking temperatures of meats but did not record the final cooking temperatures. The RD acknowledged the cooks should know the appropriate final cooking temperatures of meats. The DSS was unable to provide documentation of in-service education training regarding appropriate final cooking temperatures of food for the kitchen employees. 3. Review of the facility's P&P titled Pots and Pans- Sanitizing Solution revised 8/31/18 showed in part, .2. Fill all tanks 2/3 full. a. Fill first tank with water and an effective concentration of detergent. b. Fill second tank with clean rinse water. c. Fill third tank with tepid water for sanitizing to fill line. If third sink is not available or is not used, pots and pans are run through the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 54 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many dish machine to sanitize as an alternate method. 3. Add sanitizing agent to third tank according to EPA-registered label use directions. a .200 ppm or 150-400 ppm (depending on which kind you use) is the required concentration of sanitizer-to-water ratio using a quaternary ammonia-base sanitizer .5. Scrub pots and pans in first tank using a scouring pad or appropriate cleaning tool, 6. Rinse pots and pans free of detergent in second tank. 7. Sanitize pots and pans in third tank by immersing in water with sanitizing agent for at least two minutes or per manufacturer guidelines. On 5/18/23 at 0817 hours, an interview was conducted with Diet Aide (DA) 1 regarding the manual dishwashing procedure with the DSS present. DA 1 stated the pots and pans were washed manually with hot water and soap, then sanitized and air dried. The DA stated manual dishwashing was a two step process. The DSS confirmed DA forgot to state the pots and pans were rinsed before being sanitized. The DSS was unable to provide documentation of in-service education training regarding manual dishwashing for the kitchen employees. 4. Review of the facility's document titled Recipe: Puree Breads, Cakes, Cookies, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and Other Bread Products dated 3/17 showed, for 24 servings to add warm milk or cold milk three ups to 1 ½ quarts, thickener ¾- 1 ½ cups. Directions: 1. Complete regular recipe. Measure out the number of portions needed for puree diets. 2. Puree on low speed adding milk gradually. See above for recommended amounts of milk, starting with the smaller amount and adding in more as needed to achieve desired consistency. 3. Puree should reach a consistency of applesauce. 4. Add stabilizer to increase density of the pureed food if needed. Review of the facility's document titled Daily Spreadsheet dated 5/17/23 showed the puree diets received a #10 scoop of pureed strawberry shortcake. On 5/17/23 at 1059 hours, an observation of the portioning of the puree cake for all puree diets was conducted with DA 2. DA 2 stated he was preparing 23 portions of the puree cake. DA 2 stated he used a #12 scoop to serve the puree strawberry shortcake. When finished, DA 2 had portioned out 28 servings of puree strawberry shortcake. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all portion sizes must be followed to ensure resident nutritional needs are met. The DSS was unable to provide documentation of in-service education training regarding following the resident menu for the kitchen employees. Cross reference to F803, example #3. An interview regarding kitchen employee competency was conducted with the DSS on 5/18/23 at 1448 hours. The DSS stated he assessed his employees' competency with an annual competency evaluation that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 55 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0802 was based on knowledge and demonstration. Level of Harm - Minimal harm or potential for actual harm Review of the facility's document titled Employee Performance Appraisal signed by DA 1 on 5/3/23, showed DA 1's knowledge and quality of work was good. Residents Affected - Many Review of the facility's document titled Verification of Job Competency Demonstration - Diet Aides for DA 1 dated 2022 showed DA 1's initials for emergency dish washing procedure and when to use it. The column titled Verified by was blank. There was no documentation from the DSS showing DA 1 was competent in emergency dish washing procedures. Review of the facility's document titled Employee Performance Appraisal signed by [NAME] 1 on 5/11/22 showed [NAME] 1's knowledge and quality of work was excellent. Review of the facility's document titled Verification of Job Competency Demonstration - Cooks for [NAME] 1 dated 2022 showed [NAME] 1's initials for use of recipes, glove use and food preparation, hand washing procedure, how to clean and sanitize equipment, counter tops and food storage procedures for dry storage. The column titled Verified by was blank. There was no documentation from the DSS showing [NAME] 1 was competent in use of recipes, glove use and food preparation, hand washing procedure, how to clean and sanitize equipment counter tops and food storage procedures for dry storage. Review of the facility's document titled Employee Performance Appraisal signed by [NAME] 4 on 3/23/23, showed [NAME] 4's knowledge and quality of work was excellent. Review of the facility's document titled Verification of Job Competency Demonstration - Cooks for [NAME] 4 dated 2022 showed [NAME] 4's initials for use of recipes, cutting board use, glove use in food preparation, hand washing procedure, how to clean and sanitize equipment, counter tops, food storage procedures for dry storage. The column titled Verified by was blank. There was no documentation from the DSS showing [NAME] 4 was competent in the use of recipes; cutting board use; glove use in food preparation; hand washing procedure; how to clean and sanitize equipment and counter tops; and food storage procedures for dry storage. An interview regarding new employee training was conducted with the DSS on 5/19/23 at 0950 hours. The DSS confirmed DA 2 was newly hired on 3/31/23. The DSS was asked how the new employees were trained. The DSS stated the new employees were trained by other employees who did the same job for 1-2 weeks then he let the new employee work alone. The DSS stated DA 2's first day alone was on 5/18/23. The DSS was asked how he ensured the new employee were competent prior to working alone. The DSS stated there was a competency form that he filled out but had not completed the competency form for DA 2. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed any new employee should be deemed competent prior to working alone. The RD stated she did a walk through with new employees but had not completed a walk through with DA 2 because she was too busy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 56 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, facility document and P&P review, the facility failed to ensure the resident menu was followed as evidenced by: Residents Affected - Some 1. Puree vegetable recipes were not followed for the American and Vietnamese menus. 2. Puree meat recipes were not followed for the American and Vietnamese menus. 3. Puree cake recipe was not followed for all menus. 4. Puree rice recipe was not followed for the Vietnamese menu. These failures posed the risk for an inconsistent product and to not meet the nutritional needs of the 23 residents who received puree diets. Findings: Review of the facility's P&P titled Cycle Menus revised 9/14/18, menus must be followed as written. Review of the facility's Diet Count by Diet dated 5/17/23, showed there were 23 regular pureed servings. However, the Diet Count sheet did not distinguish between American and Vietnamese menus. Review of the facility's Diet Count by Diet dated 5/18/23, showed there were 24 regular pureed servings. However, the Diet Count sheet did not distinguish between American and Vietnamese menus. 1. Review of the facility's Recipe: Pureed Vegetables (undated) showed options for six, 12, 24, and 48 servings. For 24 servings, use 24 servings of regular vegetables. Warm fluid such as milk, or low sodium broth ½ cup to 1 ½ cups. If needed: stabilizer: instant potatoes ¾ cup to 1 ½ cup. The directions are as follows: - Complete regular recipe. - Measure out the number of portions needed for puree diets. - Puree on low speed to a paste consistency before adding any liquid. - Gradually add warm liquid (low sodium broth or milk) if needed. - See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. - Puree on low speed, adding stabilizer where needed. See above for amounts. a. Review of the facility's Daily Spreadsheet dated 5/17/23, showed spring blend vegetables serving size was four ounces. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 57 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 5/17/23 at 1026 hours, an observation of the vegetable puree preparation for the American lunch menu and concurrent interview was conducted with [NAME] 1 with the DSS as a translator. [NAME] 1 stated he was preparing 20 puree portions. Using a four-ounce scoop, [NAME] 1 placed ten scoops of vegetables that included water the vegetables were cooked in, into the RC. [NAME] 1 stated he wanted honey consistency for the pureed vegetables. [NAME] 1 then, added an unmeasured quantity of instant mashed potatoes to the RC and blended the mixture. [NAME] 1 added an unmeasured quantity of instant mashed potatoes to the RC with a total of four additional times; and blended the mixture after adding each quantity of instant mashed potatoes. [NAME] 1 was asked if he added a certain amount of instant mashed potatoes to the vegetables. [NAME] 1 stated it depended on the type of vegetable. The DSS confirmed a consistency of mashed potatoes was the goal for pureed foods. [NAME] 1 did not refer to any recipe during the vegetable puree preparation for the American lunch menu. b. Review of the facility document titled Garlic [NAME] Beans (undated) showed the portion size was four ounces. On 5/18/23 at 0905 hours, an observation of the vegetable puree preparation for the Vietnamese lunch menu and concurrent interview was conducted with [NAME] 4. It was noted [NAME] 4 prepared green peas instead of garlic green beans. [NAME] 4 stated she substituted green peas for green beans for lunch today. [NAME] 4 stated she was preparing about 18 puree servings. [NAME] 4 stated she used 2.5 pounds (equivalent to 10 four-ounce servings) of frozen peas cooked in water. [NAME] 4 stated she substituted peas for green beans for lunch today. [NAME] 4 placed an unmeasured quantity of the peas and water mixture into the RC and added one four-ounce cup of instant mashed potatoes. The mixture was blended. [NAME] 4 added another unmeasured quantity of the pea and water mixture to the RC. The peas and water mixture was blended again. The final product had a liquid consistency. [NAME] 4 stated the mixture would thicken over time and placed the pureed peas on top of the steam table. [NAME] 4 did not refer to any recipe during the vegetable puree preparation for the Vietnamese lunch menu. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all recipes must be followed to ensure the residents' nutritional needs were met. The RD acknowledged adding unmeasured quantities of liquid to puree foods prior to blending the food, then adding an unmeasured quantity of stabilizer was not ideal. 2.a. Review of the facility's Recipe: Puree Meats dated 4/1, showed options for six, 12, 24 and 48 servings. For six servings, use six serving of regular meat recipe, warm fluid such as gravy, or low sodium broth. If the meat is moist, you can start with only a few ounces of liquid. These amounts are only an average and may vary, ¾ to 1 ½ cups of liquid. Stabilizer: instant potato 0-6 Tablespoons. The directions are as follows: - Complete regular recipe. - Measure out the number of portions needed for puree diets. - Puree on low speed to a paste consistency before adding any liquid. - Gradually add warm liquid (low sodium broth or gravy). See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 58 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some - Puree should reach a consistency slightly softer than whipped topping. May add more liquid if needed to reach this consistency. - Add stabilizer to increase the density of the pureed food if needed. On 5/17/23 at 1133 hours, an observation of the puree meat preparation for the American lunch menu and concurrent interview was conducted with [NAME] 1. [NAME] 1 stated he was preparing five puree meat portions, three ounces each. Using the three-ounce scoop, [NAME] 1 measured five meat portions into the RC. [NAME] 1 then added an unmeasured quantity of chicken broth to the RC. The meat and broth mixture was blended. After blending, the meat and broth mixture had a liquid consistency. [NAME] 1 then added an unmeasured quantity of instant mashed potatoes to the RC and blended the mixture. The meat and broth mixture was too thick so [NAME] 1 added an additional three 3-ounce scoops of chicken broth to the RC to achieve mashed potato consistency. b. Review of the facility document titled Chicken Curry and Sweet Potatoes (undated) showed ingredients for 50 servings included 6 2/3 pounds of boneless, skinless chicken thigh meat, fresh yellow onion, fresh garlic clove peeled, fresh ginger root, fresh herb lemon grass, fresh carrots, fresh sweet potato, fresh red chili pepper paste, Thai curry paste, light brown sugar, coconut milk, fish sauce, hot water, and chicken soup base. Review of the facility's Recipe: Puree Meats dated 4/17 showed options for six, 12, 24 and 48 serving options. For 24 servings, use 24 servings of regular meat recipe, warm fluid such as gravy, or low sodium broth. If the meat is moist, you can start with only a few ounces of liquid. These amounts are only an average and may vary, three cups to 1 ½ quarts of liquid. Stabilizer: instant potato ¾- 1 ½ cups. The directions are as follows: - Complete regular recipe. - Measure out the number of portions needed for puree diets. - Puree on low speed to a paste consistency before adding any liquid. - Gradually add warm liquid (low sodium broth or gravy). See above for recommended amounts of liquid, starting with the smaller amount and adding in more as needed to achieve the desired consistency. - Puree should reach a consistency slightly softer than whipped topping. May add more liquid if needed to reach this consistency. - Add stabilizer to increase the density of the pureed food if needed. On 5/18/23 at 0821 hours, an observation of the puree meat preparation for the Vietnamese lunch menu and concurrent interview was conducted with [NAME] 4. [NAME] 4 stated she was preparing about 18 servings of chicken curry for the puree diet. After cutting an unmeasured quantity of raw chicken and onion, [NAME] 4 added the chicken, onion and unmeasured quantities, packages of curry powder, turmeric powder and white mushroom seasoning salt directly to a cooking pot. [NAME] 4 then, added unmeasured quantities of coconut milk and water to the chicken mixture; and boiled it on the stove. [NAME] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 59 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0803 4 did not refer to any recipe during the preparation of the chicken curry. Level of Harm - Minimal harm or potential for actual harm On 5/18/23 at 0925 hours, [NAME] 4 poured the chicken mixture from the pot into the RC and blended the mixture. Residents Affected - Some On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all recipes must be followed to ensure the residents' nutritional needs were met. The RD acknowledged adding unmeasured quantities of liquid to puree foods prior to blending the food then adding an unmeasured quantity of stabilizer was not ideal. 3. Review of the facility's Recipe: Puree Breads, Cakes, Cookies, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas, Sandwiches and Other Bread Products dated 3/17, showed for 24 servings, add warm milk or cold milk three cups to 1 ½ quarts, thickener ¾- 1 ½ cups. The directions are as follows: - Complete regular recipe. - Measure out the number of portions needed for puree diets. - Puree on low speed adding milk gradually. See above for recommended amounts of milk, starting with the smaller amount and adding in more as needed to achieve desired consistency. - Puree should reach a consistency of applesauce. - Add stabilizer to increase density of the pureed food if needed. Review of the facility's Daily Spreadsheet dated 5/17/23, showed the residents on puree diet will be served a #10 scoop (3 to 4 ounces) of pureed strawberry shortcake. On 5/17/23 at 1054 hours, an observation of the puree strawberry shortcake preparation for the lunch meal was conducted with [NAME] 1. [NAME] 1 stated he was preparing 20 portions of puree cake. [NAME] 1 added 12 pieces of strawberry shortcake to the RC. [NAME] 1 then poured an unmeasured quantity of milk directly from the milk carton into the RC. The cake and milk mixture was blended. [NAME] 1 added four more pieces of strawberry shortcake and added an unmeasured quantity of milk directly from the milk carton to the RC, blended the mixture again. [NAME] 1 added two more pieces (total of 18 pieces) of strawberry shortcake to the RC and blended the mixture. [NAME] 1 added a #16 scoop (two ounces) of thickener to the RC and blended the mixture. The pureed cake was placed in a pan. [NAME] 1 did not refer to any recipe during the strawberry shortcake puree preparation. On 5/17/23 at 1059 hours, an observation of the portioning of the puree cake for all puree diets was conducted with DA 2. DA 2 stated he was preparing 23 portions of puree cake. DA 2 stated he used a #12 scoop (2 1/2 to 3 ounces) to serve the puree strawberry shortcake. When finished, DA 2 had portioned out 28 servings of puree strawberry shortcake. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all recipes must be followed to ensure resident nutritional needs are met. The RD acknowledged adding unmeasured quantities of liquid to puree foods prior to blending the food then adding an unmeasured quantity of stabilizer was not ideal. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 60 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0803 Level of Harm - Minimal harm or potential for actual harm 4. Review of the facility document titled pureed starch (undated) showed options for six, 12, 24, and 48 servings. For 24 servings, prepare 24 starch servings, warm milk 3 cups to 1 ½ quarts, if needed: stabilizer instant potato ¾ - 1 ½ cups. The directions are as follows: Residents Affected - Some - Complete regular recipe. - Measure out the number of portions needed for puree diets. - Puree on low speed to a paste consistency before adding any liquid. - Gradually add warm milk. See above for recommended amounts of liquids, starting with the smaller amount and adding in more as needed to achieve consistency. If starch is already moist after being pureed, you may not need much added milk. - Puree should reach a consistency slight softer than whipped topping. May add more liquid if needed to reach this consistency. - Add stabilizer to increase the density of the pureed food if needed. On 5/18/23 at 0830 hours an observation of the puree rice preparation for the Vietnamese lunch menu was conducted with [NAME] 4 with the DSS present. [NAME] 4 stated she was pureeing about 18 servings. When asked how she measured the 18 servings she stated she used the scoop located in the rice bin. [NAME] 4 asked the DSS how big the scoop was that was stored in the rice bin. The DSS replied it was a large scoop. [NAME] 4 added an unmeasured quantity of cooked rice to the RC followed by an unmeasured quantity of water. The mixture was blended. When asked how much water she added, [NAME] 4 stated she just watched the mixture and added more water as needed. [NAME] 4 then added more unmeasured quantity of water to the rice mixture and blended the mixture. [NAME] 4 stated the product was too runny and added an unmeasured quantity of instant mashed potatoes. [NAME] 4 did not refer to any recipe during the puree rice preparation. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all recipes must be followed to ensure resident nutritional needs are met. The RD acknowledged adding unmeasured quantities of liquid to puree foods prior to blending the food then adding an unmeasured quantity of stabilizer was not ideal. Review of the facility document titled Sanitation Audit Report (SAR) completed by the RD on 2/10 and 4/28/23 showed the recipes were available and being followed. However, the SAR completed by the RD on 3/30/23, showed inappropriate textures were served. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 61 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure one of 24 final sampled residents (Resident 51) was provided with food prepared in a form to meet the resident's individual need. * The facility failed to ensure Resident 51 was provided with pureed dessert as per the resident's diet order. This failure posed the risk for Resident 51 to develop complications like aspiration (accidental breathing in food or fluid into the lungs) and choking. Findings: Medical record review for Resident 51 was initiated on 5/16/23. Resident 51 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 51's MDS assessment dated [DATE], showed Resident 51 was edentulous (lacking teeth). Review of Resident 51's H&P examination dated 2/23/23, showed Resident 51 had diagnoses of Parkinson's disease, dementia, and dysphagia. Review of Resident 51's Order Summary Report as of 5/18/23, showed a physician's order dated 4/27/23, to provide a regular pureed texture diet. Review of the facility's Daily Spreadsheet for lunch on 5/16/23, showed to serve citrus streusel bar for dessert. The Daily Spreadsheet for lunch on 5/16/23, showed a pureed citrus streusel bar will be provided for the residents on puree diet. On 5/16/23 at 1218 hours, a dining observation was conducted in Resident 51's room. Resident 51 was served with pureed food. However, a slice of citrus streusel was observed on Resident 51's meal tray. On 5/16/23 at 1224 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 verified Resident 51 was on a puree diet and should not be served with a slice of citrus streusel. Review of Resident 51's Meal Ticket for lunch on 5/16/23, showed Resident 51 was on a regular pureed diet. On 5/17/23 at 1539 hours, an interview with LVN 5 was conducted. When asked what type of dessert that the residents on puree diet should have, LVN 5 stated it should be baby food, apple sauce, pudding or yogurt consistency or ice cream. LVN 5 acknowledged Resident 51 was not provided with the appropriate dessert based on her diet order during the lunch meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 62 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, facility document review, and P&P review, the facility failed to ensure the professional standards for food safety and sanitation guidelines were followed when: Residents Affected - Many 1. Potential for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) was not prevented. A scoop was stored in the instant mash potato container and the kitchen staff did not use proper color coded cutting board when cutting raw chicken and vegetable. 2. Time Temperature Control for Safety (TCS) Foods (food that require time and temperature controls to limit the growth of illness causing bacteria) were not handled safely as no cooling down log for the leftover chicken and turkey cooked on the previous day. 3. Proper hand hygiene was not performed by the kitchen staff. 4. Food preparation equipment was not sanitized when washed manually. 5. Kitchen surfaces were not sanitized. 6. Refrigerated and frozen foods were not stored safely. 7. Hair restraints were not worn appropriately by the kitchen staff. 8. Food preparation equipment and ice machine were not clean. 9. Non-food contact surfaces in the kitchen were not clean. 10. A rolling ice chest with soiled wheels was stored on a food preparation table. 11. Employee food was not stored appropriately. These failures had the potential to cause food borne illnesses in a medically vulnerable population of 115 residents who received food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 5/16/23, showed 115 of 115 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Storage revised 4/6/23, showed in part, Dry Storage 7. Any opened products should be placed in seamless plastic or glass containers with tight-fitting lids and labeled and dated .8. Remove food stored in bins from their original packaging. Label and date all storage containers or bins. Keep free of scoops. Lids need to be tight fitting and in good condition .Clean and sanitize insides of food bins when product is changed out or is outdated. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed no concerns with the scoops stored inside the bulk storage. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 63 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many a. On 5/17/23 at 1026 hours, an observation of the puree meal preparation and concurrent interview was conducted with [NAME] 1 with the DSS as an interpreter . An unlabeled, undated white plastic container with a cracked red plastic lid was used to store instant mashed potatoes. A metal four-ounce measuring cup covered with dried instant mashed potatoes was observed stored inside the white plastic container. The white plastic container was almost empty. [NAME] 1 filled the white plastic container with instant mashed potatoes from a new instant mashed potato plastic container, put the four-ounce measuring scoop inside covered with dried instant mashed potatoes inside and placed the red cracked lid on top. The DSS confirmed the scoop should not be store inside the plastic container. The four-ounce measuring scoop covered with dried instant mashed potatoes was placed on top of the white plastic container. On 5/18/23 at 0905 hours, an observation of the Vietnamese menu puree preparation and concurrent interview was conducted with [NAME] 4 and the DSS. [NAME] 4 obtained the white plastic container with a cracked red plastic lid containing the instant mashed potatoes. The DSS was asked if original plastic food containers with a cracked lid was appropriate for storage, the DSS stated, No. The DSS asked [NAME] 4 to change the storage container for the instant mashed potatoes. [NAME] 4 obtained a clear plastic container, labeled and dated the container, then transferred the instant mashed potatoes into the container. Once the Vietnamese menu puree preparation was completed, [NAME] 4 stored the metal four-ounce measuring cup covered in dried instant mashed potatoes used inside the clear plastic container which contained instant mashed potatoes. On 5/19/23 at 1014 hours, a telephone interview was conducted the RD. The RD confirmed the original plastic food containers should be discarded and not used for food storage. Scoops should be clean and not be stored inside bins. b. According to the USDA Food Code 2022 Annex 4. Management of Food Safety Practices - Achieving Active Managerial Control of Foodborne Illness Risk Factors, F. Facility-wide Considerations: In order to have active managerial control over personal hygiene and cross-contamination, certain control measures must be implemented in all phases of the operation. All of the following control measures should be implemented regardless of the food preparation process used .Prevention of cross-contamination of ready-to-eat food or clean and sanitized food-contact surfaces with soiled cutting boards, utensils, aprons, etc., or raw animal foods. Review of the facility's P&P titled Food Storage revised 4/6/23, showed for Raw Meat, under Number 2. Wash hands before and after handling raw meat to prevent the transmission of bacteria to food from the hands and from objects that have been touched by hands. 