Health inspection·July 8, 2025

F 0880 Provide and implement an infection prevention and control program. 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 implement the infection control practices designed to provide a safe and sanitary environment to help prevent the development and transmission of diseases and infections for one sampled resident (Resident 8) observed for infection control practices. * The facility failed to ensure CNA 1 donned the appropriate PPE when providing care to Resident 8 with a physician's order for EBP. This failure posed the risk of transmission of infections to the residents throughout the facility.Findings:Review of the facility's P&P titled Enhanced Standard Precautions revised on 5/2024 showed the following:- Enhanced Standard Precautions provide the Skilled Nursing Facility a framework for reducing Multi-Drug Resistant Organism (MDRO) transmission through Healthcare Professional (HCP) use of gowns and gloves while caring for residents at high risk for MDRO transmission at the point of care during specific activities with the greatest risk for MDRO contamination of HCP hands, clothes, and the environment. Also is a resident-centered and activity-based approach for preventing MDRO transmission in SNF;- Enhanced Barrier Precautions (EBP) is an approach of targeted gown and glove use during high contact resident care activities, designed to reduce transmission of Staphylococcus aureus and MDROs;- California Department of Public Health (CDPH) recommends the use of ESP primarily the use of gowns and gloves for specific high contact care activities based on the resident's characteristics that are associated with a high risk of MDRO colonization and transmission including presence of indwelling devices such as urinary catheter, feeding tube, endotracheal or tracheostomy tube, vascular catheters and wounds; and- Six Moments of Enhanced Standard Precautions include everyone must perform hand hygiene before entering the room. Anyone participating in any of the following six moments must don gown and glove, which includes during morning and evening care, toileting or changing of incontinence briefs, care for devices, invasive procedures sites and giving medical treatment, wound care, mobility assistance and preparing to leave the resident's room and cleaning of the environment. Medical record review for Resident 8 was initiated on 7/8/25. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 12/28/24, showed Resident 8 had no capacity to understand and make decisions. Review of Resident 8's MDS assessment dated [DATE], showed the BIMS assessment was not conducted for Resident 8 due to not having the capacity to understand. Review of Resident 8's Order Summary Report dated 7/8/25, showed the following physician's order:- dated 12/26/24, to check the GT placement and patency every shift; and- dated 12/27/24, for EBP every shift due to GT.On 7/7/25 at 0925 hours, an EBP signage was posted outside Resident 8's room and a PPE cart was also observed outside the resident's room. CNA 1 was observed providing care to Resident 8 and was not wearing a gown. On 7/7/25 at 0930 hours, an observation and concurrent interview for Resident 8 was conducted with RN 2. RN 2 was asked regarding the use of PPE for the residents on EBP. RN 2 stated the PPE was used when the staff were providing care to the residents as shown on the six moments of the EBP signage posted outside Resident 8's room. RN 2 stated all the residents in Resident 8's room were on EBP due to the presence of a Foley catheter or GT. RN 2 observed CNA 1 was providing incontinent care to Resident 8 and not wearing a gown. RN 2 verified the above findings. RN 2 stated Resident 8 had a GT and was on EBP. Furthermore, RN 2 stated the staff must wear the appropriate PPE which included the gloves and gowns when providing the incontinence care for the residents on the EBP. On 7/7/25 at 1105 hours, an observation and concurrent interview for Resident 8 was conducted with the DSD. The DSD observed and verified Resident 8's room was on EBP and the resident had a GT. The DSD was asked about the facility's practice pertaining to the residents on the EBP. The DSD stated the staff must wear the appropriate PPE (gloves and Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055816 If continuation sheet Page 2 of 3 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 07/08/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete gowns) inside Resident 8's room during the specified six moments signage posted outside the resident's door. The DSD stated the staff must wash their hands and don a gown and gloves prior to providing care on each resident in the room. The DSD stated the staff's failure to follow the infection control protocol for the residents on the EBP would compromise the residents' health. On 7/7/25 at 1330 hours, an interview was conducted with CNA 1. CNA 1 was asked about the EBP in Resident 8's room. CNA 1 stated for the resident's on the EBP, there was a signage posted outside Resident 8's room with the information on what PPE to use and when to use it. CNA 1 stated it was his mistake for not wearing a gown when he provided the incontinent care to Resident 8. CNA 1 stated Resident 8 had a GT, and he must wear the appropriate PPE which included the gloves and gown during care. On 7/7/25 at 1525 hours, an interview was conducted with the IP. The IP was asked about the facility's practice pertaining to the residents on EBP. The IP stated the staff must wear gowns and gloves when the staff provided care to the residents listed under the six moments of EBP, perform hand hygiene before and after providing care, change the gloves, and perform hand hygiene or wash hands if visibly soiled between residents. In addition, the IP stated the importance of following infection control protocol was for the residents and staff to be free from possible infection.On 7/8/25 at 1650 hours, an interview was conducted with the Administrator and DON. The DON stated the staff must wear the appropriate PPE for the residents on the EBP, which included face mask, gloves, and gowns when providing care to the residents as listed on the six moments of EBP. The DON and Administrator were informed and acknowledged the above findings. Event ID: Facility ID: 055816 If continuation sheet Page 3 of 3