Inspection visit

Health inspectionMay 9, 2022

CHAPMAN CARE CENTERCMS #0558167 citations on this visit

7 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 7 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to follow up with the regional center's correspondence to enquire if a Preadmission Screening and Resident Review (PASRR) Level II Screening were to be completed to determine specialized services available for one of 18 final sampled residents (Resident 15). This failure had the potential to delay additional services for individualized care and support to enhance their quality of life and to assist them in realizing their full potential, as well as integrating services into the plan of care. Residents Affected - Few Findings: According to Medicaid.gov, Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care .PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness (SMI) and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings); and 3) receive the services they need in those settings . Medical record review for Resident 15 was initiated on 5/3/22. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's Preadmission Screening and Resident Review (PASRR) Level I Screening dated 2/6/22, showed the resident was suspected or had a primary diagnosis of an ID (intellectual disability), DD (developmental delay) or RC (related condition), present since birth. The screening data showed the resident experienced functional limitations as a result of the ID/DD. The PASRR showed the Level I screening was negative and was closed yes for ID/DD/RC. Review of Resident 15's medical record showed the letter form the Department of Health Care Services dated 2/6/22. The letter showed Resident 15's PASRR Level I screening indicated a Level II Mental Health Evaluation was not required. Review of Resident 15's medical record showed the fax transmittal addressed to the DON from the Regional Center of Orange County (RCOC), dated 2/25/22. The fax showed the RCOC received Resident 15's PASRR request from the Department of Developmental Services. The letter showed the regional center could provide services to the residents with developmental disabilities and their families seeking to obtain local support and services. The RCOC would collaborate with the persons with DD, their families and the community to secure individualized services and supports that enhance their quality of life and to assist them in realizing their full potential. In order to determine eligibility, the regional center would require further documentation (i.e. medial records), and in order to reactivate (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 16 Event ID: 055816 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0645 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 15's case, an authorized representative would need to contact the RCOC to make the request. The fax showed per the above, a Level II Screening/PASRR could not be completed at this time. On 5/3/22 at 0935 hours, a telephone interview was conducted with Resident 15's RP (responsible party). When asked about the RCOC services, Resident 15's RP stated they had not heard anything regarding the RCOC from the facility or RCOC, but hoped Resident 15 was still getting services. Resident 15's RP stated the resident did not receive many RCOC services at the prior facility since so many other services were already being provided, for example, the local school district provided special education school services. The RP stated they were not sure what was going on with services at the current facility, but they were very interested in getting more services for Resident 15. On 5/4/22 at 1500 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed the fax transmittal letter dated 2/25/22, addressed to her from the RCOC. When asked if the DON had followed-up on the letter, the DON stated no, and that she did not recall seeing the letter. On 5/5/22 at 1058 hours, a telephone interview was conducted with the RCOC Federal Programs and Benefits Coordinator. The RCOC Federal Programs and Benefits Coordinator stated they sent to the fax to the facility, with the understanding the facility would reach out to Resident 15's responsible party to see if they would like the RCOC to reopen Resident 15's case. The RCOC Federal Programs and Benefits Coordinator stated if Resident 15's case was reopened, a service coordinator would be assigned to determine appropriate services, interventions, and case management support for the resident and their family. The RCOC Federal Programs and Benefits Coordinator stated Resident 15 was young enough to still qualify for school services, and once they were no longer of school-age, the RCOC could look into day programs. The RCOC Federal Programs and Benefits Coordinator stated the RCOC also would assist with long-term placement options if needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 2 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **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 develop the individualized resident-centered plans of care for two final sampled residents (Residents 15 and 41). * Residents 15 and 41's care plan interventions were not appropriate for their functional abilities. This failure had the potential for Residents 15 and 41 to not receive adequate and individualized care to support safety and well-being, and not communicate their appropriate plan of care to the interdisciplinary team. Findings: Review of the facility's P&P titled Assessment and Care Planning - Interdisciplinary Team revised 01/2018 showed the Interdisciplinary Team is responsible for the development of an individualized resident centered assessment and comprehensive care plan for each resident. 