Health inspection·February 15, 2024

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Potential for minimal harm Based on interview and facility document review, the facility failed to provide one nonsampled resident (Resident 526) with the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055). This failure had the potential of not allowing Resident 526 to make an informed decision regarding their Medicare services. Residents Affected - Some Findings: Medical record review for Resident 526 who was discharged from the facility showed no documented evidence of the SNF ABN Form CMS-10055 was provided to the resident. On 2/15/24 at 1025 hours, an interview and concurrent facility document review was conducted with the Social Worker and DON. The Social Worker was asked to provide the evidence of the original notice or documentation the SNF ABN Form CMS-10055 was provided to three residents who were discharged with Medicare Part A benefit days remaining. The Social Worker stated it was before his time, and he thought the facility did not provide the SNF ABN form to the residents. The DON stated they were informed by the billing department as to how many Medicare days the residents had left; however, did not provide any SNF ABN form to the residents. On 2/15/24 at 1342 hours, a follow-up interview and concurrent facility document review was conducted with the Social Worker. The Social Worker verified the facility had not been providing the SNF ABN form to the residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 2 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to provide the personal privacy for two nonsampled residents (Residents 2 and 17) when the nurses failed to provide full privacy to the residents during the medication administration via GT. This failure had the potential to negatively affect the dignity of the residents and violate the residents' right to privacy. Residents Affected - Some Findings: Review of the facility's P&P titled Resident Privacy & Confidentiality revised 8/2005 showed the resident's right to personal privacy and confidentiality will be fully recognized, and always use curtains to provide full visual privacy when caring for the resident. 1. Medical record review for Resident 17 was initiated on 2/13/24. Resident 17 was admitted to the facility on [DATE]. On 2/14/24 at 0815 hours, a medication administration observation was conducted with LVN 3 in Resident 17's room. LVN 3 did not pull Resident 17's privacy curtain all the way prior to accessing the resident's GT site for medication administration. Resident 17's privacy curtain was halfway closed while the door was open, and the resident's abdomen was exposed during the medication administration. On 2/14/24 at 1035 hours, an interview was conducted with LVN 3. LVN 3 verified the findings and she should have closed Resident 17's privacy curtain all the way to provide privacy. 2. Medical record review for Resident 2 was initiated on 2/13/24. Resident 2 as admitted to the facility on [DATE]. On 2/14/24 at 1415 hours, a medication administration observation was conducted with LVN 4 in Resident 2's room. LVN 4 did not pull Resident 2's privacy curtain all the way prior to accessing the resident's GT site for medication administration. Resident 2's blinds and door were open and abdomen was exposed. When the medication administration was completed, LVN 4 acknowledged the findings and verified she did not pull the curtain all the way to provide privacy and the door was open for Resident 2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 3 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 ensure one of 12 final sampled residents (Resident 7) was free from the physical restraints. Residents Affected - Few * The facility failed to conduct an assessment and implement the least restrictive measures prior to applying a mitten (mitten which look like boxing gloves with a Velcro or tie at the wrist to hold them in place and immobilize the resident's fingers) to Resident 7's left hand. In addition, the facility failed to obtained the physician's order and informed consent from the responsible party. These failures posed the risk of compromising the residents' independence and psychosocial well-being. Findings: Review of the facility's P&P titled Restraints dated 11/2021 showed the restraints will be used only with a written order from a physician, ensure the least possible discomfort to the resident, and informed consent was obtained. All restraints use is documented in the care plan, nurse's notes, and reviewed by the interdisciplinary team. On 2/12/24 at 0926 hours, and 2/13/24 at 0851 hours, Resident 7 was observed lying in bed with a left-hand mitten in place. Medical record review for Resident 7 was initiated on 2/13/24. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's MDS dated [DATE], showed Resident 7's cognitive skills for daily decision making was severely impaired. Review of Resident 7's medical record failed to show documentation of the physician's order, informed consent, assessment, and least restrictive measures completed prior to implementing the left hand mitten. Review of Resident 7's plan of care showed a care plan problem dated 11/29/22, addressing the use of physical restraints. However, it was not spcific to the use of mitten on left hand. Further review of Resident 7's medical record failed to show documented evidence the left hand mitten was released every two hours for 10 minutes for circulation. On 2/13/24 at 1051 hours, an interview was conducted with CNA 2. CNA 2 verified Resident 7 was wearing a cloth gloves on the left hand. CNA 2 stated Resident 7 was wearing the mitten because the resident was pulling out his GT. On 2/13/24 at 1143 hours, a concurrent interview and medical record review was conducted with LVN 7. LVN 7 stated Resident 7's left hand gloves soft cloth was brought in by his mother and not considered as a restraint. LVN 7 stated Resident 7's family brought the mitten and wanted just to put it on for circulation. LVN 7 verified there was no documentation about the application of the mitten on Resident 7's left hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 4 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0604 Level of Harm - Minimal harm or potential for actual harm On 2/14/24 at 0956 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 stated Resident 7 has a left hand mitten to prevent Resident 7's from scratching himself. RN 1 stated Resident 7's mother made aware the facility would not allow to place the left hand mitten but she insisted to put the mitten on. RN 1 verified there were no documented evidence the physician's order, informed consent, assessment, and least restrictive messures prior to applying the left hand mitten on Resident 7. Residents Affected - Few On 2/15/24 at 1429 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 5 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to obtain the physician's order for an adaptive device for one nonsampled resident (Resident 9). This failure had the potential for Resident 9 to not receive the appropriate care and services in the facility. Residents Affected - Some Findings: Review of the facility's P&P titled Physician Orders revised 12/2008 showed all orders for the medications, procedures, and devices shall be clearly documented in writing in the resident's medical record. Medical record review for Resident 9 was initiated on 2/12/24. Resident 9 was readmitted to the facility on [DATE]. On 2/12/24 at 1148 hours, observation was conducted with CNA 4 who was assisting and feeding Resident 9. CNA 4 placed the adaptive device on Resident 9's left hand. Further review of Resident 9's medical record failed to show documented evidence of a physician's order for the use of adaptive device and spoon to assist the resident during the mealtime. On 2/13/24 at 1126 hours, medical record review and concurrent interview was conducted with OT 1. OT 1 confirmed there was no current physician's order for the use of adaptive device, and it required an order from the physician. On 2/13/24 at 1347 hours, medical record review and concurrent interview was conducted with RN 1. RN 1 stated there was an order for the adaptive device with the discontinued date of 5/25/21 at 0739 hours. RN 1 verified an adaptive device was not included in the current physician's orders because it was discontinued and stated it should be reinitiated since Resident 9 was using it again. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 6 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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** 2. On 2/13/23 at 1115 hours, Resident 8 was observed in bed with 0.9% normal saline infusing at a rate of 10 ml/hr via Resident 8's left lower leg peripheral IV line. Medical record review for Resident 8 was initiated on 2/12/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's physician's order showed an order dated 2/8/24, for cefiderocol (antibiotic medication) 2000 mg IV every eight hours. Review of Resident 8's plans of care failed to show a care plan problem was developed to address Resident 8's use of IV peripheral line. On 2/14/24 at 0825 hours, an interview and concurrent medical record review for Resident 8 was conducted with RN 1. RN 1 reviewed a physician's order dated 1/4/24, to insert an IV into the lower extremities due to difficult IV access . When asked, RN 1 stated the resident with a peripheral IV should have a care plan. RN 1 verified a care plan problem addressing Resident 8's IV peripheral line was not developed. On 2/15/24 at 1117 hours, an interview was conducted with the DON. The DON stated the IV peripheral line should be care planned and initiated from the first date of an IV insertion. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan for one of 12 final sampled residents (Resident 8) and one nonsampled resident (Resident 9). * The facility failed to develop a care plan problem for Resident 9's use of adaptive device (a beige colored velcro strap that was used to assist in holding utensils during meal times). * The facility failed to develop a care plan problem to address the use of peripheral IV (peripheral intravenous access for IV fluids and/or medications) for Resident 8. These failures posed the risk of not providing the appropriate, consistent, and individualized care to the residents. Findings: 1. Review of the facility's P&P titled Care Planning revised 8/2010 showed the resident care plan will be maintained as part of resident health, will identify the problems or needs. After information has been gathered, the data is analyzed to determine what problems and needs exist. On 2/12/24 at 1148 hours, during the lunch meal observation, CNA 4 placed an adaptive device on Resident 9's hand, then secured a spoon on the strap. CNA 4 stated the strap and spoon were brought by the family. Medical record review for Resident 9 was initiated on 2/12/24. Resident 9 was admitted on [DATE], (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 7 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 and readmitted to the facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Further review of the medical record showed no documented evidence the resident's care plan addressed the use of the adaptive device during the mealtime. Residents Affected - Few On 2/12/24 at 1452 hours, medical record review and concurrent interview for Resident 9 was conducted with RN 1. RN 1 verified Resident's 9's current care plan did not reflect the use of the adaptive device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 8 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 provide the necessary care and services to ensure one of 12 final sampled residents (Resident 7) attained and maintained their highest practicable well-being. Residents Affected - Few * The facility failed to ensure Resident 7 was provided with the heel protectors while in bed as per the physician's order and resident's care plan. This failure had the potential for the resident to not receive appropriate care and treatment to prevent a skin problem. Findings: Review of the facility's P&P titled Pressure Ulcer Prevention, Management Protocol and Treatment with a revised date of 10/21 showed the prevention of pressure ulcer techniques included the protection on all bony prominences, application of heel protectors, reposition the resident every two hours, and keep the skin clean and dry. On 2/12/24 at 0926 hours, and 2/13/24 at 0851 hours, Resident 7 was observed in bed and no heel protector in place on both feet. Medical record review for Resident 7 was initiated on 2/13/24. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Physician Order Report for the month of February 2024, showed an order dated 11/24/23, to apply bilateral heel protectors while in bed. Review of Resident 7's plan of care showed a care plan problem addressing Resident 7's at risk for skin breakdown and pressure ulcer related to immobility and cognitive impairment. The interventions included to apply the bilateral heel protectors while in bed. On 2/13/24 at 1051 hours, an interview for Resident 7 was conducted with CNA 2. CNA 2 verified Resident 7 had no heel protector in place on both feet. On 2/13/24 at 1143 hours, an interview for Resident 7 was conducted with LVN 7. LVN 7 verified Resident 7 was not wearing a heel protector while in bed. On 2/14/24 at 0956 hours, an interview for Resident 7 was conducted with RN 1. RN 1 verified there was a physician's order for bilateral heel protectors for Resident 7 while in bed. RN 1 stated she would provide heel protector to Resident 7. On 2/15/24 at 1429 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 9 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. 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, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure injuries and promote the healing of the existing pressure injuries for two of 12 final sampled residents (Residents 8 and 12). Residents Affected - Few * The facility failed to ensure the LAL mattress setting was consistent with Resident 8's weight and the service light on the LAL mattress unit was addressed; and failed to ensure Resident 8 was administered wound treatments as per the physician's orders. These failures put Resident 8 at higher risk for developing new pressure injuries and worsening of the existing pressure injury on the left buttock. * The facility failed to ensure the LAL mattress setting was appropriate for Resident 12's weight. This failure posed the risk for Resident 12 to not benefit from the therapy provided by the LAL mattress. Findings: Review of the facility's P&P titles Pressure Ulcer Prevention, Management Protocol and Treatment dated 8/2023 showed the pressure ulcer prevention and/or treatment orders will be initiated if indicated and included in the chart. Prevention techniques may include any of the following: a. Pressure relief mattress/low air loss mattress/egg crate/overlay- to follow manufactures recommendation for settings Review of the Power Pro Operating, Maintenance and Trouble Shooting Insert, undated, under the section Operation, showed to select the resident's comfort setting: based on average the resident's weight. Further review of the insert showed for a 36-inch mattress, to select the following: - light 4 (four) for 145-200 lbs, - light 5 (five) for 175-230 lbs, - light 6 (six) for 200-265 lbs, - light 7 (seven) for 230-300 lbs, and - light 8 (eight) for 265-330 lbs. 1.a. Medical record review for Resident 8 was initiated on 2/12/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's MDS dated [DATE], showed Resident 8 was totally dependent for mobility to roll from left and right. The MDS also showed Resident 8 was at risk for developing pressure injuries and had a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure injury, not present on admission. Review of Resident 8's Physician's Orders Report for February 2024, showed a physician's order (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 10 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0686 dated 10/7/22 for low air loss mattress for wound management. Level of Harm - Minimal harm or potential for actual harm Review of Resident 8's plan of care showed a care plan problem initiated on 11/20/13, addressing Resident 8's risk for skin breakdown and pressure ulcer related to total dependence with mobility. The interventions included a pressure relieving mattress or device to the bed at all times. Residents Affected - Few Review of the facility's Monthly Weight Log showed on 2/1/24, Resident 8 weighted 85.3 kg (187.66 lbs). During the initial tour of the facility on 2/12/24 at 0833 hours, Resident 8 was observed lying on a LAL mattress. The service light on the LAL unit was on and the LAL mattress was set at light 8. On 2/13/24 at 1333 hours, an interview was conducted with the Central Service Supervisor. The Central Service Supervisor stated if there were any issues with the LAL mattress unit, he would be notified by the staff or the DON, and he would contact the company to get the unit replaced. The Central Service Supervisor further stated he had not been notified of any maintenance issues for any LAL mattress units. On 2/13/24 at 1444 hours, an interview and concurrent observation was conducted with LVN 6. LVN 6 stated Resident 8 had pressure injuries on his left and right buttocks and had a low air loss mattress. LVN 6 further stated the level of firmness on the mattress was related to Resident 8's weight. LVN 6 verified the firmness level on the LAL mattress unit was set at the light eight, and the service light was on. On 2/13/24 at 1615 hours, an interview and concurrent observation was conducted with RN 1. RN 1 stated she rounded on and checked all the LAL mattress units every couple of hours on her shifts. RN 1 stated she checked if the units were on, and the setting was appropriate to the residents' weight. Concurrent observation of Resident 8's LAL mattress unit was conducted with RN 1. RN 1 verified Resident 8's LAL mattress was set at the 8th light. RN 1 reviewed the Power Pro insert for Resident 8's LAL mattress and stated Resident 8 was not between 265 to 330 lbs. RN 1 was observed adjusting the settings of the unit and pushing the buttons. RN 1 stated she was not aware of any units with the service light on. RN 1 further stated during her rounds, she only checked to see the LAL mattress units were on, and stated she did not pay attention to the firmness settings on the units. On 2/14/24 at 0931 hours, the Central Service Supervisor stated he called the supplier for the LAL mattress unit and was notified by the representative, all the LAL mattresses sent to the facility were 35 inches. On 2/15/24 at 1117 hours, an interview was conducted with the DON. The DON stated all staff were responsible for checking if the LAL mattress units were working and the settings were correct. The DON stated the settings on the LAL mattress unit should be specific to the resident's weight and inappropriate setting of the mattress may delay the wound healing. b. Review of Resident 8's MAR dated 2/13/24, showed the following: - an order dated 5/16/23, to cleanse the left gluteal area with normal saline, pat dry, then apply vitamin E topically two times per day. The treatment was documented as administered twice a day from 2/1 to 2/12/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 11 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0686 Level of Harm - Minimal harm or potential for actual harm - an order dated 1/5/24, to cleanse the wound bed with normal saline, pat dry, loosely pack gauze with medihoney (an ointment made with a special honey with antibacterial properties and anti-inflammatory effects used for wound management and treatment) and collagen powder, and apply vitamin E to the periwound and cover with an abdominal pad, daily and PRN if soiled. The treatment was documented as administered from 2/2 to 2/12/24. Residents Affected - Few Review of Resident 8's plan of care showed a care plan problem initiated on 10/25/23, addressing Resident 8's Stage IV left buttock pressure injury. The interventions included to administer the treatments as ordered, and to clean the wound bed with normal saline, pat dry, loosely pack gauze with medihoney and collagen powder, apply vitamin E to the peri wound, and cover with an abdominal pad, every shift and PRN if soiled. On 2/14/24 at 1057 hours, a wound treatment observation was conducted with LVN 4. LVN 4 with the help of the CNA turned Resident 8 to his right side. LVN 4 started to perform the wound care for Resident 8's left buttock wound. LVN 4 removed the old dressing, discarded her gloves, applied hand sanitizer, and applied new gloves, cleansed the wound and the peri wound with normal saline and gauze, discarded her gloves, applied hand sanitizer and donned new gloves, applied medihoney mixed with collagen powder, and loosely packed the wound with gauze, applied zinc oxide to the surrounding skin on the left and right buttocks with a tongue depressor, and covered the left buttock wound with a dry dressing. On 2/15/24 at 0900 hours, an interview and concurrent record review was conducted with LVN 4. LVN 4 reviewed Resident 8's MAR and verified she did not apply vitamin E to Resident 8's buttock area and periwound. LVN 4 stated the nurse practitioner had told her that for some residents, vitamin E was easier to remove without damaging the skin. LVN 4 further stated she should have followed the physician's order when providing treatment. On 2/15/24 at 1117 hours, an interview was conducted with the DON. The DON stated he expected the nursing staff to follow the physician's order for treatment orders. 2. Medical record review for Resident 12 was initiated on 2/12/24. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's MDS dated [DATE], showed Resident 12 was in a persistent vegetative state, dependent on staff for bed mobility to roll from left to right, and was at risk for developing pressure injuries. Review of Resident 12's Physician's Orders Report for February 2024 showed a physician's order dated 12/18/23 for low air loss mattress. Review of Resident 12's plan of care showed a care plan problem created 12/8/15, addressing Resident 12's risk for skin breakdown and pressure injury related to total dependence with all ADL care and mobility, quadriplegia, and fragile skin. The intervention included the use of LAL mattress. Review of the facility's Monthly Weight Log showed on 2/1/24, Resident 12 weighed 86.0 kgs (189.2 lbs). During the initial tour of the facility on 2/12/24 at 0810 hours, Resident 12 was observed lying on a LAL mattress. The firmness setting on the LAL mattress unit was set at light eight. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 12 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/13/24 at 1337 hours, Resident 12 was observed lying on a LAL mattress. The setting on the LAL mattress was set at light eight. On 2/13/24 at 1615 hours, an interview and concurrent observation was conducted with RN 1. RN 1 stated she rounded and checked the LAL mattress units every couple of hours on her shifts. RN 1 stated she checked the LAL mattress units were on, and the settings were appropriate to the residents' weight. RN 1 verified Resident 12's LAL mattress was set at the 8th light. RN 1 reviewed the Power Pro insert for Resident 12's LAL mattress unit and stated Resident 12's LAL mattress setting was not appropriate for his weight. RN 1 further stated during her rounds, she only checked to see the LAL mattress units were on, and stated she did not pay attention to the firmness settings on the units. On 2/14/24 at 0931 hours, the Central Service Supervisor stated he called the supplier for the LAL mattress unit and was notified by the representative, all the LAL mattresses sent to the facility were 35-inches. On 2/15/24 at 1117 hours, an interview was conducted with the DON. The DON stated all the staff were responsible for checking if the LAL mattress units were working and the settings were correct. The DON stated the settings on the LAL mattress unit should be specific to the resident's weight and inappropriate setting of the mattress may delay the wound healing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 13 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0688 Level of Harm - Minimal harm or potential for actual harm Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Based on interview and medical record review, the facility failed to ensure the residents with limited ROM functions consistently received the treatments and services. Residents Affected - Few * All 23 residents with orders for RNA services (including the ROM exercises and application of splints) did not consistently receive their treatments on multiple occasions. This failure had the potential for the residents to develop further decrease in ROM functions. Findings: On 2/13/24, the facility census was 23. On 2/14/24, while conducting the sufficient staffing task, the 2/14/22 daily staffing documentation showed one RNA was assigned to perform ROM exercises and application of splints to all residents. Further review of the daily staffing documents showed no staff was assigned to perform ROM exercises and applications of splints to the residents on 1/3, 1/7, 1/20, 1/22, 1/27, 1/28, 1/29, 2/11, and 2/10/24. Review of the facility's RNA binder showed all residents had the orders for daily RNA services. Further review of the RNA binder showed no RNA services were provided to the residents on 1/1, 1/3, 1/7, 1/8, 1/15, 1/20, 1/22, 1/27, 1/28, 1/29, 2/3, 2/4, 2/10, and 2/11/24. 