Health inspection·April 4, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **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 provide the necessary care and services to prevent a fall incident for one of two sampled residents (Resident 1). * Resident 1's shower chair wheels were not locked when arriving at the shower room; therefore, when the resident removed his cover and leaned forward, the shower chair moved and tilted forward, causing the resident to fall on his left knee and sustaining a fracture. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Fall Risk and Prevention of Injury to include Pathological Fractures revised 03/2019 showed it is the policy of the facility to identify residents that are at risk for falls and to implement a plan of care in an attempt to prevent falls. This includes minimizing the risks for pathological fractures. Under the section for approaches to prevent falls and/or fractures, it includes locking the brakes on beds, gurneys, or wheelchairs. Review of the facility's P&P titled Falling Start Program revised 7/2018 showed to identify the residents who are at high risk for falls, to try to prevent falls and to attempt to increase supervision for the residents assessed to be high risk for falls. Under the section for Prevention, the general safety precautions and interventions should be used for the residents and include locking the brakes on beds, gurneys, or wheelchairs. Medical record review for Resident 1 was initiated on 4/4/24. Resident 1 was readmitted to the facility on [DATE], with diagnoses of paraplegia. Review of Resident 1's History and Physical examination dated 10/10/23, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's quarterly MDS assessment dated [DATE], showed the following: - Section C - Cognitive Patterns showed Resident 1's BIMS score was 15 (cognitively intact) - Section GG - Functional Limitation in Range of Motion showed Resident 1's upper extremity has impairment on one side (shoulder, elbow, wrist, and hand), and the lower extremity has impairment on both sides (hip, knee, ankle, and foot) (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 04/04/2024 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)