1. Medical record review for Resident 15 was initiated on 5/3/22. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's History And Physical Examination dated 2/7/22, showed Resident 15 did not have the capacity to understand and make decisions and was a G-Tube (a tube inserted through the abdominal wall into the stomach) dependant. Review of Resident 15's Physician Order Report for May 2022 showed a physician's order dated 2/6/22, for NPO (nothing by mouth). Review of Resident 15's MDS dated [DATE], showed Resident 15 rarely/never understood others and had short and long-term memory problems and severely impaired cognitive skills for daily decision making. The MDS showed Resident 15 was incontinent of bowel and bladder and was totally dependant on the staff for bed mobility, dressing, eating, toileting, personal hygiene and bathing. Resident 15 did not ambulate during the look-back period (2/6/22-2/12/22), and had functional limitations in range of motion to the bilateral upper and lower extremities. Review of Resident 15's Care Plans showed the following: * A short term care plan for urinary retention initiated 4/30/22, showed to encourage voiding every four hours. * A plan of care for respiratory distress initiated 2/6/22, showed to teach the resident relaxation techniques. * A plan of care for vision initiated 2/6/22, showed to discourage the resident from rubbing their eyes. * A plan of care for eye dryness initiated 2/6/22, showed to discourage the resident from touching or rubbing their eyes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 3 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0656 Level of Harm - Minimal harm or potential for actual harm * A plan of care for pain initiated 2/6/22, showed to discuss with the resident's risk factors that precipitate pain and what may reduce it, instruct the resident about pain care and pain medication, and instruct the resident to request pain medication before their pain becomes severe. * A plan of care for bowel incontinence initiated 2/6/22, showed to remind the resident to call for assistance. Residents Affected - Few * A plan of care for constipation/impaction initiated 2/6/22, showed to encourage mobility and exercise if able. * A plan of care for urinary tract infection initiated 2/6/22, showed to instruct the resident in proper cleaning of perineal area after voiding or bowel movement, encourage increased fluid intake if not contraindicated, encourage frequent voiding, and offer cranberry juice with snacks. * A plan of care for osteoporosis (condition in which bones become weak and brittle) initiated 2/6/22, showed to encourage 75-100% consumption of diet. On 5/5/22 at 1420 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 stated Resident 15 was immobile, unable to move their extremities, responded to audio and tactile stimulation with eye opening; and had no other purposeful movement. LVN 6 further stated Resident 15 was incontinent of bowel and bladder, dependent on the staff for all care, and received all fluids via G tube. Resident 15 could not be taught on relaxation techniques, use the call light, or encourage to void or perform other tasks. LVN 6 reviewed Resident 15's care plan and verified the above interventions were not appropriate for Resident 15 and the resident's plan of care was not resident centered and appropriate for the resident's functioning level. 2. Medical record review for Resident 41 was initiated on 5/6/22. Resident 41 was admitted to the facility on [DATE], with a diagnosis of cerebrovascular accident (sudden death of some brain cells due to lack of oxygen). Review of Resident 41's H&P dated 3/11/22, showed Resident 41 did not have the capacity to understand and make decisions and was a G-Tube dependant. Review of Resident 41's MDS dated [DATE], showed Resident 41 needed extensive assistance with bed mobility, transfer, dressing, toileting, personal hygiene, and bathing. Resident 41 was cognitively impaired and incontinent of bowel, had impairment of both upper and lower extremities and balance problems. Review of Resident 41's Care Plans showed the following interventions: * A care plan problem dated 3/13/22, addressed Resident 41's high risk for falls. The interventions included to encourage the resident to ask for assistance, use non-slip footwear/proper shoes, encourage the resident to use canes or walkers, assist the resident with ambulation, encourage the resident to rise slowly from a sitting position, encourage the resident to use the handrails, and use of urinals and/or commodes to minimize ambulation distance. * A care plan problem dated 3/13/22, addressed Resident 41's pain. The interventions included to discuss with the resident about the factors that precipitate pain and what may reduce it, instruct the resident about pain care and pain medication, and instruct the resident to request for pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 