Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garden Park Care Center during CMS and state inspections, most recent first.
A resident with capacity to understand and make decisions had an episode of verbal aggression toward staff and refused to allow the door to remain open for close monitoring of a confused roommate at risk for falls; police were called to the facility. The record showed no change of condition report and no documentation that the physician was notified, and interviews with an LVN, RN, and DON confirmed the physician had not been notified.
Surveyors found that the facility failed to consistently implement and document fall-related interventions and assessments for three residents with recent falls. One resident had floor mats and a fall mattress in use without corresponding physician orders or care plan interventions, while the DON stated the resident was supposed to have a big boy bed instead of floor mats. Another resident on a blood thinner had care-planned orthostatic BP monitoring that was not carried out as ordered, incomplete 72-hour neuro checks after a fall, and a physician order for bilateral floor mats that was only partially implemented, with staff confirming only one mat was in place. A third resident with a fall-related head injury had orders and care plan interventions for 72-hour orthostatic BP monitoring and neuro checks, but the MAR lacked BP results despite being marked complete, and the neuro flowsheet contained multiple blank entries; an RN and the DON acknowledged that the ordered orthostatic BPs and neuro assessments were not fully completed.
A resident returned from the hospital with bilateral soft hand mittens in place, but staff did not obtain a physician’s order, informed consent, or complete required assessments and monitoring for restraint use. Facility records lacked any documentation of a medical symptom warranting restraints, a care plan, or scheduled removal and ROM exercises, despite policies requiring these elements. An LVN reported the resident arrived with mittens and that no consent or hand/wrist assessments were done, while another LVN stated she recognized the mittens as restraints without orders and said she told a CNA to remove them, which the CNA denied. The DON stated she was unaware of the mittens and confirmed that, per facility policy, any restraint use should have documented orders, consent, assessments, two-hour release for circulation checks, and a care plan.
A resident with moderately impaired cognition alleged physical abuse by a caregiver and identified her roommate as a witness. Although the roommate, who also had moderately impaired cognition, was interviewed by the SSA and reported hearing the resident yelling, the interview was not provided to the Abuse Coordinator and was instead discarded. This omission resulted in an incomplete investigation, as not all potential witness information was considered.
A resident with severe cognitive impairment and high assistance needs experienced a fall when their wheelchair became stuck in a carpet while being wheeled by a CNA. Although the resident was assessed immediately after the fall, licensed nurses did not continue required monitoring and assessment every shift for 72 hours as outlined in facility policy, resulting in a failure to provide necessary post-fall care.
The facility failed to maintain complete and accurate medical records for two residents in the Falling Star Program, which required hourly monitoring to prevent falls. Documentation was missing for specific dates, and staff interviews revealed lapses in the process, with CNAs either not receiving the necessary forms or failing to document the checks, despite claims of performing them.
A resident's care plan was not updated to address critically low hematocrit and hemoglobin levels, despite these results being reported to the physician. The facility did not complete a change of condition evaluation or revise the care plan accordingly, as confirmed by the DON during a review.
A facility failed to accurately conduct infection surveillance and assessment for a resident with a skin and soft tissue infection. Despite meeting criteria for infection in August and September, the resident's condition was not properly documented in the Infection Surveillance Monthly Reports. Interviews with the IP and DON confirmed these discrepancies, highlighting a lapse in the facility's infection control processes.
Failure to Notify Physician of Resident Behavior Change
Penalty
Summary
The facility failed to notify the resident's physician of a change in condition for one sampled resident who had an episode of verbal aggression toward staff. The facility's policy required prompt notification of the resident, consultation with the resident's physician, and notification of the resident's representative when there was a change requiring notification. Resident 1 was admitted and later readmitted to the facility, and the H&P dated 12/16/25 showed the resident had the capacity to understand and make decisions. A nursing progress note dated 4/28/26 documented that Resident 1 became verbally aggressive toward staff and refused to allow staff to keep the door open for close monitoring of a confused roommate who was at risk for falls; police were called to the facility because of the incident. The medical record did not show that a change of condition report was completed for this incident, and there was no documentation that the physician was notified. During interviews, an LVN stated she could not recall whether the physician had been notified, an RN verified the physician had not been notified but should have been, and the DON verified the findings.
