Health inspection·June 26, 2025

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 care and services to ensure one of five final sampled residents (Resident 4) attained and maintained their highest practicable well-being. Residents Affected - Few * The facility failed to continuously monitor Resident 4 after the resident had a witnessed fall. This failure had the potential for not providing the necessary care and services if the residents had a change in condition. Findings: Review of the facility's P&P titled Fall Prevention Program revised 12/28/23, showed each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. When any resident experiences a fall, the facility will assess the resident and document all assessments and actions. Medical record review for Resident 4 was initiated on 6/25/25. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 4/10/25, showed Resident 4 had no capacity to understand and make decisions. Review of Resident 4's MDS assessment dated [DATE], showed Resident 4 had severe cognitive impairment and needed substantial/maximal assistance with mobility. Review of Resident 4's SBAR Communication Form dated 5/13/25, showed Resident 4 was being wheeled by the CNA to go to the dining area and the wheelchair got stuck in the carpet by the door to the patio which caused Resident 4 to slide off the wheelchair and fall forward. Resident 4 did not hit her head on the ground and did not sustain any injuries. The carpet was taken off the dining room right away. Review of Resident 4's plan of care initiated on 5/13/25, showed a care plan problem addressing Resident 4's fall incident on 5/13/25. The interventions included to monitor Resident 4 for pain or discomfort, vital signs, change in level of consciousness and notify the physician as needed. Further review of Resident 4's medical record failed to show documented evidence of continued monitoring/assessment for Resident 4 by the licensed nurses after the fall incident on 5/13/25. (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 06/26/2025 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)