Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chapman Care Center during CMS and state inspections, most recent first.
Infection control practices were not followed during resident care and room cleaning. An RN provided care to a resident on EBP for a trach, G-tube, and C. auris history without wearing a gown, a CNA handled soiled linen and other dirty items without hand hygiene, and EVS staff placed a mop against a clean bed and touched the bed footboard while cleaning. The IP and other staff confirmed the observations.
Kitchen utensils and equipment were observed in unsanitary condition during a kitchen tour. Multiple scoops, spatulas, a basting brush, a wooden spoon, a plastic spoon, and a whisk were damaged, melted, cracked, discolored, or worn out, and several utensils had dry residue, crusted residue, watermarks, or black residue. A heavy-duty blender used for puree prep was still wet when stored, and the microwave had dry food residue inside. The DSS verified the findings, and the facility’s diet type report showed 54 of 90 residents ate food prepared in the kitchen.
Infection control practices were not consistently followed in the LTC facility. A staff member’s personal clothing was stored with clean linens in the laundry area, the water management program for Legionella lacked specific control limits and regular testing, and multiple staff failed to perform hand hygiene after contact with potentially contaminated items during med pass and wound care. The facility also used non-hard foam padding and tape on a resident’s side rails and did not properly disinfect those materials, and a wound VAC canister with drainage was discarded in regular trash.
Improper Consent for Psychotropic Medication: A resident who was self-responsible and had capacity to make decisions was prescribed amitriptyline, but informed consent for the psychotherapeutic medication was obtained from a family member instead of the resident. Facility policy required consent from the resident or responsible party, and the record showed the prescriber discussed the medication’s rationale, risks, side effects, duration, and right to refuse, yet the consent source did not match the resident’s decision-making status.
Two LVNs failed to use proper technique when checking GT placement by placing the stethoscope on the abdomen instead of the epigastrium area. One LVN was observed doing this with a resident who had diabetes and a GT, and the other LVN was observed placing the stethoscope near the resident’s belly button while checking GT placement; both LVNs acknowledged the findings.
Improper LAL Mattress Settings for Residents With Pressure Injury Needs: The facility failed to keep LAL mattress settings consistent with residents’ body weights for multiple residents receiving skin/wound care. A resident was observed on a mattress set at 300 lbs despite weighing 118 lbs, another was on a mattress set at 120 lbs despite weighing 100 lbs, and another was on a mattress set at 350 lbs despite weighing 199 lbs. The residents had impaired cognition, no capacity to make decisions, and were dependent on staff for ADLs; staff stated the mattress setting should be based on body weight and checked each shift.
GT feeding care was not provided as ordered for two residents. One resident’s enteral feeding order lacked a specific hourly rate, while the care plan and nutrition notes referenced 55 mL/hr and weekly summaries showed 50 mL/hr being given; the ADON verified the order should have been clarified. Another resident had GT feeding formula and water flush bags left in place past the 24-hour limit, and staff acknowledged the tubing was expired despite the manufacturer’s instruction not to use it for greater than 24 hours.
A resident receiving nebulizer treatment had the mask and tubing left in a basin at the bedside instead of being stored in a dedicated bag. The ADON, RT, IP, and DON all confirmed this was not appropriate, noting the equipment should be washed, dried, and bagged after use.
Medication administration errors exceeded the allowed rate, with an observed error rate of 7.41%. An LVN used dissolved Miralax to flush GT medications instead of the ordered water flushes for a resident with a GT and no decision-making capacity, another LVN omitted ordered ascorbic acid for a resident with no capacity, and an LVN gave multiple eye drops to a resident whose order was for one drop in each eye every hour.
Medication storage was not maintained securely and in a cleanable condition. An LPN found a UTI-Stat oral liquid bottle on a med cart without an expiration date, a treatment cart was left unlocked and unattended in a hallway while an LPN provided care, and another med cart had a cracked drawer front covered with layered paper tape rather than a hard, nonporous surface.
A resident on hospice had medication discontinuations that were not documented as communicated to the hospice physician, and the hospice record did not clearly show whether scheduled RN, LVN, and CHHA visits occurred. The hospice flowsheet entries lacked staff designation, and interviews with CNA and LVN staff did not confirm the visit pattern.
A resident who was documented as self-responsible and able to make decisions did not receive the required Medicare beneficiary notices. The record showed SNF ABN and NOMNC forms were signed by a family member as the responsible party, even though the resident should have been provided and signed the forms, leaving the resident without the notice and appeal rights.
Failure to maintain privacy during personal care: An LVN provided coccyx care to a resident with the privacy curtain only partially closed and the room door wide open. During the treatment, the resident's buttocks and lower back were exposed from the waist down, and the LVN later acknowledged the curtain and door were open.