4 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0656 medication before pain becomes severe. Level of Harm - Minimal harm or potential for actual harm * A care plan problem dated 3/13/22, addressed Resident 41's potential for pain, respiratory distress, and cardiac failure. The interventions included to monitor for comfort of chest pain, heaviness, squeezing, burning, and choking; monitor for complaint of pain in back, neck, shoulders, and arms; educate the resident about avoiding over exertion, emotional, stress, over-eating, cold temperatures, and importance of promptly reporting symptoms; and educate the resident about risks of smoking and assist with smoking cessation. Residents Affected - Few * A care plan problem dated 3/13/22, addressed Resident 41's potential for activity intolerance. The interventions included to encourage the resident afternoon nap and instruct the resident to report decreased activity intolerance. * A care pan problem dated 3/13/22, addressed Resident 41's risk for potential for constipation. The interventions included to encourage intake of roughage in the diet and encourage the resident to drink all fluids in the meal trays. * A care plan problem dated 3/13/22, addressed Resident 41's at risk for gastrointestinal discomfort. The interventions included to give the resident smaller, more frequent meals, and avoid large intake at one time; instruct the resident to sit up when eating, eat slowly, and chew food thoroughly; instruct the resident to avoid foods that spicy, citrus, greasy or fried, or contain caffeine, and encourage soothing food. * A care plan problem dated 3/13/22, addressed Resident 41's hypercholesterolemia (high levels of cholesterol in the blood). The interventions included to encourage the resident to adhere to diet regimen. * A care plan problem dated 3/13/22, addressed Resident 41's hypotension (low blood pressure). The interventions included to record blood pressure (pressure of the circulating blood against the walls of blood vessels) supine (laying flat), sitting, and standing positions; educate resident on importance of changing positions slowly; and observe for signs and complaints of dizziness. On 5/6/22 at 0706 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 41 was a nonverbal, unable to move on her own, and required extensive assistance. On 5/6/22 at 0940 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 41 was not able to verbalize needs and needed extensive assistance from the staff. On 5/6/22 on 1421 hours, a concurrent interview and record review of Resident 41's medical records was conducted with the Subacute Program Manager. The Subacute Program Manager stated Resident 41 was nonverbal, cognitively impaired, and required extensive assistance from the staff. The Subacute Program Manager further stated Resident 41's plan of care did not reflect her individualized needs and interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 5 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 19's Physician Order Report showed a physician order dated 2/7/22, for a fluid restriction of 1000 mls per day. The order showed the fluid would be distributed between the dietary department for meal tray and the nursing department for each shift for a total of 1000 mls of fluid intake per day as follows: Residents Affected - Few * breakfast tray - 240 mls * lunch tray - 120 mls * dinner tray - 120 mls * nursing 0700-1500 hour shift - 200 mls * nursing 1500-2300 hour shift - 200 mls * nursing 2300 - 0700 hour shift - 120 mls Review of Resident 19's Physician Order Report showed a physician order dated 3/9/22, for Nepro (a nutritional supplement) one carton by mouth twice a day for weight loss and low oral intake. Review of Resident 19's Intake and Output Records from 4/3/22 through 5/9/22, showed no entries on 5/7 and 5/8/22, for 0700-1500 and 1700-2300 shifts, and for the day's total intake. On 5/9/22 at 1311 hours, an interview and concurrent record review were conducted with LVN 1. LVN 1 reviewed Resident 19's physician orders and verified Resident 19 was on a fluid restriction of 1000 mls per day and had an order for a container of Nepro nutritional supplement twice a day. LVN 1 stated for the 0700-1500 shift, nursing may provide the resident with 200 mls of water. The LVN stated the 200 mls consisted of water given during the medication administration, and sometimes the resident requested a cup of coffee. LVN 1 stated they administered one can of Nepro nutritional supplement to Resident 19 on their shift, and the next shift (1500-2300) staff administered the second nutritional supplement. When asked if the LVN included Nepro as part of Resident 19's fluid intake, the LVN stated no. On 5/9/22 at 1315 hours, an interview was conducted with the DON. The DON stated Nepro should be counted as part of the resident's intake. The DON stated if the nurses were providing the supplement to the resident, the nurses should count the supplement as part of the nursing fluid allotment. On 5/9/22 at 1423 hours, a telephone interview was conducted with the RD. The RD verified the Nepro nutritional supplements should be included in the resident's fluid intake. The RD stated if the supplement was delivered on the resident's meal trays, then it would be included with the dietary departments allotment, but