Health inspection·May 2, 2025

F 0695 Review of facility's P&P titled Code Blue reviewed [DATE] showed Code Blue is to be called: Level of Harm - Minimal harm or potential for actual harm a. In emergency situations when a patient has a significant change or Residents Affected - Few b. On any patient in cardiac or respiratory arrest unless there is a specific physician order to the contrary. (See withholding/withdrawing life support). Examples of significant changes: i. Decreasing level of consciousness – unresponsiveness ii. Hypotension – lack of audible/palpable BP iii. Dyspnea – apnea iv. Sudden decreasing or absent peripheral pulses v. Uncontrolled hemorrhage vi. Ventricular fibrillation vii. Ventricular tachycardia viii. Asystole c. Rapid Response is to be called when a patient is identified as at risk according to selected criteria. Review of facility's P&P titled Tracheostomy Tube Suctioning with an In-line Catheter reviewed on [DATE] showed the resident with tracheostomy tube will be suctioned every two hours and as needed. Review of [NAME] Respironics Trilogy 202 Ventilator User Manual showed: Alarm Summary Table indication of high, medium, and low priority and recommended clinical actions as follows: - Low Circuit Leak: High priority, recommended clinician action was to remove obstruction in leak device. Reduce the flow rate to in line nebulizer or low pressure oxygen bleed into the circuit. If the alarm continues, have the device serviced. - High Resp Rate: High priority, recommended clinician action was to verify patient status - High Insp Pressure: Escalates from audible indicator to medium priority and then high priority, recommended clinician action was to verify patient status. If the problem continues, have the device serviced. - Circuit disconnect: High priority, recommended clinician action was to reconnect tubing or fix leak. - Low minute ventilation: High priority, recommended clinician action was to verify patient status. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 2 of 7 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 05/02/2025 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 1. Closed medical record review for Resident 1 was initiated on [DATE]. Resident 1 was readmitted on [DATE] at 1330 hours, and discharged on [DATE] at 1706 hours, to the acute care hospital. Review of Resident 1's Patient Orders for [DATE] showed the following orders: - dated [DATE], for mechanical ventilation, vent mode: assist control, Tidal Volume 450, set rate 16, FiO2: 30%, PEEP: 5, Maintain oxygen saturation: above 92% - dated [DATE], suction, artificial airway every twohours PRN: for retained or increased secretions every shift - dated [DATE], full code There was no documented evidence Resident 1 was suctioned on [DATE]. Review of Resident 1's RT note dated [DATE] at 1330 hours, showed Resident 1 was alert, awake, and oriented to person and place. Resident 1 was placed on the ventilator with ventilator settings as per the physician's order. Further review of Resident 1's RT notes failed to show any documentation of the ventilator and/or settings after 1330 hours on [DATE]. Review of Resident 1's Nurse Progress Notes dated [DATE], showed the following sequence of events: - At1345 hours, Resident 1 was alert and oriented and denied pain. - At 1453 hours, Resident 1 indicated she wanted to get up and sit at the edge of the bed. - At 1600 hours, Resident 1 was found lying on her side, disconnected from the ventilator, and unresponsive. The resident was immediately connected to an ambu bag while the resident's pulse oximetry was assessed. The peripheral oxygen saturation level was initially in the 60s range (normal range: 95%-100%). The manual ventilation continued while the RT was called. The interventions were maintained until the RT arrived. The CAT was activated, followed by a Code Blue. Review of Resident 1's Code Blue Record dated [DATE], showed the following sequence of events: - At1645 hours, the time of arrest. The type of arrest was respiratory, initial ventilation via tracheostomy ambu bag. Resident 1's heart rhythm was sinus bradycardia. - From 1648 hours to 1651 hours, Resident 1's heart rhythm was Pulseless Electrical Activity. - At 1652 hours, Resident 1's heart rhythm was supraventricular tachycardia. - At1653 hours, Resident 1's heart rhythm was sinus tachycardia. - At 1706 hours, the code blue was stopped. The resident was transferred to the acute care hospital. Review of Resident 1's H&P examination dated [DATE], from the acute care hospital showed under the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 3 of 7 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 05/02/2025 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 history of present illness, the resident was noted to be disconnected from the ventilator, faint pulses, the atropine was given, and the resident was ambu bagged by the RN charge nurse. Resident 1 went into asystole and the CPR was started. Review of Resident 1's Neurology Consult dated [DATE], from the acute care hospital showed the history of recent suspected cardiac arrest status post ROSC neurology was consulted for evaluation of encephalopathy and anoxic brain injury. The problem or assessment showed hypoxic respiratory