0n 2/14/24 at 0924 hours, an interview with RNA 1 was conducted. RNA 1 stated one RNA was assigned to complete the RNA services for all residents in the facility. RNA 1 stated RNA services included providing the ROM exercises and applying the splints to all 23 residents. RNA 1 stated the residents' RNA services had to be rushed due to time constraints of completing all therapy and documenting while also helping out other CNAs as needed within a 12 hour shift. RNA 1 stated the RNA staff were reassigned from doing the RNA services when the facility needed the RNAs to work as the CNAs. RNA 1 stated the management staff had already been made aware that the RNA services were sometimes not provided to the residents due to the RNAs having to work as the CNAs. On 2/14/24, at 1008 hours, a concurrent interview and medical record review was conducted with the DSD. The DSD verified the above findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 14 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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** 7. On 2/12/24 at 0926 hours, and 2/13/24 at 0851 hours, Resident 7 was observed in bed with the bilateral padded upper side rails elevated. However, the paddings were not properly placed on the side rails as the top part of the side rails were exposed, which would not protect the resident from injury in the event of seizure activity. Medical record review for Resident 7 was initiated on 2/13/24. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's MDS dated [DATE], showed Resident 7 had a diagnosis of seizure disorder. Review of Resident 7's physician's order dated 11/23/22, showed an order for a bilateral side rail due to history of falls. Another physician's order dated 3/10/23, showed an order for a padded side rail for seizure precaution. Review of Resident 7's plan of care showed a care plan problem dated 11/29/22, addressing the risk for injury related to episode of involuntary jerking movements for a diagnosis of seizure. The interventions included padded side rails for seizure precaution. On 2/13/24 at 1051 hours, an interview for Resident 7 was conducted with CNA 2. CNA 2 verified Resident 7's side rail pads were not properly placed. On 2/13/24 at 1143 hours, an interview for Resident 7 was conducted with LVN 7. LVN 7 verified Resident 7 had a history of seizure and with a physician's order for padded side rails. LVN 7 verified the side rail pads were not properly placed. On 2/14/24 at 0956 hours, an interview for Resident 7 was conducted with RN 1. RN 1 verified Resident 7 had a diagnosis of seizure disorder and there was a physician's order to place a pad on the side rail for safety. RN 1 verified Resident 7's side rail pads were not properly placed. 8. Medical record review for Resident 13 was initiated on 2/13/24. Resident 13 was admitted to the facility on [DATE]. On 2/12/24 at 1039 hours, and 2/13/24 at 0845 hours, Resident 13 was observed in bed with four side rails elevated. Resident 13's two upper side rails were padded; however, the two lower side rails had no pads in place. Review of Resident 13's MDS dated [DATE], showed Resident 13 had a diagnosis of seizure disorder. Review of Resident 13's physician's order dated 3/10/23, showed an order for four side rails for involuntary movement. Another physician's order dated 3/10/23, showed an order for a padded side rails for seizure precaution. Review of Resident 13's plan of care showed a care plan problem dated 5/3/21, addressing the risk for injury related to a diagnosis of seizure disorder. The interventions included the padded side rails for seizure precaution. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 15 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 3/13/24 at 1039 hours, an interview for Resident 13 was conducted with CNA 2. CNA 2 verified Resident 13 have side rails in bed and the upper side rail with the pads in place and there were no pads on the lower side rails. CNA 2 stated the side rails were padded for safety. On 2/13/24 at 1129 hours, an interview for Resident 13 was conducted with LVN 7. LVN 7 verified Resident 13 had a history of seizure and with a physician's order for the padded side rails. LVN 7 verified the side rail pads were placed on the upper side rails and there were no pads on the lower side rails. On 2/14/24 at 0956 hours, an observation and concurrent interview for Resident 13 was conducted with RN 1. RN 1 verified Resident 13 had a diagnosis of seizure disorder with a physician's order to place a pad on the side rail for safety. RN 1 verified Resident 13's upper side rails had padding in place but the lower side rails had no pads in place. 9. Medical record review for Resident 23 was initiated on 2/12/24. Resident 23 was admitted to the facility on [DATE]. On 2/12/24 at 1059 hours, and 2/13/24 at 0852 hours, Resident 23 was observed in bed with an enclosed bed. Review of Resident 23's MDS dated [DATE], showed Resident 23's cognitive skills for daily decision making was severely impaired. Review of Resident 23's medical record failed to show documentation of an informed consent, assessment, and least restrictive measures use prior to implementing the enclosed bed. On 2/15/24 at 0915 hours, an observation and concurrent interview for Resident 23 was conducted with LVN 3 in Resident 23's room. LVN 3 verified Resident 23's using of enclosed bed. LVN 3 stated Resident 23 was in the enclosed bed to prevent the resident from falling. On 2/15/24 at 0929 hours, an interview and concurrent medical record review for Resident 23 was conducted with the MDS Coordinator. The MDS Coordinator verified there was a physician's order for the use of enclosed bed for Resident 23. The MDS Coordinator verified there were no informed consent, monitoring, and assessment of the enclosed bed. On 2/15/24 at 1415 hours, an interview and concurrent medical record review for Resident 7, 13, and 23 was conducted with the DON. The DON was informed and verified the above findings. 4. Medical record review for Resident 3 was initiated on 2/13/24. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 9/14/23, showed Resident 3 had an altered mental status and vent dependent. Review of Resident 3's Physician's Orders Report dated 2/24, showed a physician's order dated 3/10/23, to monitor seizure episodes every shift, and a physician's order dated 12/25/16, for padded side rails for seizure precautions. Review of Resident 3's MDS dated [DATE], showed Resident 3 had severe cognitive impairment and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 16 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0689 required staff assistance for all her activities of daily living. Level of Harm - Minimal harm or potential for actual harm Review of Resident 3's plan of care problem addressing the resident's seizure disorder revised 2/5/24, showed to use padded side rails for seizure precautions. Residents Affected - Some On 2/13/24 at 0846 hours, Resident 3 was observed lying in bed. The bilateral side rails were observed elevated, with padding; however, the paddings of the right and left side rails were observed not covering the top part of the side rails. On 2/13/24 at 1414 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified the above findings and stated the padding should have been placed correctly for seizure precaution and the resident could possibly get hurt when padding was incorrectly placed. 5. Medical record review for Resident 19 was initiated on 2/13/24. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 8/1/23, showed Resident 19 had an altered mental status with no meaningful response and history of seizures. Review of Resident 19's Physician's Orders Report dated 2/24, showed a physician's orders dated 7/31/23, to monitor the seizure episodes every shift and use padded siderails for seizure precautions. Review of Resident 19's MDS dated [DATE], showed Resident 19 had severe cognitive impairment and required staff assistance for all his activities of daily living. Review of Resident 19's plan of care problem addressing the resident's seizure disorder revised 2/9/24, showed to use bilateral side rails and padded for safety and seizure disorder. On 2/13/24 at 1359 hours, Resident 19 was observed lying in bed. The bilateral side rails were observed elevated, with padding; however, the padding of the right side rail was observed not covering the top part of the side rail. On 2/13/24 at 1405 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified the above findings and stated the padding should have been placed correctly for seizure precautions. 6. Medical record review for Resident 20 was initiated on 2/13/24. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 5/30/23, showed Resident 20 had acute encephalopathy with nonconclusive epilepticus and myoclonic jerks (a condition characterized by recurrent seizures (epilepsy), abnormal brain function (encephalopathy), and intellectual disability). Review of Resident 20's Physician's Orders Report dated 2/24, showed a physician's orders dated 5/19/23, to monitor the seizure episodes every shift and a physician's order dated 12/18/23, for padded siderails for seizure precautions. Review of Resident 20's MDS dated [DATE], showed Resident 20 had a BIMS of 5 and required staff assistance for all his activities of daily living. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 17 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 20's plan of care problem revised 1/18/24, showed the interventions included to use the padded bilateral side rails. On 2/13/24 at 0820 hours, Resident 20 was observed lying in bed. The bilateral side rails were observed with padding and elevated; however, the paddings of the right and left side rails were observed not covering the top part of the side rails. On 2/13/24 at 1402 hours, Resident 20 was observed lying in bed. The bilateral side rails were observed with padding and elevated; however, the paddings of the right and left side rails were incorrectly placed as they did not cover the top part of the side rails, leaving the top part of the side rails exposed. On 2/13/24 at 1405 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified the above findings and stated the paddings should have been placed correctly for seizure precautions. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure nine of 12 final sampled residents (Residents 3, 7, 11, 12, 13, 15, 19, 20, and 23) remained free from accident hazards. * The facility failed to ensure the residents' side rail paddings were properly placed as ordered by the physicians and residents' care plans for Residents 3, 7, 11, 12, 13, 15, 19, and 20. * The facility failed to ensure an informed consent was obtained, conduct an assessment, and implement the least restrictive measures prior to utilizing the enclosed bed (Posey Bed - a hospital bed with canopy and mattress designed to help provide a safe, controlled environment for residents at extreme risk of injury from a fall. It is a restraint and must be prescribed by a licensed physician) for Resident 23. In addition, the facility failed to ensure the monitoring of the device was documented. These failures had the potential risk for injury to the residents. Findings: Review of the facility's P&P titled Seizure Precautions reviewed 6/2020 showed the purpose is to prevent injury to the resident during the seizure. The P&P also showed nursing responsibility for seizure precautions was to have side rails (padded) up at all times. 1. Medical record review for Resident 11 was initiated on 2/12/24. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's MDS dated [DATE], showed Resident 11 had a diagnosis of seizure disorder. Review of Resident 11's Physician's Orders Report for February 2024 showed a physician's order dated 8/31/21, for bilateral side rails up for involuntary movements and family's request for safety, and to apply padded side rails for seizure precautions. Review of Resident 11's plan of care showed a care plan problem created 8/31/21, addressing the use of bilateral side rails for involuntary movements and family's request for safety. The care plan (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 18 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0689 interventions included a padded bilateral side rails both sides for safety related to seizure disorder. Level of Harm - Minimal harm or potential for actual harm On 2/13/24 at 0829 hours, Resident 11 was observed lying in bed with bilateral side rails elevated. The left side rail was observed padded covering the top part of the side rail; however, the right side rail was not observed with the pad covering the top part of the side rail. Residents Affected - Some On 2/13/24 at 1045 and 1339 hours, Resident 11 was observed lying in bed with bilateral side rails elevated. Paddings were observed on both side rails, however, the right side rail was not fully covered exposing the top part of the side rail. On 2/13/24 at 1424 hours, an interview and concurrent observation was conducted with CNA 1. CNA 1 stated Resident 11 had a history of seizures and had bilateral padded side rails to prevent injury. Concurrent observation of Resident 11's side rails was conducted with CNA 1. CNA 1 verified the right side rail was not properly padded to cover the top part of the side rail. On 2/13/24 at 1439 hours, an interview and concurrent observation was conducted with LVN 6. LVN 6 stated Resident 11 had a history of seizures and interventions included padded side rails and visual checks. LVN 6 verified the padding on Resident 11's right side rail was not properly placed. LVN 6 stated the right side rail was not padded to cover the top part of the side rail. On 2/14/24 at 0801 hours, and interview was conducted with the DSD. The DSD stated paddings on the side rails should cover the top part of the side rails to prevent injury, especially for the residents with seizures who would be at risk for hitting the exposed side rails. 