since Resident 19's Nepro was provided by the nursing staff, the nurses would include the supplement in the shift's fluid allotment. On 5/9/22 at 1441 hours, a follow-up interview and observation were conducted with LVN 1. LVN 1 was asked how much fluid was in the container of the Nepro. LVN 1 was unsure and retrieved a container from the medication room and stated the container was labeled as providing 237 mls. LVN 1 verified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 6 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few one container of Nepro was more than the allotted 200 mls for the 0700-1500 and 1500-2300 shifts. LVN 1 stated when the resident's intake went above the fluid restriction amount, the staff should monitor for fluid overload and shortness of breath and notify the physician. Based on observation, interview, and medical record review, the facility failed to ensure one of 18 final sampled residents (Resident 19) received services consistent with professional standards of practice when: * Resident 19's arm with a dialysis access site was used for taking blood pressures despite a physician's order not to do so. * Resident 19's fluid restriction orders were not followed and the resident's fluid intake logs were inaccurate. These failures had the potential to negatively impact the resident's physical well-being. Findings: 1. According to the facility's P&P titled Dialysis Care dated 9/2017, blood pressure and venous punctures will not be performed on the extremity where the shunt is located. Medical record review for Resident 19 was initiated on 5/9/22. Resident 19 was admitted to the facility on [DATE], and had a diagnosis of end stage renal disease which required hemodialysis. Review of Resident 19's Physician Order Report dated 5/1/22, showed a physician's order dated 2/6/22, for AV shunt to the left forearm but non-functioning, no blood pressure and blood draw to the left arm. Review of Resident 19's care plan dated 2/8/22, showed the AV shunt to the left upper arm non-functioning. The intervention showed no blood pressure, and blood draw to left arm. On 5/9/22 at 0829 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 was observed taking a blood pressure on Resident 19's left arm and stated Resident 19's dialysis access site was on her right chest. CNA 3 further stated there was nothing on the resident's arms. On 5/9/22 at 1516 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 19 had a permacatheter (a special IV line inserted into the blood vessel in the neck or upper chest just under the collarbone, used for short-term dialysis treatment). LVN 1 was asked how he monitored the dialysis access site before and after dialysis for Resident 19. LVN 1 stated he monitored the dialysis access site for signs and symptoms of bleeding. The above finding was verified with LVN 1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 7 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, medical record review, and facility P&P review, the facility failed to ensure proper accounting and safeguarding of the controlled medications to prevent loss, diversion, or accidental exposure when the incoming and outgoing licensed nurses assigned to Medication Carts A and B were inconsistent with signing the shift count log. This failure posed the risk for loss or diversion of controlled medications. Findings: Review of the facility's P&P titled Controlled Medication Storage dated 8/2014, under the section for Policy showed the medications included in the Drug Enforcement Administration classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state and other applicable laws and regulations. The Procedures section showed at each shift change, a physical inventory of all controlled medications, including the emergency supply is conducted by two licensed nurses and is documented on the controlled medication accountability record. 1. Review of the Medication Cart A narcotic logbook showed the Floor Narcotic Release log with the missing licensed nurses' signatures on the following dates: - 4/26/22, for the 3-11 outgoing shift - 4/28/22, for the 3-11 incoming shift - 4/29/22, for the 11-7 outgoing shift and 3-11 outgoing shift - 5/1/22, for the 7-3 incoming shift and 3-11 incoming shift - 5/2/22, for the 11-7 outgoing shift On 5/6/22 at 1412 hours, an interview and concurrent facility document record review was conducted with LVN 3. LVN 3 verified multiple licensed nurses' signatures were missing in the Floor Narcotic Release log. When asked what the shift count log was for, LVN 3 stated the incoming and outgoing nurses counted the medications at the end of shift to ensure the narcotic medication counts were reconciled properly to prevent possible diversion of narcotic medications. LVN 3 stated once the count was confirmed, the incoming and outgoing licensed nurses had to sign the Floor Narcotic Release log. 2. Review of the Medication Cart B narcotic logbook showed the Floor Narcotic Release log with the missing licensed nurses signatures on the following dates: - 4/13/22, for the 1900-0700 outgoing shift - 4/22/22, for the 1900-0700 outgoing shift On 5/6/22 at 1454 hours, an interview and concurrent facility document record review was conducted with LVN 4. LVN 4 verified multiple licensed nurses' signatures were missing in the Floor Narcotic Release log. LVN 4 stated the licensed nurses forgot to sign the Floor Narcotic Release log. When (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 8 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0755 Level of Harm - Minimal harm or potential for actual harm asked what the shift count log was for, LVN 4 stated the incoming and outgoing nurses counted the medications and signed the Floor Narcotic Release log at the end of shift to ensure the narcotic medications counts were reconciled properly. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 9 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the pharmacy consultant's recommendation was acted upon for one of 18 final sampled residents (Resident 15). This had the potential for the resident to be administered a sub-therapeutic medication. Findings: Review of the facility's Drug Regimen Review P&P revised 10/2017 showed the pharmacy consultant reviews each residents' medical records monthly and will report any irregularities. The P&P showed the physician will respond within 72 hours, or the nurse will call the physician to follow up. Medical record review for Resident 15 was initiated on 5/3/22. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's physician progress notes showed a note to the resident's physician from the consultant pharmacist printed 3/18/22. The note showed Resident 15 was on Ativan (a sedative that can be used to treat seizures) 1 mg IM (intramuscular -injected in to the muscle) every 12 hours as needed for seizures, and IM Ativan was not preferred due to erratic absorption and slow time to peak drug level. The note asked the physician to consider an alternate and listed other appropriate alternates. A hand written note on the bottom was dated 4/1/22, and showed, agree was selected and to administer Ativan IV (intravenous -into the vein) every 12 hrs as needed for seizure activity. Review of Resident 15's Physician Order Report for 5/1/22-5/31/22, showed a physician's order dated 2/8/22, for Ativan 1 mg IM every 12 hours as needed for seizure activity. Further review of the physician's orders did not show the Resident 15's Ativan was changed from IM to IV based on the consultant pharmacy notes which the physician agreed to. Review of Resident 15's Medication Flowsheet for April 2022 showed on 4/20/22 at 1830 hours, Ativan 1 mg IM was administered to Resident 15 as needed for seizure activity. On 5/5/22 at 1008 hours, an interview and concurrent medical record review was conducted with the Subacute Program Manager. The Subacute Program Manager stated the pharmacy consultant reviewed each resident medical records monthly and made recommendations if needed. The DON would distribute copies of the recommendation to the nursing staff to follow-up. The pharmacy consultant's notes to the physician were placed in the physician's progress notes section of the resident's medical record for the physician to review. If the physician agreed with the recommendation, the approved recommendation was transcribed as an order. The Subacute Program Manager reviewed the pharmacy consultant's recommendation for Resident 15's Ativan order and stated on 4/1/22, the resident's physician documented he agreed to the consultant's recommendation, and wrote Ativan 1 mg to be administered IV every 12 hours as needed for seizure activity. The Subacute Program Manager verified Resident 15's Ativan was not changed from IM to IV. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 10 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner for one of two medications rooms (Medication Room A) and one of eight medication carts (Treatment Cart A). * Eight expired telfa dressings, expired hydrocerin lotion (a moisturizer used to treat or prevent rough, dry skin) and a bag of expired foley catheter leg bag were observed in Treatment Cart A. This failure had the potential for the residents to be exposed to the expired or deteriorated medications or biologicals. * The facility failed to ensure Residents A and B's medications were disposed of at the time of their discharges. This failure had the potential for the medications to be accidentally administered and/or diverted. Findings: According to the facility's Policy and Procedure titled Storage of Medications dated 4/2008, under the section Policy, showed the medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. The Procedures section showed only licensed nurses, pharmacy personnel, and those lawfully authorized are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Outdated, contaminated, or deteriorated medications and those containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. 1. On [DATE] at 1126 hours, during the inspection of Treatment Cart A with LVN 5, the following was observed: - eight telfa adhesive dressings with an expiration date of 1/2022, - a tube of used hydrocerin extra dry skin care lotion with an expiration date of 5/2020, and - a bag of foley catheter leg bag with an expiration date of [DATE]. LVN 5 acknowledged the above findings and stated it was the responsibility of the treatment nurses to check the treatment carts and ensure all items were up to date and not expired. LVN 5 verified the findings and stated the expired items should have been disposed. 