failure status concerns for anoxic brain injury global cerebral dysfunction (signifies widespread dysfunction affecting the brain's overall functioning). On [DATE] at 1105 hours, an interview was conducted with RN 3. RN 3 stated Resident 1 was awake and alert upon return to the facility on [DATE] at approximately 1330 hours. Resident 1 was able to communicate by writing or mouthing words and wanted to sit up at the edge of the bed. Resident 1 had the capability to use the call light. RN 3 further stated Resident 1 did not want the ventilator circuit to be touching the resident's bed. RN 3 stated she told the resident she would tell the RT to fix the ventilator circuit with an arm to hold the tubing; however, she had not seen the RT since the RT set up the ventilator on [DATE] at 1330 hours. RN 3 stated at approximately 1600 hours, she responded to Resident 1's call lightand found Resident 1 unresponsive. RN 3 stated the circuit from the ventilatorwas disconnected off the resident and was placed along the side of the bed. RN 3 further stated she reconnected the circuit and started to use ambu bag and give manual breaths to Resident 1. RN 3 further stated she called for the RT and then called for code blue. RN 3 stated she did not know how long the call light was on prior to responding to the resident's call light. On [DATE] at 1149 hours, an interview was conducted with RT 1. RT 1 stated Resident 1 was alert and tried to communicate by writing and pointing. RT 1 stated she set up the Resident 1's ventilator at approximately 1300 hours, then left the facility to go to the acute care unit of the hospital. RT 1 stated she had not seen Resident 1 since she left the resident until she heard a call for the RT to the facility. RT 1 stated she was not aware the resident did not want the circuit touching her bed. The RT stated she should have gone back to Resident 1 to check for suctioning every two hours; however, she was at the acute care unit of the hospital. On [DATE] at 1222 hours, an interview was conducted with RN 3. RN 3 stated she could not remember if Resident 1's ventilator alarm sounded. RN 3 further stated she went to Resident 1's room to answer the call light and was focused to intervene when she saw Resident 1 was unresponsive. On [DATE] at 1620 hours, a concurrent observation, interview, and facility document review was conducted with RT 3. RT 3 showed the ventilator machine used forResident 1. RT 3 showed the ventilator alarm log. RT 3 stated the time for the ventilator machine was not accurate and the ventilator was supposed to be checked every four hours and should have been documented. On [DATE] at 0932 hours, an interview was conducted with the RT Manager. The RT Manager stated the ventilator circuit should not easily loosen. The RT Manager stated the ventilator would alarm when the circuit got loose or disconnected. The RT Manager stated the number of residents with ventilators in the facility wasdivided for the RT assigned in the acute care hospital. The RT Manager further stated there was no dedicated RT assigned in the facility. The RT Manager expected the RT to suction the residents with a ventilator in the facility every twohours and check in with the RN in charge. On [DATE] at 0946 hours, an observation of Resident 1's ventilator machine alarm log was conducted with the RT Manager. The ventilator machine showed the inaccurate time. At the time of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 4 of 7 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 05/02/2025 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 observation, the ventilator machine time showed 1649 hours, but the ventilator machine clock setting was seven hours and three minutes in advance from actual time of observation. Level of Harm - Minimal harm or potential for actual harm The ventilator machine alarm showed the following: Residents Affected - Few - at 0906p Low circuit - at 0942p Low circuit leak - at 0938p High respiratory rate - at 1038p High inspiratory pressure - at 1059p Low circuit leak - at 1101p High inspiratory pressure - at 1102p High respiratory rate - at 1106p High respiratory rate - at 1108p Low circuit leak - at 1111p Circuit disconnect - at 1117p High inspiratory pressure - at 1118p Low minute ventilation - at 1118p Circuit disconnect - at 1119p Low minute ventilation - at 1124p Audio paused - at 1124p Low minute ventilation - at 1131p Audio paused - at 1133p Power off The RT Manager acknowledged the inaccuracy time of the ventilator machine used by Resident 1. The RT Manager stated she would call the manufacturer to make sure the time display of the ventilators was accurate. The RT Manager stated the ventilator alarm should sound but was not sure whether the ventilator alarmed during the incident. On [DATE] at 1425 hours, a concurrent interview and closed medical record review was conducted with the Subacute Unit Manager. The Subacute Unit Manager stated there was no dedicated RT in the unit; the RT was usually called when needed. The Subacute Unit Manager verified Resident 1's progress (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 5 of 7 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 05/02/2025 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 notes on [DATE], when the resident was found lying on the side, disconnected from the ventilator, and unresponsive. The Subacute Unit Manager verified the Code Blue Record dated [DATE], showed the time of arrest was 1645 hours. On [DATE] at 1640 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings as above. 