2. Medical record review for Resident 12 was initiated on 2/12/24. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's MDS dated [DATE], showed Resident 12 had a diagnosis of seizure disorder. Review of Resident 12's Physician's Orders Report for February 2024, showed the following physician's order: - dated 8/31/21, for bilateral side rails up for involuntary muscular spasms and family's request for safety, every shift. - dated 2/16/23, to apply padded side rails at all times for seizure precautions. Review of Resident 12's plan of care showed a care plan problem, created 12/8/15, addressing Resident 12's risk for injury related to seizure disorder. The interventions included to pad the bilateral side rails for safety due to diagnosis of seizure disorder. On 2/13/24 at 0814 hours, Resident 12 was observed lying in bed. The bilateral side rails were observed elevated, with padding. Hhowever, the padding of the right side rail was observed at the inner base of the side rail, leaving the top part of the right side rail exposed. On 2/13/24 at 1337 hours, Resident 12 was observed lying in bed with bilateral side rails elevated, with padding; however, the padding on the right side rail was observed not covering the top part of the side rail. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 19 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 2/14/24 at 1356 hours, Resident 12 was observed lying bed with bilateral side rails elevated. The padding on the right side rail was observed not covering the top part of the side rail. On 2/14/24 at 1407 hours, an interview and concurrent observation was conducted with LVN 4. LVN 4 verified the above finding and stated the padding on the right side rail was incorrectly placed and should cover the top of the side rail as well, to prevent injury. On 2/15/24 at 1117 hours, an interview was conducted with the DON. The DON stated he expected the staff to apply paddings on the side rails so that the pads were not lower than the top part of the side rails. The DON further stated the staff should provide visual inspections and adjust the pads accordingly to prevent possible injuries. 3. Medical record review for Resident 15 was initiated on 2/12/24. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's MDS dated [DATE], showed Resident 15 had a diagnosis of seizure disorder. Review of Resident 15's Physician's Orders Report for February 2024 showed a physician's order dated 3/10/23, to implement padded side rails for seizure precaution every shift. Review of Resident 15's plan of care showed a care plan problem dated 8/10/21, addressing Resident 15's risk for injury during seizures, twitching, tremors, or involuntary spasms. The intervention included to pad side rails for seizure precautions. On 2/13/24 at 0821 hours, Resident 15 was observed lying in bed with bilateral side rails elevated, with paddings; however, the padding was observed covering the inner base of both side rails, but the top part of both side rails were exposed. On 2/13/24 at 1338 hours, Resident 15 was observed lying in bed with bilateral side rails elevated, with padding, however, the padding on the left side rail did not cover the top part of the side rail. On 2/13/24 at 1415 hours, an interview and concurrent observation of Resident 15 was conducted with CNA 1. CNA 1 stated Resident 15 had a history of seizures and coughing episodes where Resident 15's upper body would lift up from the pillow. CNA 1 stated the side rails were padded to prevent injury during coughs or seizures. CNA 1 verified the padding on the left side rail was incorrectly place, leaving the top of the side rail exposed. CNA 1 further stated Resident 15 could injure himself while coughing if side rails were not padded correctly. On 2/14/24 at 0801 hours, an interview was conducted with the DSD. The DSD stated the paddings on side rails should cover the top part of the side rails to prevent from injury, especially for the residents with seizures who would be at risk for hitting the exposed side rails. On 2/15/24 at 1117 hours, an interview was conducted with the DON. The DON stated he expected the staff to apply the paddings on side rails so the pads were not lower than the top part of the side rails. The DON further stated the staff should provide visual inspections and adjust the pads accordingly to prevent for possible injuries. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 20 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **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 provide the necessary enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) care and services for five of 12 final sampled residents (Residents 3, 14, 15, 19, and 20) and one nonsampled resident (Resident 2). * The facility failed to ensure Residents 3, 14, 19, and 20's enteral feeding bottles were completely labeled to include the time and rate. * The facility failed to ensure the medications were administered via GT by gravity for Residents 2 and 15. These failures posed the risk for complications related to the use of the enteral feeding for Residents 2, 3, 14, 15, 19, and 20. Findings: 1. Review of the facility's P&P titled Enteral Feeding revised 8/23 showed the enteral feeding will be administered as ordered by the physician, in collaboration with the Registered Dietitian. The procedure also showed to label bag and tubing with date and time hung. a. During the initial tour of the facility on 2/12/24 at 1138 hours, an observation was conducted for Resident 3. Resident 3 was observed lying in bed with an enteral feeding hanging and connecting via enteral feeding pump. Resident 3's enteral feeding was labeled with the resident's name, room number and date; however, no start time and rate indicated on the enteral feeding bottle. Medical record review for Resident 3 was initiated on 2/13/24. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 9/14/23, showed Resident 3 had a GT feeding. Review of Resident 3's Physician Order Report dated 2/24, showed a physician's order dated 10/3/23, for Glucerna 1.2 at 55 ml/hour to provide a total of 1320 ml/1584 kcals via enteral pump via GT every shift. Review of Resident 3's care plan problem dated 10/3/23, showed to provide a tube feeding per the physician's order. Enteral formula of Glucerna 1.2 at 55 ml/hour for 24 hours, to provide 1320 ml/1584 kcals via enteral pump via GT. Review of Resident 3's MDS dated [DATE], showed under Section K for Swallowing/Nutritional Status, Resident 3 had a feeding tube. On 2/12/24 at 1609 hours, an observation and concurrent interview was conducted with the DSD. The DSD verified the above findings and stated the enteral feeding bottle should have been labeled with the start time and rate to know when the enteral feeding was exactly changed and if it was old or new and had to be consistent with the physician's order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 21 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few b. Medical record review for Resident 14 was initiated on 2/13/24. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's H&P examination dated 9/14/23, showed Resident 14 had a GT feeding. Review of Resident 14's Physician Order Report for February 2024 showed a physician's order dated 1/31/22, for Nepro to run 45 ml/ hour for 20 hours to provide total 900 ml/1620 kcals via enteral pump via GT. Review of Resident 14's care plan problem dated 1/31/22 showed to provide Nepro at 45 ml/hour for 20 hours, to provide 900 ml/1620 kcals. Review of Resident 14's MDS dated [DATE], showed under Section K for Swallowing/Nutritional Status, Resident 14 had a feeding tube. On 2/12/24 at 1427 hours, an observation was conducted with Resident 14. Resident 14 was observed lying in bed with an enteral feeding hanging and connecting via enteral feeding pump. Resident 14's enteral feeding was labeled with the resident's name, room number and date; however, no start time and rate indicated on the enteral feeding bottle. On 2/12/24 at 1603 hours, an observation and concurrent interview was conducted with LVN 6. LVN 6 verified the above findings and stated the enteral feeding bottle should have been labeled with the start time and rate to ensure enteral dose was met and the resident did not miss her nutrition. c. Medical record review for Resident 19 was initiated on 2/13/24. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 8/1/23, showed Resident 19 has a PEG tube. Review of Resident 19's Physician Order Report for February 2024 showed a physician's order dated 9/19/23, for Jevity 1.5 at 75 ml/hour to provide a total of 1500 ml/2250 kcals via enteral pump via GT. Review of Resident 19's care plan problem dated 9/19/23, showed to provide tube feeding per the physician's order, Jevity 1.5 at 75 ml/hour to provide 1500 ml/2250 kcals. Review of Resident 19's MDS dated [DATE], showed under Section K for Swallowing/Nutritional Status, Resident 19 had a feeding tube. On 2/12/24 at 0920 hours, an observation was conducted with Resident 19. Resident 19 was observed lying in bed with an enteral feeding hanging and connecting via enteral feeding pump. Resident 19's enteral feeding was labeled with the resident's name, room number, and date; however, no start time and rate indicated on the enteral feeding bottle. On 2/12/24 at 1159 hours, an observation was conducted with Resident 19. Resident 19 was observed lying in bed with an enteral feeding hanging and connecting via enteral feeding pump. Resident 19's enteral feeding was labeled with the resident's name, room number, and date; however, the enteral feeding bottle did not show the start time and rate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 22 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 2/12/24 at 1549 hours, an observation and concurrent interview was conducted with LVN 6. LVN 6 acknowledged the above findings and stated the enteral feeding bottle should have been labeled with the start time and rate to ensure the enteral dose was met and the resident did not miss his nutrition. d. Medical record review for Resident 20 was initiated on 2/13/24. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 5/30/23, showed Resident 20 had a GT feeding. Review of Resident 20's Physician Order Report for February 2024 showed a physician's orders dated 10/2/23, for Jevity 1.2 at 75 ml/ hour to provide a total of 1500 ml/1800 kcals via enteral pump via GT. Review of Resident 20's care plan problem dated 6/20/23 showed to provide tube feeding per the MD order, Jevity 1.2 at 75 ml/hour for 20 hours to provide 1500 ml/1800 kcals. Review of Resident 20's MDS dated [DATE], showed under Section K for Swallowing/Nutritional Status, Resident 20 had a feeding tube. On 2/12/24 at 0931 hours, an observation was conducted with Resident 20. Resident 20 was observed lying in bed with an enteral feeding hanging and connecting via enteral feeding pump. Resident 20's enteral feeding was labeled with the resident's name, room number, and date; however, no start time and rate indicated on the enteral feeding bottle. On 2/12/24 at 1112 hours, an observation was conducted with Resident 20. Resident 20 was observed lying in bed with an enteral feeding hanging and connecting via enteral feeding pump. Resident 20's enteral feeding was labeled with the resident's name, room number and date; however, the enteral feeding bottle did not show the start time and rate. On 2/12/24 at 1558 hours, an observation and concurrent interview was conducted with LVN 6. LVN 6 verified the above findings and stated the enteral feeding bottle should have been labeled with the start time and rate to ensure the enteral dose was met and the resident did not miss his nutrition. 