Failure to Implement and Document Fall-Related Interventions and Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and care to prevent or minimize injuries from falls, as required by facility policies on documentation, care plan revision upon status change, and the fall prevention program. The facility’s policies required licensed staff and the interdisciplinary team to document all assessments and services in the medical record, to review and revise care plans after a status change, and to implement fall interventions based on fall risk, including environmental measures and monitoring of vital signs. Despite these policies, surveyors identified multiple instances where fall-related interventions were not resident-centered, physician orders were not fully implemented, and required assessments were incomplete or missing. For one resident with a history of a fall and a documented unwitnessed fall with a bump on the left forehead, the care plan created after the fall did not include interventions for bilateral floor mats, even though therapy documentation showed the bed was lowered and bedside mats and an additional mattress were in place. Observations on two separate days showed the resident in bed with a fall mattress on one side and a floor mat on the other side of the bed. During interview and record review, the DON confirmed there was no physician order or care plan intervention for floor mats and stated the resident was not supposed to have floor mats because a big boy bed had been implemented instead, indicating that the fall-related environmental intervention in use was not reflected in the resident’s care plan. For another resident on an antiplatelet (blood thinner) for stroke prophylaxis, the facility documented two separate falls. After the first fall, the care plan called for vital signs every shift and orthostatic blood pressures (lying, sitting, standing) within the first 24 hours. The neurological flowsheet for that event showed repeated blood pressure readings only in the lying position and did not show orthostatic measurements as care planned. When the resident was transferred to an acute care facility and returned later the same day, the orthostatic blood pressure intervention was not continued or revised within the 24-hour period, and the DON later verified that the care plan should have been continued or updated. After a subsequent fall, the neurological flowsheet contained multiple blank entries for vital signs, pupil response, motor response, consciousness, speech, and patient response at several time points, indicating incomplete 72-hour neurological assessments. In addition, a physician order and care conference recommendation for bilateral floor mats were not fully implemented, as repeated observations showed only one floor mat in place, and an LVN and the DON confirmed that bilateral mats were ordered but not provided. For a third resident who experienced a fall with a bump and laceration to the left forehead, the change in condition evaluation documented provider recommendations to keep ice on the forehead, monitor blood pressures for 72 hours, and notify the physician. A subsequent physician order directed monitoring for orthostatic hypotension with blood pressures taken lying, sitting, and standing every shift for three days. The MAR showed a check mark indicating the task was completed, but no orthostatic blood pressure results were documented. The care plan for this resident’s fall included neuro checks per facility protocol and monitoring orthostatic blood pressure as ordered. However, the neurological flowsheet contained multiple blank entries for vital signs, pupil response, motor response, consciousness, speech, and patient response at several scheduled times. During interview, an RN stated the check mark on the MAR indicated completion of the task but acknowledged that the orthostatic blood pressure data could not be seen and verified that neurological assessments were incomplete and orthostatic blood pressures were not obtained per order. The DON later confirmed these findings.
Failure to Obtain Orders, Consent, and Monitoring for Use of Soft Mitt Restraints
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate use and management of physical restraints for one resident who was readmitted to the facility and returned from an acute care hospital with bilateral soft hand mittens in place. The facility’s own policies on a restraint-free environment and informed consent require that physical restraints only be used to treat a specific medical symptom, with a practitioner’s order, informed consent, and clear parameters for use, monitoring, and release. The policies also require that behavioral interventions be exhausted before restraints are used, and that informed consent be verified and documented by licensed nursing staff, except in documented emergencies. For this resident, medical record review showed no physician’s order, no signed informed consent, no assessment, no monitoring documentation, and no care plan addressing the use of the bilateral soft mitten restraints. There was also no documentation that the mittens were removed at regular intervals, that the resident’s hands and wrists were assessed, or that range of motion (ROM) exercises were performed every two hours as required by the facility’s policy. Medication Administration Records and shift assignment sheets identified LVN staff assigned to and administering medications to the resident during the period in question, but the records still lacked any restraint-related documentation. In interviews, LVN 1 stated the resident arrived with bilateral hand mittens and acknowledged being unaware of any informed consent and that the resident’s hands and wrists were not assessed while the mittens were on. LVN 4 reported that the resident returned to the facility with mittens, recognized them as restraints, and stated there were no orders for restraints, so she said she instructed a CNA to remove them; however, CNA 1 denied being instructed to remove the mittens and only recalled seeing the mittens in the resident’s closet. The DON stated she was unaware the resident was admitted with mittens and asserted that the facility does not use mittens, further stating that if a resident were admitted with soft mitten restraints, there should be documentation of physician orders, consent, assessments, two-hour removal for circulation checks, and a care plan. The Administrator and DON later acknowledged the findings identified in the review.
Failure to Include Key Witness Interview in Abuse Investigation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident physical abuse involving a resident who reported being slapped, choked, and having her hands squeezed by a caregiver. The resident, who had moderately impaired cognition, stated that her roommate was present during the alleged incident and reported the event to facility staff. The facility's policy requires immediate investigation of abuse allegations, including interviewing all involved individuals and potential witnesses. During the investigation, the facility staff responsible for conducting witness interviews did not provide the Abuse Coordinator with the interview conducted with the resident's roommate, who was identified as a potential witness. The roommate, also with moderately impaired cognition, stated she did not see the abuse due to poor vision but heard the resident yelling about being hit. The interview with the roommate was conducted by the Social Services Assistant (SSA), but the documentation was not included in the investigation file and was instead placed in the facility's shred box by the Social Services Director (SSD) after being told by the MDS Coordinator that the roommate had no capacity to be interviewed. The Administrator, who served as the Abuse Coordinator, confirmed that the interview with the roommate should have been included in the investigation, as per facility policy. The omission of this interview meant that not all potential witness information was available to determine whether abuse occurred, and the facility's investigation was incomplete as a result.
