Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0657
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**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 update the plan of care for one
of four sampled residents (Resident 1).
* Resident 1's care plan problem was not updated to address the low hematocrit (measurement of the
percentage of red blood cells in the blood) and hemoglobin (protein in red blood cells that carries oxygen)
levels. This failure had the potential to affect the provision of care for Resident 1.
Findings:
Review of the facility's P&P titled Care Plan Revisions Upon Status Change dated 12/2022 showed the
comprehensive care plan will be reviewed and revised as necessary when a resident experiences a status
change. The care plan will be updated with the new or modified interventions.
Closed medical record review for Resident 1 was initiated on 10/11/24. Resident 1 was admitted to the
facility on [DATE], and discharged on 9/23/24.
Review of Resident 1's Progress Note dated 9/22/24, showed Resident 1's laboratory results regarding
hematocrit of 16 % (normal range from 35.5 % to 44.9 %) and hemoglobin of 5 grams/dL (normal range
from 11.6 to 15 grams/dL) was reported to the physician.
Review of Resident 1's medical record failed to show a change of condition evaluation was completed and
the care plan was updated to address Resident 1's low hematocrit and hemoglobin level.
On 10/15/24 at 1529 hours, a concurrent interview and medical record review was conducted with the
DON. The DON verified the change of condition evaluation and updated care plan were not completed for
Resident 1's low hematocrit and hemoglobin levels.
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
10/15/2024
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Potential for
minimal harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, medical record review, facility document review, and facility P&P review, the facility failed to
provide an accurate surveillance and assessment of the skin and soft tissue infection for one of four
sampled residents (Resident 4). This failure posed the risk for not identifying and managing Resident 4's
skin infection.
Residents Affected - Some
Findings:
Review of the facility's P&P titled Infection Prevention and Control Program revised 12/2022 showed the
facility maintains 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 disease
and infections as per accepted national standards and guidelines. On surveillance the RNs and LPNs
participate in surveillance through assessment of the residents and reporting changes in condition to the
resident's physicians and management staff, per protocol for notification of changes and in-house reporting
of communicable diseases and infection.
Medical record review for Resident 4 was initiated on 10/15/24. Resident 4 was admitted to the facility on
[DATE].
a. Review of Resident 4's Infection Screening Evaluation dated 8/14/24, showed Resident 4's symptom of
pus (a thick yellowish liquid produced in infected tissue) for skin/wound characteristics met the McGeer's
Criteria (used to evaluate the accuracy of infection diagnoses and reporting in nursing homes).
Review of Resident 4's Order Summary dated 8/13/24, showed the physician ordered doxycycline
(antibiotic medication) 100 mg for five days from 8/13/24 to 8/18/24, for Resident 4's abscess on the left
side of lower back.
However, review of the Infection Surveillance Monthly Report for August 2024 showed Resident 4 was
treated with doxycycline 100 mg for the left lower back abscess (pus-filled lump) and did not meet criteria
for skin and soft tissue infection.
b. Review of Resident 4's Infection Screening Evaluation dated 9/16/24, showed Resident 4's symptoms of
redness and new or increasing swelling at affected site met the Loeb's Criteria (set of minimum signs and
symptoms that indicate a resident may have an infection and might need antibiotics) for suspected skin and
soft tissue infection.
Review of Resident 4's Order Summary dated 9/16/24 showed the physician ordered doxycycline 100 mg
for ten days from 9/16/24 to 9/26/24, for Resident 4's ruptured boil (pus filled bump) to buttock area.
However, review of the Infection Surveillance Monthly Report for September 2024 showed Resident 4 was
not included in the category under skin and soft tissue infection.
On 10/15/24 at 1214 hours, an interview and concurrent facility document review was conducted with the
IP. The IP verified the Infection Surveillance Monthly Report for August 2024 did not match the Infection
Screening Evaluation. Furthermore, the IP verified the Infection Surveillance Monthly
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555667
If continuation sheet
Page 2 of 3
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
10/15/2024
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)
F 0880
Level of Harm - Potential for
minimal harm
Report for September 2024 failed to show Resident 4 was included in the criteria for the skin and soft tissue
infection.
On 10/15/24 at 1529 hours, an interview and concurrent record review was conducted with the DON. The
DON verified the above findings.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555667
If continuation sheet
Page 3 of 3
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Back to topCitations
2 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.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the October 15, 2024 survey of GARDEN PARK CARE CENTER?
This was a inspection survey of GARDEN PARK CARE CENTER on October 15, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GARDEN PARK CARE CENTER on October 15, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a t..."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.