Health inspection·December 14, 2023

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the accuracy of the medical record for one of the two sampled residents (Resident 1) was complete and accurate. * The facility failed to ensure Resident 1's Change in a Resident's Condition or Status was initiated. This failure had the potential for the resident's care needs to not be met as their clinical information was incomplete. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised January 2012 showed the nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. Closed medical record review for Resident 1 was initiated on 12/12/23. Resident 1 was admitted to the facility on [DATE], and discharged on 12/7/23. Review of Resident 1's Physician's Order Summary Report for November 2023 showed to transfer Resident 1 to an acute care hospital. Review of the Resident's 1 nurses' progress note dated on 11/22/23 at 1350 hours, showed Resident 1 was transferred to the acute care hospital. Further review of the nurses' progress note dated 11/22/23 at 1800 hours, showed Resident 1 returned to the facility with the right eyebrow laceration and was placed on high risk for falls. On 12/12/23 at 1349 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with LVN 2. LVN 2 verified Resident 1 had an unwitnessed fall on 11/22/23. Resident 1 was sent out to the acute care hospital on [DATE]. LVN 2 confirmed there was no change of condition initiated to show Resident 1 had sustained a fall on 11/22/23. LVN 2 further stated the change of condition must be initiated for any changes that may have occurred to any residents like falls. On 12/12/23 at 1422 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON stated a change in condition must be completed for every change in the residents such as falls. The DON verified Resident 1 sustained an unwitnessed fall on 11/22/23, the DON further verified no change of condition was documented to show Resident 1 had sustained a fall on 11/22/23. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 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 12/14/2023 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)