Health inspection·August 10, 2023

F 0580 Level of Harm - Potential for minimal harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **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 notify the physician and family member of an unwitnessed fall incident in a timely manner for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to not receive the appropriate care and services in a timely manner. Findings: Review of the facility's P&P titled Change of Condition dated 3/2021 showed it isthe facility's policy that any changes in the residents' conditions be thoroughly assessed and evaluated with the physician's notification for early clinical management to avoid unnecessary readmission to the acute care hospitals. Medical record review for Resident 1 was initiated on 8/8/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical examination dated 8/5/23, showed Resident 1 had the capacity to understand and make decisions. Review of the Resident 1's Care Plan dated 8/2/23, showed a care plan problem addressing high risk for falls with the interventions including to notify thephysician of any fall incidents. Review of Resident 1's Physician Order dated 8/2/23, showed to inject enoxaparin (blood thinner) prefilled syringe 40 mg/0.4 ml subcutaneously (inject to fatty tissue under the skin) every 24 hours. Review of the Resident 1's 72 Hours Neuro-check List showed the neuro check was initiated on 8/3/23 at 0245 hours, after Resident 1 had an unwitnessed fall. Review of the Nurses Notes dated 8/3/23, showed the following: - At 0315 hours, the continued neuro check was performed, and Resident 1 denied hitting his head. - At 0615 hours, the continued monitoring for unwitnessed fall was performed with 72 hours neuro check. - At 0700 hours, the family was notified and left a message for the on-call physician. (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: 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 08/10/2023 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)