2. Review of the facility's P&P titled Medication Administration Via Feeding Tube revised 8/2021 showed to ensure that proper protocol is followed during medication administration; and to administer medications via gravity by pouring one after another, flushing with a minimum of 10 ml of water between each medication. a. On 2/14/24 at 1415 hours, an observation of medication administration for Resident 2 via GT was conducted with LVN 4. LVN 4 crushed the Keppra (medication to treat seizure) 500 mg tablet and poured into a medicine cup, then went inside Resident 2's room. LVN 4 checked Resident 2's GT placement and residual and poured 50 ml of water into the piston syringe and pushed the water with the syringe plunger to flush the GT. LVN 4 added 40 ml of water in the medication cup containing the crushed Keppra, mixed the content, poured in the piston syringe, and administered the medication by pushing with syringe plunger. After the medication administration, LVN 4 pushed another 10 ml of water to flush the GT. Medical record review for Resident 2 was initiated on 2/14/24. Resident 2 was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 23 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0693 facility on [DATE]. Level of Harm - Minimal harm or potential for actual harm Review of Resident's physician's orders showed an order dated 11/6/23, for levetiracetam (Keppra) 500 mg via GT at 0600, 1400, and 2200 hours. Residents Affected - Few b. On 2/14/24 at 1451 hours, an observation of medication administration for Resident 15 via GT was conducted with LVN 4. LVN 4 prepared two medications in two separate medication cups: Gabapentin (medication to treat seizure) 300 mg and Baclofen (medication to treat muscle spasms) 20 mg. LVN 4 went inside Resident 15's room and checked Resident 15's GT placement and residual. LVN 4 mixed 20 ml of water to each medication cup and poured the medications one by one into the piston syringe and pushed the medications into Resident 15's GT with a syringe plunger, with 10 ml water flush in between. Post administration of medications via GT for Residents 2 and 15, an interview was conducted with LVN 4. LVN 4 was asked regarding the facility's process to administer medications via GT. LVN 4 stated per the facility's policy, the medication was supposed to have been given by gravity and verified she was not supposed to have pushed the medications through the GT. Medical record review for Resident 15 was initiated on 2/14/24. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's physician's orders showed an order dated 11/6/23, for baclofen 20 mg via GT at 0600, 1400, and 2200 hours, for decreased muscle tone; and an order dated 11/6/23, for gabapentin 300 mg via GT every eight hours for tremors m/b involuntary shaking. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 24 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. 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 ensure the appropriate care and services for IV therapy (the administration of fluids or medications through an IV line) for one of 12 final sampled residents (Resident 8) and one nonsampled resident (Resident 5). Residents Affected - Few * The facility failed to change Resident 8's IV tubing per the date on the label; and the facility failed to ensure Resident 8 had an order for TKO. * The facility failed to label Resident 5's IV tubing with the date to be changed; and the facility failed to ensure Resident 5 had an order for TKO. These failures had the potential for complications related to IV therapy and negative effects related to the residents' medical condition. Findings: Review of the facility's P&P titled Intravenous Therapy Administration reviewed 6/2020 showed specific flow rates or TKO (to keep open) must be ordered by the physician; IV administration set and extension tubing shall be changed two times per week; and all IV tubing must be labeled with date to be changed. 1. Medical record review for Resident 8 was initiated on 2/12/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's physician's orders for February 2024 showed an order dated 2/8/24, for cefiderocol (an antibiotic) 2000 mg IV every eight hours. Further review of Resident 8's physician's orders failed to show a physician's order for TKO. On 2/12/24 at 0833 hours, Resident 8 was observed in bed with IV fluids and cefiderocol IV medication hanging on Resident 8's IV pump. The IV fluid was labeled as 0.9% normal saline and was observed to be infusing at a rate of 10 ml/hour. A sticker label was observed on the IV tubing connected to the IV fluid. The sticker label showed to change on Sunday 2/11/24. On 2/12/24 at 1130 hours, an interview and concurrent observation was conducted with RN 1. RN 1 verified the sticker label on Resident 8's IV tubing showed to change Sunday 2/11/24, and should have been changed on 2/11/24. On 2/13/24 at 1115 hours, a follow-up interview and concurrent record review for Resident 8 was conducted with RN 1. RN 1 stated all IV antibiotics would be piggybacked to a primary line with 0.9% NS at TKO rate of 10 ml/hour. RN 1 stated there should be an order for TKO. RN 1 reviewed Resident 8's physician's orders and verified there were no physician's order for TKO. 2. Medical record review for Resident 5 was initiated on 2/12/24. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's physician's orders for February 2024 showed an order dated 2/11/24, for meropenem (an antibiotic) 500 mg IV every 12 hours. Further review of Resident 5's physician's orders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 25 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0694 failed to show a physician's order for TKO. Level of Harm - Minimal harm or potential for actual harm On 2/12/24 at 0815 hours, Resident 5 was observed in bed with IV fluids and meropenem hanging on Resident 5's IV pump. The IV pump was observed infusing IV fluid, 0.9% normal saline (NS) at 10 ml/hour into Resident 5's right forearm. The IV tubing connected to the IV fluid was not labeled with the date to be changed. Residents Affected - Few On 2/12/24 at 1130 hours, an observation and concurrent interview was conducted with RN 1. RN 1 verified Resident 5's primary tubing was not labeled with the date to be changed. On 2/15/24 at 1113 hours an interview and concurrent closed record review for Resident 5 was conducted with RN 2. RN 2 stated all residents on IV antibiotics would receive 0.9% NS at 10 ml/hours (TKO). RN 2 reviewed Resident 5's physician's orders and verified Resident 5 did not have a physician's order for TKO while Resident 5 was on the IV meropenem medication. On 2/15/24 at 1117 hours, an interview was conducted with the DON. The DON stated the IV tubings should be changed twice a week and labeled with the change date. The DON also stated all residents on antibiotics should have a physician's order for IV fluids at TKO rate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 26 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0695 Provide safe and appropriate respiratory care for a resident when needed. 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 provide safe respiratory care to meet the needs for one of 12 final sampled residents (Resident 13). Residents Affected - Few * The facility failed to ensure Resident 13 was placed on the correct ventilator settings ordered by the physician. In addition, the ventilator machine alarms were not set for high pressure alarms. These failures had the potential to result in poor health outcomes to the resident and posed the risk of delayed intervention in the event of an emergency. Findings: Review of the facility's P&P titled Continuous Mechanical Ventilator revised 7/2023 showed the residents are placed on a mechanical ventilator per the physician's order. The physician will be contacted if the order requires further clarification or if there's a change in the resident condition that requires a change in vent setting. Review of the facility's P&P titled Ventilator Alarm Setting guidelines, troubleshooting and Corrective Action revised 7/2023, showed the resident would be place on ventilator according to the physician's order. The alarm settings should be adjusted the high/low pressure and make sure the ventilator is still audible/functional after every movement of the resident, and to document all ventilator alarm settings in the resident's medical record. It is the responsibility of the RT to test the alarms with each ventilator check, and resident movement. On 2/12/24 at 1040 hours, and 2/13/24 at 0845 hours, Resident 13 was observed in bed with a tracheostomy tube in place and connected to a mechanical ventilator. Resident 13's ventilator was observed set to SIMV mode, rate of 12, tidal volume of 600 ml, and PEEP of 5. On 2/13/24 at 1027 hours, Resident 13's mechanical ventilator was observed set to SIMV mode, rate of 12, tidal volume of 600 ml, and PEEP of 5. The mechanical ventilator machine had the red flashing light showing high pres, and with numbers 40,12, and 30. There was no audible sound of the mechanical ventilator machine alarm was heard in the room or in the hallway. Medical record review for Resident 13 was initiated on 2/13/24. Resident 13 was admitted to the facility on [DATE]. Review of Resident 13's Physician's Order Report showed an order dated 6/6/23, to set Resident 13's ventilator to SIMV mode, rate of 15, tidal volume of 500 ml, and PEEP of 5. Review of Resident 13's Respiratory Flow Sheet dated 2/11/24 from 0100 to 1914 hours, showed Resident 13's tidal volume was set to 600 ml. However, there was no documented evidence to show a physician's order to change Resident 13's tidal volume from 500 to 600 ml. In addition, further review of the respiratory flowsheet document failed to show the high-pressure alarm was set on the mechanical ventilator machine. On 2/13/24 at 1421 hours, an interview and concurrent medical record review was conducted with RT 1. RT 1 verified the findings and confirmed there was no documentation as to why the resident's tidal volume was changed. RN 1 verified there was no physician's order to change Resident 13's tidal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 27 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few volume from 500 to 600 ml. RT 1 was asked about the ventilator machine with blinking light high pres, and no audible sound. RT 1 stated there should have been a loud sound alarm when the machine was blinking and able to hear in the room and in the hallway. RT 1 verified the respiratory flowsheet document failed to show the high-pressure alarm was set on the machine. On 2/14/24 at 0909 hours, Resident 13 was observed in bed with the mechanical ventilator machine with blinking red light high pres. There was no alarm sound was heard from the ventilator machine. On 2/14/24 at 0926 hours, an observation and concurrent interview with the DSD was conducted in Resident 7's room. The DSD stated if the mechanical ventilator machine had a problem, there should be an audible sound that could be heard. The DSD stated the high-pressure alarm had a high pitch intermittent sound, meaning there was a problem with the tubing, or the resident needed to be suctioned. The DSD verified the ventilator machine had blinking light in red with high pres, and verified there was a problem with Resident 13's ventilator. The DSD summoned the RT assigned to Resident 13 to fix the resident's ventilator machine. The DSD stated there should be a sounding alarm from the machine and he did not know why the ventilator machine sound alarm was turned off. On 2/14/24 at 0943 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the ventilator machine had an alarm and when Resident 13 was in the room, the ventilator was connected to the wall alarm in the hallway to notify the staff for a problem. RN 1 verified the ventilator machine had no sounding alarm when flashing the high pres alarm. On 2/15/24 at 1409 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and verified the findings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 28 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the appropriate use of side rails for two of 12 final sampled residents (Residents 8 and 12). The facility failed to ensure the informed consents for side rail use matched the indications for side rail use ordered by the physician for Residents 8 and 12. This failure had the potential to put the residents at risk for entrapment and serious injury. Findings: 1. Medical record review for Resident 8 was initiated on 2/12/24. Resident 8 was admitted to the facility on [DATE]. On 2/12/24 at 0840 hours, during an initial tour of the facility, Resident 8 was observed lying in bed with four side rails elevated. Review of Resident 8's Physician Order Report for February 2024 showed a physician's order dated 8/30/21, for the use of bilateral side rails as per the resident's request for safety, every shift. Review of Resident 8's Consent for Use of Side Rails signed 12/10/17, showed the informed consent was obtained for bilateral side rails for safety during activities of daily living. Review of Resident 8's Quarterly Side Rail assessment dated [DATE], showed the boxes were marked for the resident/surrogate decision maker expressed a desire to have side rails raised while in bed, and bilateral upper side rails. Review of Resident 8's plan of care showed a care plan problem dated 8/30/21, addressing the use of bilateral side rails as per the resident's request for safety. On 2/13/24 at 0830 and 1341 hours, Resident 8 was observed sleeping in bed with four side rails elevated. On 2/14/24 at 0930 hours, an observation, interview, and concurrent medical record review for Resident 8 was conducted with RN 1. RN 1 verified the physician's orders for side rails and the indications for side rails on Resident 8's informed