Inaccurate MDS Coding for Resident Fall History A resident reviewed for falls had an unwitnessed fall documented in the SBAR and fall risk records, but the MDS was coded as having no falls since readmission or the prior MDS. During record review, the MDS Coordinator verified the fall was present in the chart and stated the MDS should have reflected it.
A resident’s PASRR Level I screening identified psychotropic medication use, but the facility did not accurately complete the screening after the resident’s status changed and did not respond to DHCS communication attempts for the Level II evaluation. The DON and ADON confirmed the screening should have triggered a Level II evaluation due to the resident’s psychotropic medications and serious mental illness diagnosis.
A resident’s PASARR Level I screening was coded as negative for SMI even though the resident had documented anxiety and depression and was receiving psychotropic medications, including buspirone and doxepin. The Subacute Manager and ADON verified the resident had combative behaviors and that the PASARR Level I screening should have been coded as having serious mental illness.
A facility failed to complete physician-ordered 72-hour post-fall neuro checks for two residents after unwitnessed falls. The Neuro-Check List schedule used for both residents only covered 63.5 hours instead of the full ordered period, and the ADON and DON verified the checks were not completed as ordered.
Inaccurate insulin and blood sugar documentation by an LPN. An LPN documented checking blood sugars and giving short-acting insulin to several residents at the same time, but later verified the insulin was actually administered later after the meal cart arrived. The LPN also admitted writing the wrong room number for one blood sugar result, and the glucometer did not record exact times for the readings.
An LPN documented insulin as given at the same time blood sugars were checked for multiple residents, even though she stated she began the checks earlier and did not give the insulin until after the meal cart arrived. The LPN also used dissolved Miralax to flush and administer GT medications for a resident with a GT, seizure history, stroke, and no decision-making capacity, despite the facility policy requiring each medication to be given separately and the order requiring water flushes between medications; the resident coughed during the administration.
Inaccurate weight documentation and failure to monitor significant weight changes were identified for a resident. The EHR showed conflicting weights, the MDS did not reflect any weight loss or gain, and the care plan did not address the documented weight loss. The ADON acknowledged that weekly monitoring, MD notification, RD consultation, and care plan updates were not completed, and the Subacute Manager admitted to entering an incorrect weight in the EHR and failing to accurately track the resident’s weight changes.
A resident’s Arbitration Agreement was signed in English even though the resident’s MDS showed a preferred need for Foreign Language 1 and an interpreter. The resident stated she spoke some English but preferred important documents in Foreign Language 1 and did not recall signing the agreement, while the Admissions Coordinator confirmed no interpreter was documented and she did not speak the resident’s language.
The facility failed to follow its QAPI plan and prior POC by not ensuring the Pharmacy Nurse Consultant completed the required medication pass observations for licensed nurses. The accepted POC required observations for all newly hired licensed nurses, three licensed nurses per month, and monthly reporting by the DON to the QAPI committee, but review of the QAPI binders showed that in most months the consultant completed two or fewer observations. The Administrator stated there was a miscommunication and that observations were only done for new hires.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with a gastrostomy tube and physician orders for Enhanced Barrier Precautions (EBP) did not have a care plan developed to address EBP status. Medical record review and staff interviews confirmed the absence of a care plan for EBP, despite facility policy and physician orders requiring one. The DON and Administrator acknowledged the deficiency.
The facility failed to follow food safety and sanitation guidelines, risking foodborne illnesses. Wet blenders were improperly stored, a cutting board was unsanitary, and the ice machine was not thoroughly cleaned. Additionally, food brought by families was improperly labeled and stored, contrary to facility policy. These issues were confirmed by the DSS and LVN.
A resident was found self-administering lidocaine 5% cream without a physician's order or proper assessment deeming them safe for self-administration. The facility's policy requires an IDT assessment for self-administration, which was not followed, as the resident's assessment indicated they were not a candidate for safe self-administration.
The facility failed to ensure call lights were within reach for two residents, potentially impacting their well-being and care. One resident in a wheelchair could not reach the call light clipped on the headboard, while another in bed found the call light too short to reach. Both CNAs confirmed these observations, and the DSD stated that call lights should always be accessible.
A facility failed to refer a resident for a PASRR Level II review after a diagnosis change from Alzheimer's with psychosis to schizoaffective disorder. Despite a psychiatric evaluation and a physician's order for risperidone, there was no documented evidence of a referral for the necessary review. Interviews with the ADON and DON confirmed the oversight, acknowledging that the PASRR Level I Screening did not reflect the new diagnosis and that a review should have been conducted.