2. On [DATE] at 1327 hours, an observation of Medication Room A with concurrent interview with the ADON was conducted. The following was observed inside the refrigerator: - A bottle of Aranasp (medicine used to treat a lower than normal number of red blood cells or anemia) for Resident A. The ADON stated Resident A was sent out to the hospital and had expired on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 11 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0761 [DATE]. Level of Harm - Minimal harm or potential for actual harm - A bottle of Epogen (medicine used to treat a lower than normal number of red blood cells or anemia) for Resident B. The ADON stated Resident B was discharged from the facility on [DATE]. Residents Affected - Few When asked what the process was for the medications of discharged residents, the ADON acknowledged the above findings and stated the medications should have been disposed. The ADON verified the discontinued medications had to be removed from the medication room refrigerator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 12 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by the following: Residents Affected - Some * The facility failed to ensure the storage containers for dry food were completely sealed without noticeable gaps. * The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface. * The facility failed to ensure the peelers were in sanitary condition and free of food particles. * The facility failed to ensure the kitchen equipment was air dried and free of food particles. * The facility failed to ensure the kitchen utensils were clean and free of food particles. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were not worn out. * Unlabeled white powder was observed stored inside the metal storage for clean plastic containers. *A food tray with an uncovered bowl of peaches was left on top of the PPE cart and brought to a resident's room. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the Form CMS-672 titled Resident Census and Conditions of Residents completed by the facility dated 5/4/22, showed 47 of 80 residents residing in the facility received food prepared in the kitchen. 1. According to the FDA Food Code 2017, Section 3-305.11 Food Storage. (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. During the initial tour of the kitchen on 5/3/22 at 0755 hours, a concurrent observation and interview was conducted with the DSS (Dietary Services Supervisor). The following food items on the dry storage shelves were not completely sealed: - one clear storage plastic container labeled Korean rice, - one clear storage plastic container labeled rice, and - one clear storage plastic container labeled flour. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 13 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 5/3/22 at 0755 hours, a concurrent interview was conducted with the DSS. The DSS verified the above findings and stated the plastic containers should have been completely sealed and closed to prevent the contamination of food. 2. According to the 2017 FDA Food Code Section 4-202.11, multi-use food contact surfaces shall be smooth; free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; free of sharp internal angles, corners, and crevices; and finished to have smooth welds and joints. During the initial kitchen tour on 5/3/22 at 0755 hours, a concurrent observation and interview was conducted with the DSS. A blue cutting board was observed with dry food residue and the white and brown cutting boards were observed with deep groves and to be heavily marred. The DSS verified the findings and stated the cutting boards should have been changed because food could get into the deep groves and the cutting boards could not be cleaned properly. 3. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. During the initial kitchen tour on 5/3/22 at 0755 hours, a concurrent observation and interview was conducted with the DSS. A pink peeler was observed with brownish discoloration (metal part) and yellow stain on the pink plastic part of the peeler. A black peeler was also observed with dry food residue. The DSS verified the findings. On 5/4/22 at 1005 hours, a subsequent interview with the DSS was conducted. The DSS stated the pink peeler should have been replaced. 4. According to the USDA Food Code 2017, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. a. During the initial kitchen tour on 5/3/22 at 0755 hours, a concurrent observation and interview was conducted with the DSS. A robot coupe food processor was observed with white food particle or residue inside, and a blender stored in the counter shelves with the lid on was still wet inside. The DSS verified the finding and stated the equipment should have been stored dry to prevent from dripping and developing of mold. b. On 5/4/22 at 1045 hours, an observation of puree preparation and concurrent interview was conducted with the [NAME] and the DSS. The [NAME] was observed holding the blender which was not fully air dried and placed on the blender base prior to use. The findings were verified with the DSS. The DSS stated it was not okay to use the wet blender and it needed to be air dried. 