2. Review of the facility's P&P titled Changing Disposable Equipment reviewed February 2024 showed the scope of practice: RT, RN and LVN. The HME should be changed when visible soiled or mechanically malfunctioning. The ventilator circuit T-adapter should be changed when visible soiled or mechanically malfunctioning and when needed. Review of the facility's P&P titled Oxygen Therapy reviewed [DATE] showed the scope of practice forRT, RN and LVN (nothing for CNA). The P&P showed oxygen is a drug and will only be administered by licensed nurse or respiratory therapists. Review of Resident 2's medical record review was initiated on [DATE]. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Patient Orders for [DATE] showed an order dated 5/l7/23, for HME, to check HME filter every 24 hours and as needed for high pressure or large amounts of secretions. Review of Resident 2's MDS assessment dated [DATE], showed the resident had severely impaired decision-making capacity. Review of Resident 2's Patient Orders showed the following orders: - dated [DATE], for mechanical ventilation, vent mode: SIMV, Tidal Volume 500, set rate 10, PEEP: 5, and Pressure Support: l 0 - dated [DATE], suction, every two hours. - dated [DATE], suction as needed for increased secretions. - dated [DATE], titrate FiO2 to keep oxygen saturation levels at 94% Review of Resident 2's Progress Note dated [DATE] at 1530 hours, showed about 1515 hours, the resident suddenly turned blue. The Fi02 was temporarily increased to 100%. The RT arrived around 1520 hours and by this time the resident's color was pink. On [DATE] at 1346 hours, an interview was conductedwith Family Member 1. Family Member 1 stated the ventilator machine was beeping continuously and had told the nurse to suction Resident 2. The nurse told Family Member 1 she would give the resident's medication and call the RT to suction Resident 2. Resident 2 was turning purple. CNA 1 came in to help the resident because the nurse did not know what to do. Family Member 1 further stated there was no designated RT in the facility and usually not there when needed because they work also in the acute care unit of the hospital. On [DATE] at 0843 hours, a phone interview was conducted with CNA 1. CNA 1 stated RN 2 asked for his help. When CNA 1 went to Resident 2, Resident 2 was having difficulty breathing, had excessive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 6 of 7 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 05/02/2025 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 secretion in the tracheostomy tube, and the skin looked purple. CNA 1 stated he called the RT. CNA 1 stated RN 2 was standing in front of the alarming ventilator machine and heard RN 2 stated, I don't know what is going on. CNA 1 stated he asked RN 2 to suction the resident, and she did, but there was still excessive secretion. CNA 1 further stated RN 2 asked him to get suction catheter from the supply room to get suction, when he returned the resident was still purple. CNA 1 further stated he replaced the HME filter and rinsed the T-adapter in the sink because it had excessive secretion then RN 2 put the ventilator tubing together. CNA 1 further stated he increased the FiO2 to 100%. CNA 1 stated after less than a minute, Resident 2's color became normal. CNA 1 stated the RT came to the room after the resident stabilized. CNA 1 stated he knew he was not supposed to increase the oxygen and touch the ventilator circuit, rinse the T-adapter however, it was an emergency, and he did what he could at the time to help Resident 2. On [DATE] at 0935 hours, an interview was conducted with the RT Manager. The RT Manager stated the T adapter should not have been rinsed. The RT Manager further stated the RN was trained and were expected to take care of the residents with the ventilators in the facility. The RT Manager stated the CNAs were not allowed to touch the HME and increase the FiO2. On [DATE] at 1036 hours, an interview was conducted with RN 2. RN 2 stated CNA 1 rinsed the T-adaptor because it had excessive secretion. When asked if CNA 1 was allowed to rinse the adapter RN 2 stated CNA 1 was trying to help. RN 2 verified CNA 1 increased Resident 2's FiO2 to 100%. RN 2 verified Family Member 1 had requested for Resident 2 to be suctioned and informed the family member she would suction the resident after hanging the IV medication. On [DATE] at 1640 hours, an interview and concurrent medical record review was conducted with Subacute Manager. The Subacute Manager verified the progress notes on [DATE], when the resident suddenly turned blue, and the Fi02 was temporarily increased to 100%. The Subacute Unit Manager stated there was no dedicated RT in the unit, and he RT was usually called in the subacute unit when needed. On [DATE] at 1640 hours, an interview was conducted with the DON. The DON was informed and acknowledged the findings as above. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 7 of 7