A resident experienced significant weight loss, and the facility failed to follow the RD's recommendations for nutritional interventions. Despite the resident's severe cognitive impairment and multiple comorbidities, the RD's suggestions for an appetite stimulant, snacks, and a high-calorie drink were not communicated to the physician or discussed in IDT meetings, leading to inadequate nutritional care.
The facility failed to update tube feeding care plans and ensure physician's orders included start and stop times for two residents. The care plans did not reflect the revised feeding orders, and the orders lacked critical details, posing a risk for complications. Interviews with the DON and an LVN confirmed these deficiencies.
The facility failed to provide adequate respiratory care for several residents, including improper oxygen administration, lack of required signage, and unsanitary storage of equipment. A resident's oxygen was administered by unlicensed personnel without proper documentation, and multiple residents lacked 'No Smoking/Oxygen in Use' signs. Additionally, a resident's ventilator settings were not monitored as frequently as ordered, and another resident's oxygen and suction equipment were not maintained per physician orders.
A facility failed to ensure accurate documentation of a resident's permacath site for dialysis, leading to potential delays in care. The resident's medical records incorrectly noted the permacath site on the left upper chest, while it was actually on the right. This discrepancy was confirmed by both an LVN and an RN during an observation and interview.
The facility failed to ensure two residents were free from hazards associated with elevated side rails. One resident did not have informed consent or a care plan for grab bars, while another did not have less restrictive alternatives considered before installation. Informed consent documentation was incomplete, lacking details on who obtained consent. These deficiencies posed risks of entrapment and injury.
The facility did not act on the Pharmacy Consultant's recommendations for two residents. A resident's tramadol label was not updated to reflect pain management, and another resident did not receive recommended A1C monitoring. The DON confirmed the lack of follow-up, attributing responsibility to RN 1.
A facility failed to monitor a resident for orthostatic hypotension while they were on psychotropic medications, including Wellbutrin, quetiapine, and trazodone. Despite the potential for adverse complications, there was no order or evidence of monitoring in the resident's medical record. An RN confirmed the lack of monitoring, highlighting a deficiency in the facility's care practices.
A facility failed to maintain a medication error rate below five percent, resulting in a 7.41% error rate. A resident did not receive Metamucil 4 in 1 Fiber due to unavailability, and an incorrect dosage of enoxaparin sodium was administered. The errors were made by an LVN, and the DON confirmed the findings.
A resident received 100 mg of enoxaparin sodium instead of the prescribed 10 mg dose due to a medication administration error by an LVN. The error was confirmed by the LVN and the DON, and the resident was transferred to the ER for monitoring at the family's request. The facility's policies require medications to be administered as prescribed, which was not followed in this case.
The facility failed to ensure proper medication storage and labeling, with issues including an unlocked medication cart, improper storage of on-hold medications, and damaged medication packaging. Medications were also left at residents' bedsides, and a medication label did not match the physician's order. These deficiencies were verified by nursing staff.
A resident on a mechanical soft, finely chopped diet was served large pieces of meat and hard toast, contrary to their prescribed diet. Staff, including a CNA, RN, DSS, and ADON, were involved in the oversight, with the RN and DSS acknowledging the meal did not meet dietary requirements. The ADON confirmed the meal was not consistent with the resident's prescribed diet.
A facility failed to ensure proper storage and labeling of food items brought in by family or visitors for a resident, potentially leading to foodborne illnesses. Unlabeled and undated food items were found in a resident's room, and staff interviews revealed a lack of awareness and adherence to the facility's policy on outside food. The absence of a thermometer in the resident's refrigerator indicated a lack of temperature monitoring, and the Maintenance Supervisor was unaware of the refrigerator's presence, which was against facility policy.
The facility failed to ensure accurate medical records for two residents. A resident's H&P form was improperly corrected, and another resident's psychotropic medication consent forms were incomplete. Additionally, a medication route was incorrectly documented, indicating administration via a GT, which the resident did not have. These issues were confirmed by the DON and an RN.
A facility failed to provide necessary hospice care for a resident, as a hospice aide improperly administered oxygen without notifying a nurse, and the facility did not ensure physician-ordered hospice visits were conducted. There were missing clinical notes and discrepancies in visit frequencies, leading to potential delays in care and communication issues.
The facility failed to adhere to infection control practices, including transporting uncovered linen carts and neglecting hand hygiene during resident care. A laundry aide was observed pushing an uncovered linen cart, and staff did not perform hand hygiene between assisting residents or during wound care. These actions were acknowledged by the staff and management as breaches of protocol.
The facility failed to conduct regular bed inspections to identify potential entrapment risks for three residents. Despite guidelines requiring regular inspections, the facility did not perform necessary measurements for entrapment zones, leading to potential safety hazards. For one resident, the maintenance supervisor was unaware of entrapment assessment requirements, and another resident's bed rails were found to be loose and unstable. Additionally, a third resident used grab bars without an entrapment assessment being conducted.