consent did not match. RN 1 also reviewed Resident 8's care plan addressing the use of bilateral side rails. RN 1 verified Resident 8 was in bed with all four side rails elevated. RN 1 stated the side rail consent did not match the physicians' orders or the care plan problem for side rail use. 2. Medical record review for Resident 12 was initiated on 2/12/24. Resident 12 was admitted to the facility on [DATE]. On 2/12/24 at 0810 hours, during an initial tour of the facility, Resident 12 was observed sleeping in bed with bilateral padded upper side rails elevated. Review of Resident 12's MDS dated [DATE], showed Resident 12 had a diagnosis of seizure disorder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 29 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0700 Level of Harm - Minimal harm or potential for actual harm Review of Resident 12's Physician Order Report for February 2024 showed an order dated 8/31/21, to implement bilateral side rails for involuntary muscular spasms and family's request for safety, every shift. Review of Resident 12's Consent for Use of Side Rails signed 12/8/17, showed the informed consent was obtained for bilateral side rails for safety during activities of daily living. Residents Affected - Few Review of Resident 12's Annual Side Rail assessment dated [DATE], showed the side rails were indicated due to seizure activity. On 2/13/24 at 1037 hours, Resident 12 was observed lying in bed with bilateral side rails elevated. On 2/13/24 at 1457 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 12 had bilateral side rails for seizure precautions to prevent injury. On 2/14/24 at 0801 hours, an interview was conducted with the DSD. The DSD stated the indications for side rail use would be on the informed consents and if the indication changed, there should be a new consent obtained with the new indication on the consent. On 2/14/24 at 0923 hours, an interview and concurrent observation was conducted with RN 1. RN 1 verified the physician's orders for side rails and the indications for side rails on Resident 12's informed consent did not match. RN 1 further stated the indications should match. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 30 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0759 Ensure medication error rates are not 5 percent or greater. 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 ensure the medication error rate was below 5%. Residents Affected - Few * The facility's medication error rate was 48%. Two of three licensed nurses (LVNs 3 and 5) were found to have made errors during the medication administration. These failures resulted in the residents not receiving the prescribed medications as ordered by the physician, which posed the risk of adverse effects for the residents. Findings: Review of the facility's P&P titled Medication Administration revised 7/2013 showed all medications will be administered throughout the hospital utilizing the same standards of practice. The P&P also showed to verify that the medication is being administered at the proper time, in the prescribed dose, and by the correct route. Review of the facility's P&P titled Medication Administration-Eye Drops dated 6/2016 showed where multiple drops and/or ointment are prescribed for one or both eyes, the order of administration is important to ensure maximum therapeutic effect of each. Five minutes should elapse between administration of a different eye drop to achieve maximum therapeutic effect. 1. On 2/14/24 at 0815 hours, a medication administration observation was conducted with LVN 3 in Resident 17's room. LVN 3 prepared and administered the following medications to Resident 17 via GT, eye drops instillation, and eye ointment application: - acetaminophen (medication to relieve pain and fever) Oral Solution USP 650 mg/20.3 ml, one pod - Docusate Sodium liquid 100 mg/10 ml-stool softener laxative, two pods - metoclopramide (medication to treat nausea and vomiting) oral solution USP 10 mg/10 ml, give 5 ml. - rosuvastatin calcium (medication to treat high cholesterol level) 10 mg two tablets - modafinil (medication to treat sleep disorder) 200 mg one tablet - vitamin D3 (supplement) 10 mcg/400 IU one tablet - tizanidine (medication to treat muscle spasms) 4 mg one-half tablet - famotidine (medication to treat heartburn and acids in the stomach) 20 mg one tablet - methocarbamol (medication to treat muscle spasm and pain) 500 mg one tablet - Thera (supplement) one tablet - 12 hour allergy fexofenadine hydrochloride 60 mg two tablets (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 31 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0759 - Refresh PM Lubricant Eye Ointment Night Time Relief 3.5 gm, apply 1/3 inch strip ointment to both eyes Level of Harm - Minimal harm or potential for actual harm - carboxymethylcellulose sodium (medication to temporarily relieve burning, irritation, and discomfort due to dryness) 0.5% eye drops one drop to the left eye and two drops to the right eye. Residents Affected - Few After the GT medication administration, some medication residues were observed in the medication cups labeled for the following medications: vitamin D3, methocarbamol, fexofenadine, and Thera. LVN 3 verified the findings. When asked if Resident 17 received the full dose as ordered by the physician when there were medication residues left inside the cups, LVN 3 stated no. On 2/14/23 at 1027 hours, after medication administration via GT for Resident 17, LVN 3 instilled one drop of carboxymethylcellulose sodium 0.5% eye drops to Resident 17's left eye. At 1028 hour, LVN 3 instilled two drops of carboxymethylcellulose sodium 0.5% eye drops to Resident 17's right eye, one drop after another. On 2/14/23 at 1030 hours, LVN 3 applied 1/3 of an inch strip of Refresh PM Lubricant Eye Ointment Night Time Relief 3.5 gm to the left eye, then to the right eye of Resident 17. LVN 3 did not wait five minutes to apply the eye ointment after the administration of carboxymethylcellulose sodium 0.5% eye drops. Medical record review for Resident 17 was initiated on 2/13/24. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's physician's orders showed the following orders: - dated 5/16/23, to administer methocarbamol 500 mg two times a day for fall risk medication for muscle tightness. - dated 7/4/23, to administer cholecalciferol 400 IU via GT as supplement - dated 12/6/23, to administer fexofenadine 120 mg via GT daily for excessive secretion - dated 12/6/23, to administer fexofenadine 120 mg via GT daily for excessive secretion - dated 2/9/24, to administer Refresh PM ointment 3.5 gm 1/3 inch strip ointment BID at 0900-2100 hours to both eyes for severe eye dryness - dated 2/9/24, to administer carboxymethylcelllulose sodium 0.5% eye drops instill two drops into both eyes every four hours while awake, if overlaps with ointment apply artificial tears first then ointment for severe eye dryness. The eye drops were to be administered at 0800 hours. - dated 3/13/24, to administer MVI (supplement) one tablet via GT daily On 2/14/23 at 1337 hours, an interview was conducted with LVN 3 regarding the carboxymethylcellulose sodium 0.5% eye drops. LVN 3 verified the medication was not administered as ordered to Resident 17. On 2/14/23 at 1500 hours, an interview and concurrent P&P review was conducted with the Director of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 32 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0759 Level of Harm - Minimal harm or potential for actual harm Pharmacy. The Director of Pharmacy verified the nurse needed to wait 5 minutes in between administration of two different eye medications. On 2/14/23 at 1445 hours, a follow-up interview was conducted with LVN 3. LVN 3 verified she did not wait five minutes in between administration of eye drops and eye ointment to Resident 17. Residents Affected - Few 2. On 2/15/24 at 0851 hours, a medication administration observation was conducted with LVN 5 in Resident 4's room. LVN 5 prepared and administered the following medications to Resident 4 via GT: - Miralax (laxative) PEG3350 powder - morphine (prescription medication to treat moderate to severe pain) liquid 10 mg/5 ml (2 mg/ml) - ferrous sulfate (supplement) 300 mg/5 ml - vitamin D3 (supplement) 25 mcg (1000 IU) one tablet. - metoprolol tartrate (medication to treat high blood pressure) 25 mg one tablet - calcium carbonate (supplement) 500 mg one tablet - simethicone (medication to relieve gas in the stomach) 80 mg chewable one tablet - Thera M Plus (supplement) one tablet On 2/15/24 at 1023 hours, LVN 5 completed the GT medication administration for Resident 4. Three unlabeled medication cups were observed with medication residue; however, LVN 5 identified the medications as Multi-vitamin Thera Plus, simethicone, and calcium carbonate. The pink medication tray was observed with medication residue which LVN 5 identified as calcium carbonate. LVN 5 verified the findings and stated Resident 4 did not receive the full dose of the three medications identified. Medical record review for Resident 4 was initiated on 2/15/24. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's physician's orders showed the following orders: - dated 5/16/23, to administer simethicone 80 mg oral every 12 hours via GT for gas relief - dated 5/16/23, to administer calcium carbonate 500 mg via GT daily as supplement - dated 5/16/23, to administer ferrous sulfate 300 mg via GT every two days at 0900 hours - dated 7/31/23, to administer carboxymethylcellulose sodium 0.5% 15 ml one drop to both eyes three times per day - dated 8/4/23, to administer multivitamin with mineral one tablet via GT daily as supplement Review of Resident 4's MAR showed Resident 4 received the ferrous sulfate 300 mg via GT on 2/14/24 at 1100 hours. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 33 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 2/15/24 at 1324 hours, an interview was conducted with LVN 5. When asked about Resident 4's order for the Ocular lubricant eye drop, LVN 5 verified she did not administer the eye drops because she did not have the medication available. On 2/15/24 at 1422 hours, a follow-up interview was conducted with LVN 5 regarding Resident 4's ferrous sulfate order. LVN 5 verified ferrous sulfate was administered yesterday and not supposed to have been given during the above medication administration observation because the physician's order was for every two days. LVN 5 stated she did administer the ferrous sulfate to Resident 4 today by accident. Event ID: Facility ID: 555709 If continuation sheet Page 34 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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. Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly in two medication carts (Medication Carts A and B) and failed to ensure an expired medication was not stored in Medication Cart A. * Three medications in Medication Cart B and one medication in Medication Cart A did not have clear labels and were unreadable. * Five medications in Medication Cart B and five medications in Medication Cart A did not have no open dates. * One expired medication was found in Medication Cart B. * One drawer from Medication Cart B contained 3 containers of protein powder stored with alcohol gel and hydrogen peroxide 3% in the same drawer. * Medication Cart B contained one bottle of sterile water without an open date * The medication refrigerator contained tuberculin solution without an open date These failures had the potential for the nurses to administer the incorrect medication or expired medications; and had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Medication Expiration Dating revised on 11/2018 showed multiple dose vials (with preservatives) must be used within 28 days (or the expiration date if sooner) after the initial puncture. All multiple dose vials shall have the actual expiration date noted on the vial. Certain types of insulin (eg, regular and NPH) may be stored outside of the refrigerator for maximum of 28 days or until the expiration date, whichever is sooner. Further review of the facility's P&P showed ophthalmic and otic drops shall be discarded 3 months after opening or at the time of the manufacturer's expiration date, whichever is sooner. Review of the facility's P&P titled Medication Labeling Requirements revised 1/2016 showed all medication labels shall be clear, consistent, and legible. The P&P also showed the medication label shall include resident name, resident location, generic or brand medication name, amount of drug in the dosage form, directions for use and any applicable cautionary statements. 1. On 2/13/24 at 0952 hours, an observation of medication cart B and concurrent interview was conducted with LVN 1. Medication cart B contained separate drawers assigned to the residents as follows: - Resident 20's medication drawer contained one bottle of carboxymethylcellulose sodium ophthalmic with an expiration date of 9/2025. There was no open date on the bottle. - Resident 23's medication drawer contained one bottle of carboxymethylcellulose sodium 0.5 % eye drops, with an instruction not to use after 4/17/24. There was no open date on the bottle. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 35 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 Furthermore, the label for directions to administer the eye drops was illegible. Level of Harm - Minimal harm or potential for actual harm - Resident 2's medication drawer contained one bottle of carboxymethylcellulose sodium 0.5 % eye drops, with an open date of 2/7/24, and not to use after 5/7/24. The label for direction was illegible. Residents Affected - Few -Resident 12's medication drawer contained the following medications: - One opened vial of Insulin Glargine 300 units/3 ml with an expiration date of 3/10/24. The insulin vial did not have an open date labeled. - One opened bottle of carboxymethylcellulose sodium 0.5 % eye without an open date labeled. Furthermore, the direction on the label was illegible. - One opened vial of Lantus 1000 units/10 ml with an open date labeled. The vial showed an instruction to not use after 2/24/24. - Medication Cart B had a drawer with Repair and Recover Powder, Beneportein Instant Protein Powder, and Nutrisource Fiber Powder stored with alcohol gel and hydrogen peroxide 3% in the same drawer. - Medication Cart B had a drawer containing one bottle of Regular Strength Antacid/Antigas liquid Cool Mint Flavor with an expiration date of 01/2024. -Medication Cart B had an opened bottle of sterile water for irrigation with approximately 700 ml in the bottle undated and unlabeled, stored with the expired antacid. LVN 1 acknowledged and verified all the findings. 2. On 2/13/24 at 1128 hours, an observation of Medication Cart A and concurrent interview was conducted with LVN 2. Medication cart A contained drawers assigned to the residents as follows: - Resident 3's medication drawer contained one bottle of Sodium chloride nasal (opened bottle) without an open date labeled. -Resident 14's medication drawer contained the following medications: - One opened bottle of Latanoprost ophthalmic 0.005% 2.5 ml without an open date labeled. - One opened bottle of Desmopressin nasal 10 mcg/5 ml spray for Diabetic Insipidus without an open date labeled. The direction on the label was illegible. - Resident 1's medication drawer contained one opened bottle of Ocular Lubricant without an open date labeled. - Resident 16's medication drawer contained one opened bottle of Phenol 1.4% 177 ml spray without an open date labeled. LVN 2 acknowledged and verified all the findings. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 36 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 3. On 2/13/24 at 1047 hours, an observation of the Pyxis and refrigerator inside the nursing station and concurrent interview was conducted with RN 1. In the refrigerator, a vial of Tuberculin Purified Protein Derivative was noted without an open date. RN 1 verified the findings and stated the vial should have been dated and was good for only one month. On 2/13/24 at 1436 hours, an interview was conducted with the DOP. The DOP stated all drugs should have the labels, and the label should include the resident's name, drug, strength, account number, and direction of use. When asked for the facility's process if the label was no longer clear or unreadable, the DOP stated that the nurses were to contact the pharmacy to relabel and if the medication cannot be identified with the resident's name, the medication was disposed and new medication was provided from the pharmacy. The DOP also verified all insulin and tuberculin vials expired 28 days after the date the medication was opened. Event ID: Facility ID: 555709 If continuation sheet Page 37 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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, facility document review, and P&P review, the facility failed to ensure food safety and sanitation in the kitchen as evidenced by: Residents Affected - Few * The FSS did not perform hand hygiene after removing the gloves and touched the food with the dirty gloves during the food preparation. * Resident 9's culinary utensil was not washed and sanitized as per the facility's P&P. * A handwashing sink was used for purposes other than hand washing when the CNA used hand sink to wash the spoon. * The food contact surfaces were not clean. * A hair restraint was not worn during food preparation, * The following nonfood contact surfaces were not clean. * The nonperishable food brought from the outside was not labeled or dated. * The can opener blade was worn. * The test strips used to test the dish machine sanitizer were expired. These failures had the potential to cause outbreak of foodborne illness to one of the 23 facility residents, staff and visitors who consumed food prepared in the kitchen. Findings: Review of the facility matrix showed one of 23 residents received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Preparation/Production revised 6/2012 showed hands must be washed frequently in designated handwashing sink using proper hand washing technique. Disposable gloves are to be worn when handling food. Gloves will be changed as soon as they become soiled or torn and before beginning a different task. On 2/12/2024 at 1129 hours, an observation of the lunch meal preparation was conducted with the FSS. The FSS removed his gloves and donned a new pair of gloves without washing his hands. Using a scoop, the FSS placed the ground chicken in a Styrofoam bowl. The FSS then proceeded to touch unclean surfaces, steam table, weighing scale, and counter, then placed the ground chicken into a regular bowl. Using the same gloved hands, the FSS touched the ground chicken to form it to a bowl shape. On 2/13/24 at 1336 hours, an interview was conducted with the FNSD. The FNSD verified the hands should always be washed when the gloves were changed and when working with food. 2.a. According to the 2022 USDA Food Code Section 4-702.11 Before Use After Cleaning, utensils and food-contact surfaces of equipment shall be sanitized before use after cleaning. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 38 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 - Few Review of the facility's P&P titled Cleaning-General revised 6/2014 showed all working surfaces, utensils and equipment are cleansed thoroughly and sanitized after each period use. Dishes and utensils used for eating, drinking and in the preparation and serving of food shall be cleaned and disinfected by proper dishwashing techniques after each usage. They will be washed in a National Sanitation Foundation approved commercial dish machine at a minimum wash temperature of 120 degrees Fahrenheight (F) with an approved commercial dishwashing detergent. They shall go through an automatic rinse cycle of clean water with a minimum temperature of 120 degrees F with proper sanitizing agent dispensed and shall be allowed to drain dry in racks over clean, nonabsorbent surface. Review of the facility's P&P titled Equipment revised 6/1998 showed equipment of the type and in amount necessary for the proper preparation, serving and storing of food and for proper dishwashing shall be provided and maintained in good working order. Such equipment shall be in compliance with applicable sanitation and safety law and regulation. On 2/12/24 at 1229 hours, an observation of the lunch meal service for Resident 9 and concurrent interview with CNA 4 was conducted. CNA 4 obtained a spoon from Resident 9's bedside table drawer which was wrapped in a paper towel stored in a used ziplock bag. CNA 4 put the spoon into the assistive feeding device. Resident 9 fed himself with assistance from CNA 4. CNA 4 stated that was the only spoon Resident 9 would use, and the spoon was brought to the facility by the family. After Resident 9 completed his lunch meal, CNA 4 washed the spoon in the hand sink located in Resident 9's bathroom. CNA 4 used the hand soap to wash the spoon, rinsed the spoon with water, dried the spoon with a paper towel, wrapped the spoon with a paper towel, and then stored in the ziplock bag in Resident 9's bedside table drawer. When asked if that was how he usually cleaned the spoon, CNA 4 stated Yes, that was the only way Resident 9 would allow the facility to wash the spoon. On 12/13/24 at 1028 hours, an interview was conducted with the FNSD. The FNSD stated all utensils must be washed and sanitized using the dishwashing machine or the manual dishwashing sink in the kitchen. b. According to USDA Food Code 2022 Section 5-205.11 Using a Handwashing Sink, facilities must be maintained in a condition that promotes handwashing and restricted for that use . Sinks used for food preparation and ware washing can become sources of contamination if used as handwashing facilities by employees returning from the toilet or from duties which have contaminated their hands. On 2/12/24 at 1229 hours, observed CNA 4 washed Resident 9's spoon on the bathroom sink. On 12/13/24 at 1028 hours, during an interview with the FNSD, she stated the hand sinks should not be used for dishwashing. 3. Review of the facility's P&P titled Cleaning-Handwashing Pots, Pans and Utensils in 3 Compartment Sink, revised 3/16 showed to check pots, pans & utensils for cleanliness/condition before storing and discard any that can no longer be adequately cleaned and are unsightly, unsanitary or hazardous because of chips, cracks, corrosion, rust, etc. Review of the facility's P&P titled Equipment revised 6/98 showed equipment of the type and in amount necessary for the proper preparation, serving and storing of food and for proper dishwashing shall be provided and maintained in good working order. Such equipment shall be in compliance with applicable sanitation and safety law and regulation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 39 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 On 2/12/24 at 0754 hours, during the initial tour of the kitchen, an interview was conducted with the Kitchen Supervisor. The Kitchen Supervisor acknowledged the following food contact surfaces were not in proper sanitary condition. - Four frying pans had a thick black residue on the cooking surfaces. Residents Affected - Few - A frying strainer had a brown colored sticky residue. - The ice scoop had a brown residue. - The ice machine bin had a dark reddish-brown residue. 4. Review of the facility's P&P titled Dress Code/Grooming revised 2/2017 showed the food employees shall wear hair restraints, and clothing that covers body hair, and that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, etc. Review of the facility's P&P titled Food Preparation/Production revised 6/2012 showed the hairnets, hats or caps must be worn and beard guards where indicated, when working in the kitchen and dish room. On 2/13/24 at 1559 hours, an observation and concurrent interview was conducted with [NAME] 1. [NAME] 1 did not wear a hair restraint for his beard during meal preparation in the kitchen. [NAME] 1 acknowledged he needed to wear a hair restraint for his beard . 02/13/24 at 1608 hours, an interview was conducted with the FNSD. The FNSD acknowledged [NAME] 1 should wear a beard guard when in the kitchen. 5. Review of the facility's P&P titled, Cleaning-General revised 6/2014 showed the kitchen areas should be free of food debris and visible soil, used in a manner that prevents contamination of food, equipment, utensils, etc. Review of the facility's P&P titled Equipment revised 6/1997 showed the equipments shall be in compliance with applicable sanitation and safety law and regulation. During the initial tour of the kitchen on 2/12/24 at 0759 hours, an interview was conducted with the Kitchen Supervisor. The Kitchen Supervisor acknowledged the following needed proper cleaning and/or if not, be discarded: - The freezer floor was not clean; food debris and a dark purple dried liquid spillage was noted. - A large fan located above a food preparation sink was not clean. - Six dish racks contained a black sticky residue. 6. Review of the facility's P&P titled Food from Outside Source reviewed date 7/22 showed the resident should be encouraged to eat food immediately and not store food, patient food may only be stored in patient refrigerators; all containers must be labeled with patient's name (first and last), medical record number, date and will be discarded within 48 hours unless a manufacturer expiration date is present. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 40 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 - Few On 2/12/24 at 1148 hours, a lunch meal observation of Resident 9 was conducted. Two 110 ml bottles of hot sauce and one 28 ounces bottle of hot sauce were observed in Resident 9's room without a label or date. On 2/12/24 at 1342 hours, an interview was conducted with the FNSD. The FNSD confirmed the food from outside of the facility should be labeled and dated. 