Health inspection·October 3, 2025

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 10/3/25 at 1646 hours, a telephone interview was conducted with LVN 2. LVN 2 stated Resident 1 was uncomfortable when the right arm was touched. The swelling and bruise would not be visible unless the sleeves of the hospital gown was pulled up. 2. a. Medical record review for Resident 1 was initiated on 10/1/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed the following orders: - dated 8/20/25, for PT treatment once a day for two days per week times two weeks for therapeutic activity, functional mobility, neuromuscular (network of nerves and muscles) re-education, therapeutic exercise and patient/family education.- dated 8/26/25, for OT to continue treatment two times a week for four weeks for ADL retraining, functional mobility for ADLs, neuromuscular re-education, therapeutic activities, therapeutic exercise for ADLs, resident/family education. Review of Resident 1's PT/OT Treatment Record for August to September 2025 showed only one PT treatment for the week 8/25 to 8/29/25, and no PT treatment for the week 9/1 to 9/5/25. Further review of the document failed to show Resident 1 had OT treatment from 9/1 to 9/16/25. b. Medical record review for Resident 4 was initiated on 10/2/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's MDS assessment dated [DATE], showed a BIMS score of 2 (severe cognitive impairment). Review of Resident 4's Order Summary Report showed an order dated 8/5/25, for OT to continue one time a week for four weeks for ADL retraining, functional mobility for ADLs, neuromuscular re-education, patient/family education, therapeutic activities and therapeutic exercise for ADLs. Review of Resident 4's medical record failed to show documentation Resident 4 had OT treatment for the week 9/1 to 9/5/25. On 10/2/25 at 1321 hours, an interview was conducted with the PT. The PT stated the Rehab Department serviced the whole hospital (including the SNF). If there were surgeries, the surgery patient becomes the priority for treatment. On 10/3/25 at 1200 hours, the DON was made aware and acknowledged the findings. 3. a. Medical record review for Resident 1 was initiated on 10/1/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed the following orders:- dated 7/23/25, RNA for AROM right upper extremity and AAROM left upper extremity (except left shoulder joint) daily as tolerated.- dated 7/23/25, RNA for bilateral lower extremities active assisted/passive range of motion exercise daily seven times a week.- dated 9/12/25, RNA to apply the bilateral multi Podus orthoses (boot to relieve pressure, prevent skin breakdown and correct or prevent foot and ankle contractures and foot drop) to bilateral ankles for four hours of use. Monitor for redness.- dated 9/19/25, hold ROM and exercises to RUE.- dated 9/22/26, RNA for AAROM for left upper extremity (except shoulder joint) daily as tolerated. Review of Resident 1's RNA Flowsheet for 9/1 to 9/30/25, failed to show the RNA provided RNA services on the following dates:on 9/6, 9/10, 9/11, and 9/14/25, for AROM right upper extremity and AAROM left upper extremity.- on 9/6, 9/10, 9/11, 9/14, 9/20, 9/27, and 9/28/25, for bilateral lower extremities active assisted/passive range of motion exercise.- on 9/20, 9/27, and 9/28/25, to apply bilateral multi podus orthoses to bilateral ankles for four hours of use and to monitor for redness.- on 9/27 and 9/28/25, for AAROM for left upper extremity (except shoulder joint). b. Medical record review for Resident 2 was initiated on 10/1/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Order Summary Report showed the following orders:- dated 6/4/25, RNA for bilateral lower extremities passive range of motion exercise once a day for seven days. Monitor for redness.- dated 7/15/25, RNA to apply BUE resting hand splints daily after PROM for four hours as tolerated. Check skin for redness or breakdown before and after. Apply towel rolls after removal.- dated 8/18/25, RNA to apply the ankle foot orthosis to left ankle and ankle foot orthosis (device inserted into a shoe to support and correct foot structure and function) with lateral side straps to right ankle for two hours when patient is supine for total use of four hours a day. RNA to apply the orthoses (device to correct (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555709 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555709 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2025 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete alignment and provide support) daily. Monitor for redness.- dated 9/15/25, for RNA to apply the right knee comfy splint (soft straps attached to joints to accommodate sensitive skin, edema and fragile skin) when patient is in supine for two hours twice a day daily for total of four hours. Monitor for redness. Review of Resident 2's medical record failed to show documented evidence the RNA had performed the above tasks on 9/6, 9/10, 9/11, 9/14, 9/20, 9/27, and 9/28/25. Additionally, the medical record failed to show the RNA applied the right knee comfy splint on 9/20, 9/27, and 9/28/25. c. Medical record review for Resident 3 was initiated on 10/1/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report showed the following orders:- dated 6/4/23, RNA to apply the left hand/wrist splints daily after ROM for six hours as tolerated.- dated 6/4/23, RNA to apply the right hand/wrist splints daily after ROM for six hours as tolerated.- dated 6/4/23, RNA for active/active-assist/passive ROM exercises for bilateral upper/lower extremities as tolerated daily.- dated 6/4/23, RNA to apply the bilateral hand roll-type splints daily for 3.5 hours, coordinate with hand cream for pain. Apply the hand rolls after the splints are taken off.- dated 7/18/23, RNA to apply the left roll-type goniometer wrist brace (a mechanism to control a joint's range of motion) for six hours as tolerated daily after PROM and self-care. Review of Resident 3's medical record failed to show documented evidence the RNA had performed the above tasks on 9/6, 9/10, 9/11, 9/14, 9/20, 9/27, and 9/28/25. d. Medical record review for Resident 5 was initiated on 10/2/25. Resident 5 was originally admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 5's Order Summary Report showed an order dated 5/17/23, for the RNA to provide daily active/passive/active assistive ROM for all the four extremities daily. Review of Resident 5's medical record failed to show documented evidence the RNA had performed the above tasks on 9/6, 9/10, 9/11, 9/14, 9/20, 9/27, and 9/28/25. On 10/1/25 at 1600 hours, an interview was conducted with the RNA. The RNA stated on days the facility was short staffed, the RNA was pulled out to take the role of CNA. On 10/3/25 at 0919 hours, an interview and concurrent medical record review was conducted with the DON. The DON was asked why there were days when the RNA services were not provided. The DON stated it was because the facility was short staffed that the RNA had to work as CNA. The DON verified the findings. Event ID: Facility ID: 555709 If continuation sheet Page 3 of 3