Health inspection·March 14, 2025

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, facility document review, and facility P&P review, the facility failed to ensure themedical records were complete and accurately maintained for two of ten sampled residents (Residents 9 and 10). * Residents 9 and 10's medical records failed to show the monitoring of the residents' locations was completed on 3/9, 3/10, and 3/12/25. These failures had the potential for the residents' care needs to not be met as their medical information was inaccurate and incomplete. Findings: Review of the facility's P&P titled Falling Star Program dated 8/1/18,showed the resident safety committee/interdisciplinary team will determine placement of the residents into the Falling Star Program to reduce the incidence of falls/injury for each resident in the program. Nursing staff will do every hour monitoring as followed and log completion. 1. Medical record review for Resident 9 was initiated on 3/13/25. Resident 9 was readmitted to the facility on [DATE]. Review of Resident 9's MDS assessment dated [DATE], showed Resident 9 had moderate cognitive impairment and needed substantial/maximal assistance with mobility. Review of Resident 9's Order Summary Report showed a physician's order dated 2/19/25, for the resident to be on the falling star program. Review of Resident 9's Care Plan revised on 3/13/25, showed a care plan focus problem addressing Resident 9's high risk for falls. The interventions included the falling star program and to follow facility's fall protocol. Review of Resident 9's Progress Note dated 2/15/25, showed Resident 9 was found on the floor at 1506 hours lying on his left side with head on the blanket. Resident 9 sustained a two centimeters abrasion on top of the head with minimal bleeding. Review of Resident's 9's Falling Star record for March 2025 showed no documented evidence Resident 9 was monitored for the resident's location on the following dates: - 3/9/25, from 0000 hours to 0300 hours; (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 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 03/14/2025 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)