5. According to the FDA Food Code, 2017 4-601.11, it is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the FDA Food Code Annex 4-602.13, the presence of food debris or dirt on nonfood (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 14 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. During the initial kitchen tour on 5/3/22 at 0755 hours, a concurrent observation and interview was conducted with the DSS. Two green scoops used for puree portioning were observed with dry, crusted food residue stored inside the metal drawer used for storing clean scoops and ladles. The DSS verified the findings and stated the scoops should have been washed and cleaned properly to prevent food contamination. 6. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. During the initial kitchen tour on 5/3/22 at 0755 hours, an observation and concurrent interview was conducted with the DSS. One basting brush was observed to be worn out with frayed bristles and melted handle. The DSS verified the findings and stated it should have been replaced. On 5/4/22 at 1025 hours, an observation and concurrent interview was conducted with the DSS. The [NAME] was observed using a pan with black stains inside to melt butter. The DSS verified the finding and further stated the pan needed to be replaced. 7. According to the USDA Food Code 2017, Section 3-302.12, Certain foods may be difficult to identify after they are removed from their original packaging. Consumers may be allergic to certain foods or ingredients. The mistaken use of an ingredient, when the consumer has specifically requested that it not be used, may result in severe medical consequences. The mistaken use of food from unlabeled containers could result in chemical poisoning. For example, foodborne illness and death have resulted from the use of unlabeled salt, instead of sugar, in infant formula and special dietary foods. Liquid foods, such as oils, and granular foods that may resemble cleaning compounds are also of particular concern. On 5/4/22 at 1032 hours, an observation and concurrent interview was conducted with the DSS. The [NAME] was observed reaching for a metal pitcher filled with an unlabeled white powder. The pitcher was stored inside the metal storage used for clean plastic storage containers. The finding was verified with the DSS. The DSS stated it could be a thickener but should have been labeled and not stored together with the clean plastic storage containers. 8. According to the United States Food and Drug Administration (U.S. FDA) Food Code 2017, under Preventing Contamination from the Premises Annex 3-305.11 titled Food Storage, food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination. On 5/3/22 at 1220 hours, during a dining observation, RN 1 was observed placing a food tray on top of the PPE cart located outside Room A. Room A was in the yellow zone with signs posted by the door for proper donning and doffing of PPE. The food tray had one plate with a plate dome cover, one small bowl of kimchi with plastic wrap cover, one small bowl with a translucent plastic cover, one mug (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 15 of 16 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 055816 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Care Center 12232 Chapman Ave 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 0812 with plastic wrap cover and one cup with plastic wrap cover, and one uncovered bowl of peaches. Level of Harm - Minimal harm or potential for actual harm On 5/3/22 at 1224 hours, a concurrent observation and interview was conducted with CNA 2. CNA 2 acknowledged the uncovered bowl of peaches and stated it should be covered. CNA 2 proceeded to pick up the food tray, entered Room A and placed the food tray on a side table. When asked if it was still ok to serve the uncovered bowl of peaches that was placed on top of the PPE cart at 1219 hours, CNA 2 stated no because of infection control purposes and she would throw away the uncovered bowl of peaches and get a new one from the kitchen. Residents Affected - Some On 5/3/22 at 1228 hours, an interview was conducted with the RN. The RN acknowledged the uncovered bowl of peaches and stated everything on the food tray should be covered. On 5/3/22 at 1230 hours, an interview was conducted with the DSS. When asked if it was ok to leave the food tray out for four minutes on top of the PPE cart with an uncovered bowl of peaches, the DSS stated no. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 16 of 16

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Citations

7 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.

0645GeneralS&S Dpotential for harm
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0756GeneralS&S Dpotential for harm
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
0698GeneralS&S Dpotential for harm
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0812GeneralS&S Epotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

FAQ · About this visit

Common questions about this visit

What happened during the May 9, 2022 survey of CHAPMAN CARE CENTER?

This was a inspection survey of CHAPMAN CARE CENTER on May 9, 2022. The surveyor cited 7 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at CHAPMAN CARE CENTER on May 9, 2022?

Yes, 7 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "PASARR screening for Mental disorders or Intellectual Disabilities"

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 June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·May 9, 2022