7. According the USDA Food Code 2022 Section 4-501.11 Good Repair and Proper Adjustment, (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate food when the container is opened. On 2/12/24 at 0814 hours, during the initial tour of the kitchen with the Kitchen Supervisor, an observation of the can opener was conducted. The can opener blade was worn. The Kitchen Supervisor acknowledged the can opener blade should be replaced. 8. Review of the facility's P&P titled Cleaning-Dishwashing revised 5/2005 showed the facility should assure the sanitation of the dishes and utensils by following the proper procedures for dishwashing in the dishwashing machine. On 2/12/24 at 0917 hour, an observation of the dishwashing machine area and concurrent interview was conducted with the Dietary Aide and Kitchen Supervisor. The dish machine sanitizer test strips had an expiration date of 3/1/23. The Dietary Aide and Kitchen Supervisor acknowledged the test strips were expired and should be discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 41 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on interview and facility P&P review, the facility failed to ensure the staff and visitors who brought food from outside were educated on the safe food handling practices. This failure had the potential to cause the risk of safety of usage, handling, and consumption of foods brought to the residents by the resident's family and visitors. Residents Affected - Few Findings: Review of the facility's P&P titled Food From An Outside Source dated 7/2022 did not show a process to ensure the visitors who brought food from outside or facility staff were educated on the safe food handling guidelines. On 2/13/24 at 0916 hours, an interview was conducted with the DON. The DON stated the staff did not provide the safe food handling education handouts to the visitors who brought food to the residents. On 2/13/24 at 0939 hours, an interview was conducted with the DSD. The DSD stated they did not have copies given for safe food handling education to the visitors. On 2/15/24 at 0945 hours, an interview with the FNSD was conducted. The FNSD confirmed no handouts were given to the visitors regarding education on the safe food handling practices. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 42 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0814 Dispose of garbage and refuse properly. Level of Harm - Potential for minimal harm Based on observation, interview, and USDA Food Code review, the facility failed to ensure the safe handling and collection of regular waste. This failure posed the risk for safety and pest contamination . Residents Affected - Some Findings: 1. According to the USDA Food Code 2022 Section 5-501.110. Storing refuse, recyclables and returnables, shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. According to the USDA Food Code 2022 Section 5-502.11. Frequency. refuse, recyclable and returnables, shall be removed from the premises at a frequency that will minimize the development of objectionable order and other conditions that attract or harbor insects and rodents. On 2/13/24 at 0850 hours, an observation and concurrent interview was conducted with the EVS Supervisor. Broken glass, more than ten cardboard boxes, a microwave, a weighing scale and an office chair were found on the ground in the dumpster area of the facility. The EVS Supervisor verified it was unsafe and posed the risk for pest contamination. 2. According to the USDA Food Section 2022 Section 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (B) With tight-fitting lids or doors if kept outside the food establishment. On 2/13/24 at 0822 hours, an observation of the dumpster area was conducted. Four of four dumpsters were observed uncovered. On 2/13/24 at 0850 hours, an observation and concurrent interview was conducted with the EVS Supervisor. The EVS Supervisor confirmed the dumpsters needed to be covered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 43 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 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** 2. On 2/13/24 at 1517 hours, concurrent interview and document review was conducted with the IP. Residents Affected - Few Review of the November 2023 infection control logs showed four of five residents with infection did not meet McGeer's criteria. Further review of the facility's documents showed no documented evidence the infection control committee addressed these residents who did not meet McGeer's criteria in November 2023. When asked about the last infection control committee, the IP stated the last infection control meeting was held on 8/10/23. The IP verified the infection control committee did not meet to discuss the residents who did not meet McGeer's criteria in November 2023. The IP verified the infection control committee missed one quarterly infection control meeting. Based on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented. * LVNs 3, 4, and 5 failed to perform hand washing prior to the administration of medications via GT to three nonsampled residents (Residents 2, 4, and 17). * The trash can in Resident 4's room was overfilled with yellow gowns which was used for contact precaution isolation. * The facility's infection control committee did not meet for one quarter to discuss the residents who did not meet McGeer's criteria in November 2023. These failures posed the risk for transmission of disease causing microorganism, and resulted for the committee not able to discuss about the residents on antibiotics who did not meet McGeer's criteria. Findings: 1. Review of the facility P&P titled Medication Administration Via Feeding Tube revised on 8/2021 showed steps in procedure to wash hands before crushing pills and administering medications to the resident. a. Medical record review for Resident 17 was initiated on 2/13/24. Resident 17 was admitted to the facility on [DATE]. On 2/14/24 at 0815 hours, a medication administration observation was conducted with LVN 3 in Resident 17's room. LVN 3 performed hand hygiene using alcohol hand gel prior to the administration of medications via GT; however, LVN 3 did not wash her hands prior to the administration of medications to Resident 17. On 2/14/24 at 1500 hours, an interview was conducted with LVN 3. When asked regarding the facility's process about hand hygiene prior to the administration of medications via GT, LVN 3 stated they (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 44 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 were supposed to wash their hands before the medication administration. Level of Harm - Minimal harm or potential for actual harm b. Medical record review for Resident 2 was initiated on 2/13/24. Resident 2 as admitted to the facility on [DATE]. Residents Affected - Few On 2/14/24 at 1415 hours, a medication administration observation was conducted with LVN 4 in Resident 2's room. LVN 4 donned a gown, sanitized her hands, and put on gloves prior to the administration of medications to Resident 2 via GT. LVN 4 did not wash her hands prior to the administration of medications to Resident 2. After the GT medication administration of medications, LVN 4 verified she did not wash her hands before giving medications to Resident 2. LVN 4 also stated she was aware of the policy for the nurses to wash hands before giving the medications to Resident 2. c. Medical record review for Resident 4 was initiated on 2/13/24. Resident 4 was admitted to the facility on [DATE]. On 2/15/24 at 0851 hours, a medication administration observation was conducted with LVN 5 in Resident 4's room. LVN 5 donned a gown, sanitized her hands, and put on the gloves prior to the administration of medications to Resident 4 via GT. LVN 5 did not wash her hands prior to the administration of medications to Resident 4. On 2/15/24 at 1023 hours, an interview was conducted with LVN 5. When asked regarding the facility's process about hand hygiene prior to the administration of medications via GT, LVN 5 stated she used to wash her hands during the day, but not before medication administration. 2. On 2/15/24 at 1030 hours, a trash container inside Resident 4's room, by the door, was observed overfilled with yellow gowns. Yellow gowns were hanging over the trash container. LVN 5 verified the findings and stated the EVS was in charge of emptying the trash, and the trash can should not be overfilled. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 45 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in a safe operating condition. Residents Affected - Few * The facility failed to ensure the ice machine located in the kitchen was cleaned and sanitized as per the manufacturer's guidelines. * The facility failed to ensure the medication refrigerator was maintained and the freezer compartment inside the medication refrigerator was free of ice buildup. These failures had the potential for the refrigerator not being maintained in a safe operating condition and posed the risk of ice contamination and equipment to function improperly. Findings: Review of the [Manitowoc] ice machine manufacturer's guidelines, Section 4, showed in part, to use only [Manitowoc] approved metal safe ice machine de-scaler (part number 000000084) and [Manitowoc] Sanitizer 9 (part number 9405653). Detailed De-scaling/Sanitizing procedure as follows: to be performed every six months. All ice must be removed from the bin. The ice machine and bin must be disassembled, descaled, and sanitized. The ice machine produces ice with the de-scaler and sanitizing procedure must be discarded. Sanitizing Procedures can be performed independently and more frequently than de-scaling as needed (detailed de-scaling must be performed once every six months). Detailed de-scaling and sanitizing procedure: Use Metal Safe Ice Machine De-Scaler, part number 000000084 (used to remove lime scale and mineral deposits). Use Ice Machine Sanitizer part number 9405653 (used to disinfect, remove algae and slime) .Step 5. Follow the chart and premix de-scaler and water. Amount of Water = 1gallon (4 Liters). Amount of Metal Safe De-Scaler- Part Number 000000084 = 3 ounces (90 ml). Step 6. Fill the evaporator and reservoir with de-scaling solution .Step 10. Refer to removal of parts for de-scaling/ sanitizing and disassemble parts for hand de-scaling/ sanitizing. Hand de-scale all parts. Rinse all parts with clear potable water. Sanitize all parts- do not rinse after sanitizing. Spray all interior bin surfaces with sanitizer (do not rinse sanitized areas). Spray evaporator discharge spout. Step 11. Reassemble ice machine. Step 12. Turn off the ice making water supply. Step 13 refer to chart and premix water and sanitizer: Amount of water = 1 gallon (4 L) water. Amount of sanitizer 0.5-ounce (15 ml). Ice chute removal. Step 3. Remove microswitch and bin thermostat from ice chute. Step 4. Remove retainer, ice chute elbow and ice chute. On 2/12/24 at 1050 hours, an observation and concurrent interview was conducted with the General Maintenance Staff and the Kitchen Supervisor. The General Maintenance Staff showed and stated [Ice Kleen] Ice Machine cleaner and [IMS-III] Sanitizing Concentrate were used to clean the Manitowoc Ice Machine. The General Maintenance Staff stated he did not know how the ice chute was cleaned and he did not remove parts or disassemble parts for hand de-scaling/sanitizing when cleaning the ice machine. The Kitchen Supervisor verified the solutions used should be in accordance with the guidelines, and the ice chute should be removed, cleaned, and sanitized. 2. Review of the facility's P&P titled Refrigerator Temperature Checks revised 9/2009 showed freezers shall be defrosted when the temperature cannot be maintained or excessive frost is observed. On 2/13/24 at 1047 hours, an observation of the Pyxis system and concurrent interview was conducted with RN 1. The freezer compartment of the medication refrigerator was observed with ice buildup. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 46 of 47 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 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chapman Global Medical Center D/P Snf 2601 East Chapman Avenue Orange, CA 92869 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 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete The door section of the fridge, inside the fridge, was observed with a yellow stain. RN 1 verified the findings and further stated she did not know what the yellow stain was. When asked who was responsible to clean the medication refrigerator, RN 1 stated it was the Pharmacy Technician. On 2/13/24 at 1109, an observation and concurrent interview was conducted with the Pharmacy Technician. The Pharmacy Technician stated they were responsible for checking the medication refrigerator when they conducted the audit, and the freezer was thawed every month. When asked what was the facility's process when an ice buildup was observed and the freezer was not scheduled for thawing, the Pharmacy Technician stated the freezer had to be thawed right away. Event ID: Facility ID: 555709 If continuation sheet Page 47 of 47