3. Wash and sanitize all surfaces, equipment, and utensils that have come in contact with raw meats before using for any other food to prevent cross-contamination. Review of the facility's P&P titled Dish and Utensil Procedure revised 3/3/20, showed in part, 10. Cutting boards need to be washed and sanitized between each use . Color-coded cutting boards are desirable designating boards for raw products versus cooked products. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed potential cross contamination of raw animal foods was not monitored by the RD. On 5/18/23 at 0821 hours, an observation of the Vietnamese menu lunch meal preparation and concurrent interview was conducted with [NAME] 4 and the DSS. [NAME] 4 prepared chicken curry for the Vietnamese menu lunch meal. Wearing gloves, [NAME] 4 cut raw chicken on a brown cutting board. The DSS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 64 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many confirmed a brown cutting board was to be used for cooked meats only. The DSS added [NAME] 4 should use a yellow cutting board which was for raw chicken. [NAME] 4 obtained a yellow cutting board and transferred the raw chicken to the yellow cutting board. [NAME] 4 completed cutting the raw chicken on the yellow cutting board. [NAME] 4 went to the refrigerator walk in, opened the door with the same gloved hands she touched the raw chicken and obtained a raw onion. [NAME] 4 placed the raw onion on the yellow cutting board and proceeded to cut the raw onion. The DSS stated [NAME] 4 should have used a green cutting board to cut the onion, which was designated for the fruits and vegetables only. On 5/19/23 at 1014 hours, a telephone interview was conducted the RD. The RD confirmed using a different colored cutting boards avoided the potential for cross contamination. The RD confirmed using the same cutting board for the raw chicken and raw vegetables posed the risk for cross contamination and could lead to food borne illness. 2. According the USDA Food Code 2022 Section 3-501.14 Cooling, (A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 57º Celsius (C) [135º Fahrenheit (F)] to 21ºC (70°F); and (2) Within a total of six hours from 57ºC (135ºF) to 5ºC (41°F) or less. Review of the facility's P&P titled Refrigerated Leftover Storage revised 8/31/23, showed in part, the leftover foods should not be saved and re-used for human consumption if there is any doubt of wholesome quality . Do Not Save: .Meats- precooked or cooked day before and chilled. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed TCS food was not monitored by the RD. During the initial kitchen tour with the DSS on 5/16/23 at 0800 hours, a pan of cooked turkey dated 5/15/23, was observed in the walk-in refrigerator. The DSS stated the turkey was cooked the day before and would be used as an alternative for the residents today. On 5/17/23 at 1022 hours, an interview was conducted with the DSS regarding the leftover chicken seen in the walk-in refrigerator on 5/16/23. The DSS stated the leftover chicken had been discarded. On 5/18/23 at 0830 hours, an interview was conducted regarding proper cooling of TCS foods with [NAME] 4 and the DSS. [NAME] 4 stated the kitchen never saved leftover food. [NAME] 4 stated if the leftover food was kept, the kitchen staff could eat it. When asked if [NAME] 4 was familiar with a cooling log, [NAME] 4 did not respond. The DSS stated the facility did not use a cooling log because they did not save leftover food. A telephone interview was conducted with the RD on 5/19/23 at 1014 hours. The RD stated leftover food should be properly cooled down, but the facility tried not to save the leftover food. The RD stated the facility used a cooling log if the leftover food was saved. 3. According the USDA Food Code 2022, Section 2-301.14 When to Wash Food, employees shall clean their hands and exposed portions of their arms . immediately before engaging in food preparation and .(E) After handling soiled equipment or utensils; (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. (G) When switching between working with raw food and working with ready- to-eat-food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 65 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0812 contaminate the hands. Level of Harm - Minimal harm or potential for actual harm Review of the facility's P&P titled Personal Hygiene/Safety/Food Handling/Infection Control revised 11/30/22, showed in part, 2. Clean hands, fingernails, and Gloves b. Hands must always be washed after . handling any unsanitary items. Residents Affected - Many Review of the facility's P&P titled Food Storage revised 4/6/23, showed in part, Raw Meat .2. Wash hands before and after handling raw meat to prevent the transmission of bacteria to food from the hands and from objects that have been touched by hands. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed appropriate hand washing and glove use. On 5/17/23 at 1020 hours, an observation of [NAME] 1 was conducted in the kitchen. [NAME] 1 put the soiled dishes in the dish machine, then proceeded to put plastic wrap on the resident food bowls without washing his hands. On 5/17/23 at 1037 hours, [NAME] 1 was observed to wash the soiled Robot Coupe (RC, a machine used to puree food) in the dish machine, placed prepared vegetables on the steam table, obtained a pen from his pocket and labeled the instant mashed potato container then began to puree sweet potatoes without washing his hands. On 5/17/23 at 1200 hours, [NAME] 1 was observed to touch his cell phone from his pocket, then proceeded to prepare the resident food for lunch tray line without washing his hands. On 5/18/23 at 0821 hours, during the Vietnamese food preparation, an observation of [NAME] 4 was conducted. [NAME] 4 obtained spices from the storage without wearing gloves. [NAME] 4 donned gloves without washing her hands then proceeded to touch multiple unclean surfaces: the water faucet handle, the counter, and the knife handle; then [NAME] 4 touched raw chicken. Without changing gloves and washing her hands, [NAME] 4 opened the walk-in door and obtained a raw onion. On 5/18/23 at 0830 hours, an observation was conducted of [NAME] 4. [NAME] 4 changed her gloves to puree the resident food but failed to wash her hands between glove change. On 5/18/23 at 0844 hours, an observation continued of [NAME] 4. [NAME] 4 changed her gloves prior to cutting the raw chicken for mechanically altered diets but failed to wash her hands between glove change. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD was asked when hand washing was necessary. The RD stated hand washing was necessary to prevent cross contamination between dirty and clean tasks and between glove changes. 4. Review of the facility's P&P titled Pots and Pans- Sanitizing Solution revised 8/31/18, showed in part, .2. Fill all tanks 2/3 full. a. Fill first tank with water and an effective concentration of detergent. b. Fill second tank with clean rinse water. c. Fill third tank with tepid water for sanitizing to fill line. If third sink is not available or is not used, pots and pans are run through the dish machine to sanitize as an alternate method. 3. Add sanitizing agent to third tank according to EPA-registered label use directions. a .200 ppm or 150-400 ppm (depending on which kind you use) is the required concentration of sanitizer-to-water ratio using a quaternary ammonia-base sanitizer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 66 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many .5. Scrub pots and pans in first tank using a scouring pad or appropriate cleaning tool, 6. Rinse pots and pans free of detergent in second tank. 7. Sanitize pots and pans in third tank by immersing in water with sanitizing agent for at least two minutes or per manufacturer guidelines. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed no concerns with the three-compartment sink (manual dishwashing sink) chemical concentration used for sanitizing. On 5/18/23 at 0841 hours, an observation of [NAME] 1 was conducted in the kitchen. [NAME] 1 manually washed steam table pans by scrubbing the pans with water, then rinsed the pans off with water. The DSS confirmed all the items washed manually should be washed and sanitized. On 5/18/23 at 0902 hours, an observation of [NAME] 4 was conducted in the kitchen. [NAME] 4 manually washed the Robot Coupe (RC). [NAME] 4 sprayed soap on the RC through the soap dispenser, scrubbed the top and bottom of the RC, rinsed the RC with water, then placed the RC to drain at the side of sink. On 5/18/23 at 0921 hours, an interview was conducted with the DSS. The DSS confirmed all pots and pans should be sanitized in the dish machine or the three-sink method could be utilized to wash, rinse, and sanitize the pots and pans. The DSS further stated the cook was in a rush to wash the RC, therefore, the cook did not sanitize the RC in the dish machine but should have given the RC to the dishwasher to sanitize it. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD stated she believed the pots and pans were washed and sanitized in the dish machine. The RD added all food preparation equipment and utensils must be sanitized. 5. Review of the facility's P&P titled Sanitizer Use Concentrations for Food Services and Food Production Facilities revised 4/30/20 showed in part, c. A quaternary ammonium compound solution shall have a minimum temperature and contact time based on the concentration as listed in the following chart: Concentration Range: 200 ppm (part per million) or 150-400 ppm .3. All surfaces and equipment should be washed with a sanitizing solution. On 5/18/23 at 0844 hours, an observation of [NAME] 4 in the kitchen was conducted. [NAME] 4 was preparing the chicken curry for the lunch meal. [NAME] 4 picked up a large, soiled spoon from the food preparation counter. [NAME] 4 wiped the food preparation counter with a paper towel, then continued food preparation activities for the lunch meal. On 5/18/23 at 0905 hours, an observation of [NAME] 1 in the kitchen was conducted. [NAME] 1 obtained a cleaning cloth from the sanitation bucket. [NAME] 1 rinsed and wrung the cleaning cloth three times with water in the food preparation sink. [NAME] 1 proceeded to wipe the stove top with the cleaning cloth. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed all kitchen surfaces should be sanitized with a cleaning cloth stored in the sanitizing solution. The RD confirmed cleaning food production surfaces with a paper towel or cleaning cloth that had been rinsed out with water was not appropriate. 6. Review of the facility's P&P titled Food storage revised 4/6/23, showed Eggs, Milk, and Cheese. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 67 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0812 Eggs should be checked for cracks, and any damaged one should be disposed of. Level of Harm - Minimal harm or potential for actual harm Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed food was stored labeled, dated and sealed. Residents Affected - Many During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, an observation of the walk-in refrigerator was conducted. Two broken eggs were observed with raw egg contents touching unbroken eggs. The DSS confirmed the broken eggs must be removed. a. Review of the facility's P&P titled Food Storage revised 4/6/23 showed in part, Frozen Meat/Poultry and Foods 3. Storage: .Food to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated paper. Label and date all food items. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10, 3/30, and 4/28/23, showed food was stored labeled, dated, and sealed. During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, an observation of the reach-in freezer was conducted. An open, unlabeled, and undated bag of frozen ground beef was observed. The ground beef showed signs of freezer burn, a condition of discoloration or other damage caused to frozen food by evaporation. The DSS confirmed all foods in the freezer should be sealed, labeled, and dated. 7. According to the USDA Food Code 2022, Section 2-402.11 Effectiveness (A), Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils . Review of the facility's P&P titled Personal Hygiene/Safety/Food Handling/Infection Control revised 11/30/22, showed in part, 3. Head Covering Worn a .Hair must be appropriately restrained or completely covered. c. Beards or any body hair that may be exposed . must be covered. Review of the facility document titled Sanitation Audit Report completed by the RD on 2/10 and 4/28/23, showed no concerns with hair restraints. The SAR completed by the RD on 3/30/23, showed one employee was not wearing a hair net. During the initial tour of the kitchen on 5/16/23 at 0800 hours, [NAME] 1 and the DSS were observed with facial hair not covered with a hair restraint. During the lunch meal tray line observation on 5/16/23 at 1209 hours, Cooks 1 and 2 were serving lunch with facial hair not covered with a hair restraint. During the lunch meal observation on 5/16/23 at 1225 hours, the DSS was observed inside the kitchen with facial hair not covered with a hair restraint. During the puree meal preparation with [NAME] 1 and the DSS on 5/17/23 at 1026 hours, both [NAME] 1 and the DSS had facial hair not covered with a hair restraint. On 05/17/23 at 1122 hours, an observation of [NAME] 3 was conducted. [NAME] 3's hair was not completely covered with the hair restraint while cooking. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 68 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm On 05/17/23 at 1200 hours, an observation of the lunch meal tray line was conducted. [NAME] 2 with facial hair not covered with a hair restraint was observed serving food. On 5/18/23 at 0804 hours, during a kitchen observation, the DSS and Cooks 1 and 2 were observed with facial hair not covered with a hair restraint. Residents Affected - Many On 5/18/23 at 0830 hours, an observation of the Vietnamese lunch meal preparation was conducted with [NAME] 4. [NAME] 4's hair net did not cover all her hair. On 5/19/23 at 1014 hours, a telephone interview with the RD was conducted. The RD confirmed anyone in the kitchen must wear a hair restraint. The RD added full scalp coverage was preferred. 8. According to the USDA Food Code 2022 Section 4-602.11 Equipment, Food-Contact Surfaces, Nonfood-contact Surfaces, and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Review of the facility's document titled Sanitation Audit Report completed by the RD on 2/10/23, showed the minor equipment was not clean, blender and RC with debris. Review of the facility's document titled Sanitation Audit Report completed by the RD on 3/30/23, showed the minor equipment was clean. Review of the facility's document titled Dining- Sanitation Audit completed by the RD on 4/28/23, showed the minor equipment was not clean. The comments section showed cleaning schedule to ensure cleaner equipment. a. During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, the following items were observed: -The bowl scraper of the RC was chipped and had a brown residue. -More than five sheet pans had a hard black residue. -Four muffin pans had a hard brown residue. -Four frying pans had a hard black residue. -One stock pot had a black residue. -One dome drying rack had food crumbs and a white residue. The DSS confirmed all of the food preparation equipment should be clean. On 5/17/23 at 1454 hours, an interview was conducted with the RD. The RD was asked how she communicated her concerns from the Sanitation Audit Report (SAR) that she completed monthly. The RD stated she communicated her concerns from the SAR verbally to the DSS. She added the DSS handled most things. When asked how the RD knew her concerns had been resolved, the RD stated she addressed any concerns on the spot or reminded the DSS if she had sanitation concerns. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 69 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 5/18/23 at 1014 hours, a telephone interview was conducted with the RD. The RD confirmed food preparation equipment should be clean. The RD was asked if she inspected food preparation equipment as part of the monthly SAR she conducted, the RD stated she performed a general look through of the food preparation equipment in the kitchen. b. On 5/16/23 at 1110 hours, an observation of the facility's ice machine and concurrent interview was conducted with the ESD. The ESD stated the ice machine was just purchased on 3/28/23. The ESD stated the ice machine contract company would clean the internal components of the ice machine twice a year and the ESD would clean the internal components of the ice machine quarterly. The ESD stated he had not completed the first quarterly cleaning of the ice machine yet. The internal components of the ice machine were observed with a black residue on the inside of the evaporator cover. The ESD confirmed the black residue was not normal and should not be there. On 5/17/23 at 1158 hours, an interview was conducted with the Administrator regarding the black residue found on the ice machine evaporator cover. The Administrator stated the ice machine contract company confirmed the black residue was not due to a mechanical issue with the ice machine. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD stated as part of her SAR, she checked the ice machine cleaning log and filters but did not inspect the inside of the ice machine. 9. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-contact Surfaces, and Utensils (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. Review of the facility's P&P titled Cleaning Schedules revised 8/31/23, showed the Food and Nutrition Services staff shall maintain the sanitation of the food and nutrition services department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of Food and Nutrition Services or other clinically qualified nutrition professional. During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, the kitchen floors, dry storeroom, walk-in refrigerator and chemical closet were observed to be dirty with food debris and sticky with a black residue. The DSS stated the walk-in floor was cleaned one to two times a week. The DSS stated the dry storeroom floor should be mopped nightly and could attract pests. The DSS confirmed the floor in the chemical closet was not clean. The DSS stated the kitchen floors were not deep cleaned, only swept and mopped. During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, the ceiling vent in the dish room was observed with a gray fuzzy residue. The DSS confirmed the ceiling vent in the dish room was not clean and stated it was cleaned monthly. In addition the following was observed: - The ceiling fan cover had a brown residue which resembled rust. The ceiling next to the fan cover in the walk-in refrigerator was observed with a gray and black residue. The DSS confirmed the ceiling fan cover and ceiling in the walk-in refrigerator were not clean. - A large fan was observed in the dish room with a gray residue. The DSS confirmed the large fan was not clean. - The shelves used to store food preparation equipment had peeling paint and a brown residue which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 70 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0812 resembled rust. Level of Harm - Minimal harm or potential for actual harm The DSS acknowledged the above findings and stated all kitchen equipment should be clean. Residents Affected - Many Review of the facility's document titled Dietary Cleaning Schedule from February 2023 through week 2 of May 2023 showed cleaning was completed by the PM cook for the bottom shelves for eight of 14 opportunities. Out of the 14 of opportunities, none was signed off by the DSS for cleaning of the bottom shelves. Review of the facility's document titled Dietary Cleaning Schedule from February 2023 through week 2 of May 2023 showed cleaning was completed by the PM cook for the refrigerator for one of 14 opportunities. Out of the 14 opportunities, zero was signed off by the DSS for cleaning of the refrigerator. Review of the facility's document titled Dietary Cleaning Schedule from February 2023 through week 2 of May 2023 showed cleaning was completed by the AM dietary aid for the bottom shelves and floor for zero of 14 opportunities. Out of the 14 opportunities, zero was signed off by the DSS for cleaning of the bottom shelves and floor. Review of the facility's document titled Dietary Cleaning Schedule from February 2023 through week 2 of May 2023 showed cleaning was completed by the AM dietary aide for the refrigerators and all shelves for 14 of 14 opportunities. Out of the 14 opportunities, one of 14 opportunities was signed off by the DSS for cleaning of the refrigerator and all shelves. Review of the facility's document titled Dietary Cleaning Schedule from February 2023 through week 2 of May 2023 showed cleaning was completed by the PM dietary aide for the refrigerator shelves, sweeping and moping the floors in the walk-in for two of 14 opportunities. Out of the 14 opportunities, zero of 14 opportunities was signed off by the DSS for cleaning of the refrigerator shelves, sweeping and moping the floor in the walk-in. Review of the facility's document titled Dietary Cleaning Schedule from February 2023 through week 2 of May 2023 showed cleaning was completed by the PM dietary aides for preparation area floors and floor corners for two of 14 opportunities. Out of the 14 opportunities, one of 14 opportunities was signed off by the DSS for cleaning of the preparation area floor and floor corners. Review of the facility's document titled Dietary Cleaning Schedule showed the fan located in the dish room, ceiling vent in the dish washing area, ceiling fan in the walk-in refrigerator, and reach-in freezer were not included in the facility's Dietary Cleaning Schedule. Review of the facility's document titled Sanitation Audit Report (SAR) completed by the RD on 2/10 and 4/28/23, showed the floors, walls, and ceiling were not clean. The SAR completed by the RD on 3/30/23, showed no concerns with the cleanliness of the kitchen floors, walls, or ceilings. On 5/18/23 at 1448 hours, an interview was conducted with the DSS. The DSS was asked how the RD communicated the findings from the SAR. The DSS stated the RD emailed a copy to him. The RD verbally explained the SAR to the DSS, then he would talk to his staff regarding the findings. The DSS acknowledged he did not document when he spoke with his staff regarding the RD's SAR. The DSS was asked if he performed an audit of the kitchen. The DSS stated he did a kitchen walk through but did not document the findings. The DSS was asked how he confirmed the kitchen staff completed the required (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 71 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many cleaning. The DSS stated the kitchen staff were assigned cleaning schedules. The DSS acknowledged that often times, he did not have the opportunity to check if the cleaning schedule was completed. On 5/19/23 at 1014 hours, a telephone interview was conducted with the RD. The RD stated she was not involved with the kitchen cleaning schedules but expected the cleaning schedules to be completed and the kitchen was clean. 10. According to the USDA Food Code 2022, Section 4-602.11 Equipment, Food-Contact Surfaces, Nonfood-contact Surfaces, and Utensils, (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. On 5/17/23 at 1047 hours, a large rolling ice chest with soiled wheels designed to be rolled on the ground was observed on a food preparation table. The DSS was asked why a rolling ice chest that was rolled on the ground was stored on a food preparation table. The DSS stated the facility bought ice since the ice machine was not clean and he did not want to store the rolling ice chest on the floor. The DSS acknowledged he had other ice chests that were not the rolling type but did not use them to store the ice. The DSS stated he would remove the rolling ice chest from the food preparation table. 11. Review of the facility's P&P titled Nourishment Refrigerator/Freezer Storage Guide dated 5/23 showed in part, 10. Associate's food should not be stored in resident's refrigerator refrigerator/freezer or other cold storage units where resident food is stored. Review of the facility document titled Sanitation Audit Report completed by the RD on 3/30 and 4/28/23, showed storage of employee food was a concern. During the initial kitchen tour on 5/16/23 at 0800 hours, a concurrent observation and interview with the DSS was conducted. Employee food was observed stored in the kitchen freezer. The DSS verified the finding and stated it should be stored in the employee refrigerator. On 05/19/23 at 1014 hours, a telephone interview with the RD was conducted. The RD stated employees must store their food in the designated employee's refrigerator only. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 72 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility P&P review, the facility failed to ensure the residents' family members and visitors were trained on safe food handling practices of food brought to the residents by the family members and other visitors. This failure posed the risk for the residents to have foodborne illness. Residents Affected - Few Findings: Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors (undated) showed prepared food must be consumed by the resident with three days. If not consumed in three days, the food will be thrown away by the facility staff. However, the P&P did not address educating family members on safe food handling practices. On 5/17/23 at 0832 hours, an observation of the resident's food storage refrigerator was conducted. The posted instructions on the refrigerator door showed food will be disposed after 72 hours. On 5/17/23 at 1005 hours, an interview with RN 1 was conducted. When asked about their process on how the family or visitors were educated on safe food handling when food was brought from outside, RN 1 stated they would tell the family or visitors that they would keep the food in the resident's designated refrigerator, heat it up in the microwave located in the admission area, and would discard the food after 72 hours, if not consumed. On 5/17/23 at 1015 hours, an interview with the DON was conducted. When asked about their process on how the family or visitors were educated on safe food handling when food was brought from outside, the DON stated the RD would talk with the family or visitors. On 5/17/23 at 1457 hours, an interview with the RD was conducted. When asked about their process on how the family or visitors were educated on safe food handling when food was brought from outside, the RD stated they encouraged the family members to bring food for appropriate residents. The RD further stated the facility would store it for three days in the resident's designated refrigerator and they could heat it up in the microwave. The RD stated only verbal education was provided to the family members or visitors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 73 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview, and facility P&P review, the facility failed to ensure three of three garbage dumpsters were contained and covered. This failure had the potential to attract pest and rodents that carry diseases. Residents Affected - Many Findings: According to the USDA Federal Food Code 2022, Section 5-501.113 titled Covering Receptacles, receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered with tight-fitting lids or doors if kept outside the food establishment. Review of the facility's P&P titled Garbage and Trashcans dated 5/20/20, showed all food waste must be placed in covered garbage and trashcans. The dumpster area must be free of debris on the ground and the lid must be closed. On 5/16/23 at 1429 hours, an observation of the garbage dumpsters adjacent to the facility was conducted. One of three dumpster lids was still left open. On 5/16/23 at 1433 hours, an interview with the Administrator and Environment Services Director was conducted. Both the Administrator and Environmental Services Director stated the garbage dumpsters must be kept closed at all times. On 05/18/23 at 0750 hours, three of three garbage dumpsters and one white garbage bin were observed overflowing with garbage which prevented the lids from closing. The Environment Services Director verified the findings and stated it should be fully closed at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 74 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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, and facility P&P review, the facility failed to maintain the accurate and complete medical records of one of three final closed record sampled residents (Resident 121). * The facility failed to the POLST was voided as per the facility's P&P when Resident 121's family member requested to change the treatment options and failed to ensure one of three copies of Resident 121's POLSTs was in the medical record. This failure has the potential to put the resident at risk for a delay in necessary care and treatment. Findings: Review of the facility's P&P titled Physician Orders for Life Sustaining Treatment (POLST) revised [DATE], showed to void a POLST, a draw line through the entire section A and D and write VOID on large letters across the document, then sign and date it. All voided POLST documents are to be retained in the resident's medical record. Closed medical record review for Resident 121 was initiated on [DATE]. Resident 121 was readmitted in the facility on [DATE], and had expired on [DATE]. Review of Resident 121's POLST dated [DATE], showed the following items were checked. - Do Not Attempt Resuscitation/DNR (Allow Natural Death) - Selective Treatment with request transfer to hospital only if comfort needs cannot be met in current location - Long-term artificial nutrition, including feeding tubes - No Advance Directive Review of Resident 121's Nurses Progress Note dated [DATE] at 1906 hours, showed the nurse received a call from Resident 121's PA and informed the facility that he had conversations with Resident 121's son and the responsible representative requesting to change Resident 121's POLST to full code, full treatment, and continue with no enteral feeding tubes. However, there was no POLST reflecting the full code, full treatment, and no enteral feeding tubes as per the above progress note. Review of Resident 121's POLST dated [DATE], showed the following items were checked. - Do Not Attempt Resuscitation/DNR (Allow Natural Death) - Selective Treatment with request transfer to hospital only if comfort needs cannot be met in current location - No artificial means of nutrition, including feeding tubes (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 75 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0842 - No Advance Directive Level of Harm - Minimal harm or potential for actual harm Further review of Resident 121's physical or electronic chart failed to show a copy of Resident 121's POLST dated [DATE], was voided. The POLST dated [DATE], did not show a line in Section A through D, the written word void, the date, and signature when the POLST was voided as per the facility's P&P. Residents Affected - Few On [DATE] at 1131 hours, a telephone interview was conducted with the PA. The PA stated he spoke to Resident 121's responsible representative a couple days after Resident 121 had expired. The PA stated the family member told him that some of Resident 121's family members from Vietnam visited the facility the day before Resident 121 had expired. On that same day, Resident 121's responsible representative decided to change the POLST again on Saturday, [DATE], to DNR status. On [DATE] at 1352 hours, a telephone interview was conducted with RN 2. RN 2 verified she received the call from the PA with Resident 121's responsible representative who wished to change the POLST of Resident 121 on [DATE], from DNR to full code/full treatment. RN 2 stated she filled out the POLST form with the changes and flagged the POLST form in Resident 121's medical record for the Resident 121's responsible representative to sign when he comes to the facility. On [DATE] at 1355 hours, an interview was conducted with the DON. The DON verified the above findings and stated she could not find the hard copy of the POLST for Resident 121 dated [DATE], in the medical record. The DON stated the copy of the resident's POLST should be in the medical record. On [DATE] at 1358 hours, an interview was conducted with the Medical Records Director. The Medical Records Director stated she did not find a hard copy of POLST dated [DATE], in Resident 121's chart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 76 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's document titled The Six Moments of Enhanced Standard Precautions (undated) showed for these six groups of care activities, use hand hygiene, gloves and gowns: morning and evening care, toileting and changing incontinence briefs, caring for devices and giving medical treatment, cleaning the environment, wound care, and mobility assistance and preparing to leave room. Residents Affected - Few Review of the CDPH AFL 22-21 titled Enhanced Standard Precautions for Skilled Nursing Facilities dated 10/5/22, showed Title 42 CFR section 483.80 requires that nursing facilities must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Enhanced Standard Precautions for Skilled Nursing Facilities, 2022 provides a practical, resident-centered and activity-based approach to implement measures to prevent MDRO transmission that are less restrictive than Contact Precautions. Recommendations for the use of gowns and gloves by health care providers are based on assessments of a resident's risk for being colonized and likelihood of transmitting MDRO, whether or not the resident is known to be MDRO colonized or infected. On 5/16/23 at 0948 hours, the Six Moments of Enhanced Standard Precautions sign was observed posted outside Resident 106's room alerting anyone entering the room to perform hand hygiene and don gloves and gown when providing the six groups of care activities. A cart containing gowns was observed below the posted enhanced standard precautions sign. CNA 3 was observed in the room wearing a gown and a mask. CNA 3 was not wearing gloves. CNA 3 was observed picking up the soiled bed sheet from the resident's bed, then placed it in the soiled linen cart. CNA 3 was observed pulling the Hoyer lift (medical devices that are used to transfer patients with limited mobility) out of the room. CNA 3 was observed touching the isolation cart, then pushing the soiled linen cart away. CNA 3 was observed touching another linen cart, then went out to the patio exit with her linen cart. CNA 3 was observed not performing hand hygiene between these tasks. On 5/16/23 at 0952 hours, an interview was conducted with CNA 3. When asked what isolation Resident 106 was, CNA 3 stated Resident 106 was on contact isolation for infection in the urine. CNA 3 acknowledged Resident 106 was on enhanced standard precaution. CNA 3 stated she should have worn gown and gloves while changing the linen. Medical record review for Resident 106 was initiated on 5/16/23. Resident 106 was admitted to the facility on [DATE]. Review of Resident 106's Order Summary Report showed a physician's order dated 1/24/23, for enhanced standard precautions for Candida Auris (aka C. Auris, is a yeast or a type of fungus that causes severe infections and can spread in healthcare setting). On 5/18/23 at 1503 hours, an interview was conducted with the IP. The IP verified Resident 106 was on enhanced standard precautions. The IP stated CNA 3 should have worn gloves and gowns while changing the linens, then performed hand hygiene before donning and after taking off gloves. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the proper infection control practices were followed for two of 24 final sample residents (Residents 72 and 106). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 77 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few * The facility failed to ensure RN 1 performed handwashing during the preparation of parenteral medication. This failure had the potential for Resident 72 getting infected and posed the risk of spreading infection to another resident. * The facility failed to ensure CNA 3 followed the contact precautions when providing care for Resident 106 who was on enhanced standard precaution. This posed the risk for the transmission of disease-causing microorganisms Findings: 1. Review of the facility's P&P titled Preparation and General Guidelines, IIA2 Medication Administration General Guidelines dated 10/2017 showed hands are washed before and after administration of topical, ophthalmic, otic, parenteral , enteral, rectal, and vaginal medications. On 5/17/23 at 0831 hours, RN 1 was observed during the preparation of IV medication for Resident 72. The following was observed: - RN 1 was observed performing handwashing at the office sink near the IV medication cart in Station 3. RN 1 opened the computer, opened the medication room, and went inside, came out and closed the medication room carrying the IV antibiotic bag, opened the IV medication cart, pulled out the IV tubing, then completed the preparation of IV medication. However, RN 1 was observed not performing handwashing during the preparation of the IV medication. Review of Resident 72's Order Summary Report order dated 5/12/23, showed to administer ceftriaxone sodium (antibiotic) Intravenous Solution reconstituted 1 gm intravenously one time a day for sepsis/UTI for 12 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 78 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and facility document review, the facility failed to ensure the essential kitchen equipment was maintained in safe operating condition when: Residents Affected - Few 1. The walk-in ceiling fan cover had a brown residue resembling rust. 2. The reach-in freezer had ice build-up. 3. The manual dish machine draining table was not properly attached to the adjoining dish machine draining table. Failure to maintain necessary kitchen equipment in proper working order may result in compromised food safety. Findings: According to the USDA Food Code Section 4-501.11 Good Repair and Proper Adjustment, proper maintenance of equipment to manufacturer's specifications helps ensure it will continue to operate as designed. Review of the facility document titled Maintenance Job Request, undated, showed no entries from 2/18/22 to 5/16/23. Review of the facility document titled Sanitation Audit Report (SAR) completed by the RD on 2/10 and 3/30/23, showed major equipment was in working order. The SAR completed by the RD on 4/28/23, showed the oven was not working. 1. During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, an observation of the walk-in refrigerator was conducted. The ceiling fan cover had a brown residue which resembled rust. The DSS acknowledged the findings. 2. During the initial tour of the kitchen with the DSS on 5/16/23 at 0800 hours, an observation of the reach-in freezer was conducted. There was ice build-up on the fan cover and the top of the freezer. The DSS acknowledged the findings. 3. On 5/17/23 at 1124 hours, an observation of the manual dish washing sink and concurrent interview was conducted with the DSS. Cracked, discolored white caulk was attached to the manual dish washing sink drain table. The white caulk had a paper-like substance imbedded in the caulk. The DSS stated he did not know what the substance was. When asked how he communicated maintenance issues to the maintenance, the DSS stated he called or texted the maintenance supervisor or documented in the maintenance log located in the kitchen. An interview was conducted with the RD on 5/17/23 at 1454 hours. The RD was asked if she included the maintenance problems in her monthly Sanitation Audit Report (SAR). The RD stated she did include maintenance problems in her SAR but she communicated verbally to the DSS if there were any issues. She stated the DSS handled maintenance problems. On 5/17/23 at 1610 hours, an interview was conducted with the ESD. The ESD was asked how he was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 79 of 80 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 555667 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/23/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Park Care Center 12681 Haster Street Garden Grove, CA 92840 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)

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few notified of maintenance problems in the kitchen. The ESD stated he checked the maintenance log located in the kitchen daily. When asked regarding the cracked white caulking on the manual dish washing sink in the kitchen, the ESD stated the DSS had informed him today and he was working on fixing it. On 5/18/23 at 1514 hours, an interview was conducted with the ESD. The ESD was asked if the maintenance department was responsible for routine maintenance of kitchen equipment. The ESD stated the maintenance department was not responsible for routine maintenance of any kitchen equipment. On 5/18/23 at 1520 hours, an interview was conducted with the DSS. The DSS confirmed there was no routine maintenance completed of kitchen equipment. The DSS added the outside vendors were contacted if the kitchen equipment was not functioning properly. On 5/19/23 at 1014 hours, an interview was conducted with the RD. The RD confirmed the ice build-up in a freezer was not normal. The RD stated she was aware of the ice build up in the reach-in freezer two months ago and spoke to the DSS about it, but stated she was not sure if she addressed the ice build-up in the reach in freezer on her report, the SAR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555667 If continuation sheet Page 80 of 80

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Citations

27 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0578GeneralS&S Dpotential for harm
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
0637GeneralS&S Dpotential for harm
F637 - Within 14 days after the facility determines, or should have determined,
Assess the resident when there is a significant change in condition
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0686GeneralS&S Dpotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0695GeneralS&S Epotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0697GeneralS&S Dpotential for harm
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0757GeneralS&S Dpotential for harm
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0801GeneralS&S Epotential for harm
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
0802GeneralS&S Fpotential for harm
F802 - Staffing
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
0803GeneralS&S Epotential for harm
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
0805GeneralS&S Dpotential for harm
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0813GeneralS&S Dpotential for harm
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
0814GeneralS&S Cno actual harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0908GeneralS&S Dpotential for harm
F908 - Maintain all mechanical, electrical, and patient care equipment in safe
Keep all essential equipment working safely.

FAQ · About this visit

Common questions about this visit

What happened during the May 23, 2023 survey of GARDEN PARK CARE CENTER?

This was a inspection survey of GARDEN PARK CARE CENTER on May 23, 2023. The surveyor cited 27 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at GARDEN PARK CARE CENTER on May 23, 2023?

Yes, 27 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·May 23, 2023