Health inspection·January 5, 2024

F 0580 Level of Harm - Potential for minimal harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to notify the resident's representative when there was a change of the POA for one of four sampled residents (Resident 1). * Resident 1's legal representative was changed from Family Member 1 to Family Member 2 without informing Family Member 1. This failure resulted in Family Member 1 being unaware of the change, which had the potential to negatively impact the resident's well-being. Findings: On 1/2/24 at 0816 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated she was the POA for Resident 1; however, the facility changed the POA to Family Member 2 without informing her. Medical record review for Resident 1 was initiated on 1/2/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's History and Physical Form dated 2/28/23, showed Resident 1 did not have the capacity to understand and make decisions. Review of Resident 1's History and Physical Form dated 7/13/23, showed Resident 1 did have the capacity to understand and make decisions. Review of Resident 1's Progress Note dated 7/20/23 at 1217 hours, showed Resident 1 was assisted to complete a new Advance Health Care Directive, designating Family Member 2 as his Power of Attorney. There was no documentation showing Family Member 1 was made aware. Review of Resident 1's Progress Note dated 9/26/23 at 1521 hours, showed Family Member 2 was left a voicemail regarding the change in Power of Attorney. On 1/2/24 at 1147 hours, an interview and concurrent medical record review was conducted with the SSA. The SSA verified Resident 1 changed his POA from Family Member 1 to Family Member 2 on 7/19/23, after his physician deemed him capable of understanding and making medical decisions. The SSA stated she called Family Member 1 and left a voicemail to inform her, but forgot to document the call. The SSA was unable to show any documentation Family Member 1 was made aware of the change of POA prior to 9/26/23. 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 3 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 01/05/2024 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)