Failure to Monitor Resident After Fall Incident
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained their highest practicable well-being following a witnessed fall. The resident, who had severe cognitive impairment and required substantial to maximal assistance with mobility, experienced a fall when being wheeled by a CNA; the wheelchair became stuck in a carpet, causing the resident to slide forward. Although the resident did not hit their head or sustain injuries, the facility's policy required that after any fall, the resident should be assessed and monitored for pain, discomfort, vital signs, and changes in level of consciousness, with documentation of all assessments and actions. Despite these requirements, there was no documented evidence that licensed nurses continued to monitor or assess the resident after the fall incident. Both the RN and DON confirmed that the resident was not monitored every shift for 72 hours as required by facility policy following a change in condition such as a fall. The lack of continued monitoring and assessment was verified through medical record review and staff interviews, indicating a failure to follow established protocols for post-fall care.
Incomplete Monitoring Documentation for Residents in Falling Star Program
Penalty
Summary
The facility failed to ensure that medical records were complete and accurately maintained for two residents, identified as Residents 9 and 10, who were part of the Falling Star Program. This program was designed to reduce the incidence of falls and required hourly monitoring of residents' locations, which was to be documented by the CNAs. However, there was no documented evidence of monitoring for both residents on specific dates in March 2025, indicating a lapse in the required hourly checks. Resident 9, who had moderate cognitive impairment and required substantial assistance with mobility, was readmitted to the facility and placed in the Falling Star Program following a fall incident. Despite the program's requirements, there were gaps in the documentation of Resident 9's location monitoring on March 9, 10, and 12, 2025. Interviews with facility staff revealed that the CNA responsible for Resident 9 on March 12 did not document the monitoring due to not receiving the necessary form from the charge nurse, although the CNA claimed to have performed the checks. Similarly, Resident 10, who lacked the capacity to understand and make decisions and also required substantial assistance with mobility, was admitted to the Falling Star Program after a fall. The facility's records showed missing documentation for Resident 10's location monitoring on the same dates as Resident 9. Interviews with staff indicated that the absence of documentation could mean the monitoring was either not performed or not recorded. The facility's DON confirmed the program's requirements and acknowledged the deficiencies in documentation for both residents.
Failure to Update Care Plan for Low Hematocrit and Hemoglobin Levels
Penalty
Summary
The facility failed to update the care plan for one of the sampled residents, identified as Resident 1, following a significant change in their medical condition. Resident 1 had laboratory results indicating critically low hematocrit and hemoglobin levels, which were reported to the physician. However, the medical record review revealed that the facility did not complete a change of condition evaluation or update the care plan to address these low levels. This oversight was confirmed during an interview and medical record review with the Director of Nursing (DON), who acknowledged that the necessary updates to the care plan were not made.
Inaccurate Infection Surveillance and Reporting
Penalty
Summary
The facility failed to accurately conduct surveillance and assessment of a skin and soft tissue infection for one of the sampled residents, identified as Resident 4. The facility's Infection Prevention and Control Program, revised in December 2022, mandates that RNs and LPNs participate in surveillance by assessing residents and reporting changes in condition. However, discrepancies were found in the Infection Surveillance Monthly Reports for August and September 2024. In August, Resident 4 was treated with doxycycline for an abscess on the lower back, which met the McGeer's Criteria for infection, yet the monthly report did not reflect this. Similarly, in September, Resident 4 exhibited symptoms meeting the Loeb's Criteria for a suspected skin and soft tissue infection, but the monthly report failed to include this case. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed these discrepancies. The IP acknowledged that the Infection Surveillance Monthly Reports did not align with the Infection Screening Evaluations for both months. The DON also verified the findings, indicating a lapse in the facility's infection surveillance and reporting processes, which posed a risk of not identifying and managing Resident 4's skin infection appropriately.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Garden Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alta Gardens Care Center | 0.4 mi | ★★★★★ | 39 | 0 |
| The Grove Post Acute | 0.6 mi | ★★★★★ | 3 | 0 |
| Chapman Care Center | 0.9 mi | ★★★★★ | 23 | 0 |
| Pacific Haven Subacute And Healthcare Center | 1 mi | ★★★★★ | 3 | 0 |
| Citrus Post-acute | 1.2 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.