A facility failed to implement a care plan intervention for a resident at high risk for falls. The care plan required a yellow ID band to indicate the resident's fall risk status, but during an observation, the resident was found without it. The resident had cognitive deficits, impaired safety awareness, and a seizure disorder, increasing their fall risk. LVN 11 confirmed the oversight and applied the ID band, and the DON verified the care plan requirement.
A facility failed to promote dignity and respect for a resident during meal assistance. A CNA was observed standing over a resident with moderate cognitive impairment while assisting with eating, contrary to the facility's policy requiring staff to be seated beside or at eye level with residents. The CNA acknowledged the action, and the DSD confirmed the policy, highlighting a lapse in adherence to procedures designed to support resident dignity.
A facility failed to ensure proper placement of a catheter bag for a resident with an indwelling urinary catheter, as the bag was observed above bladder level, contrary to facility policy. This oversight, confirmed by an LVN, risked urine backflow and potential infection. The resident had a care plan addressing infection risk due to obstructive uropathy.
A facility failed to monitor a resident's blood pressure before administering metoprolol, an antihypertensive medication, as prescribed. The resident's physician ordered the medication to be held if the systolic blood pressure was less than 110 mmHg. However, the medication was administered on three occasions without documented blood pressure checks, as confirmed by an RN. This oversight had the potential to negatively affect the resident's health.
An activity staff member failed to immediately report an incident where a family member hit a resident with severe cognitive impairment on the head. The facility's policy requires immediate reporting to the Charge Nurse, but the incident was reported to social services nearly 22 hours later, delaying the investigation and mandatory reporting.
A resident with hypertension did not receive the correct diet as ordered by the physician, which was a regular diet with no added salt. The meal included a salt packet, and the dietary card, diet order form, Kardex, and food cart log all incorrectly indicated a regular diet. The LVN responsible for verifying meal trays admitted to an oversight, and the DSS confirmed the incorrect transcription of dietary orders.
Infection Control Lapses During Resident Care and Environmental Cleaning
Penalty
Summary
The facility failed to ensure proper infection control practices were followed for two sampled residents and during environmental cleaning. One resident had orders for Enhanced Barrier Precautions due to a tracheostomy, gastrostomy tube, and a history of Candida auris. During an assessment when the resident became unresponsive in the hallway, the RN wore a mask and gloves but did not wear a gown while providing care. The RN later stated that staff must wear masks, gowns, and gloves when providing high-contact activities for residents on EBP, and the Infection Preventionist confirmed that staff must wear gowns and gloves when touching residents on EBP in the room or outside the room. For another resident, a CNA was observed providing care and then removed gloves and picked up a blue gown and a plastic bag containing a soiled brief from the floor with bare hands. The CNA then left the room, touched the soiled linen receptacle, touched the wheelchair handles and mask without performing hand hygiene, and continued walking toward the nursing station while holding the plastic bag. The CNA later verified that hand hygiene was not performed after handling the soiled items, and the LVN confirmed that staff must perform hand hygiene after providing care to residents or touching dirty areas. During cleaning of Room A, EVS staff was observed mopping the floor and then placing the mop against a clean bed. The staff member also touched the bed footboard and continued cleaning with the same gloves. The EVS Manager verified the observation and stated dirty cleaning supplies such as a mop must not touch clean areas. The Infection Preventionist also confirmed that dirty equipment must not touch clean surfaces, that proper hand hygiene must be performed before and after resident care or touching dirty areas, and that linens, gowns, or plastic bags should not be placed on the floor.
Kitchen Utensils and Equipment Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to ensure sanitary requirements were met in the kitchen during an initial tour and concurrent interview with the DSS. The kitchen contained multiple utensils that were damaged and no longer in good condition, including stainless steel scoops with melted, discolored, peeling, or partially melted handles; rubber spatulas that were chipped, cracked, discolored, and partially melted; a basting brush with worn-out bristles; a deformed and partially melted spatula; a partially burnt wooden spoon; a discolored and peeling plastic spoon; and a whisk with a burnt and worn-out rubber handle. The DSS acknowledged that the old and worn-out utensils should have been discarded and replaced for infection control purposes. The facility also had kitchenware and utensils that were not clean to sight and touch. During the same observation, a stainless steel scoop had dry, sticky residue and watermarks, another scoop had dry, crusted residue, a dough cutter had dry residue and watermarks, a white plastic grater had black residue between the blade, and three stainless steel tongs had dry, crusted residue and watermarks. The DSS verified these findings and stated the dirty and crusted kitchenware should have been washed for infection control purposes. In addition, one heavy-duty blender used for puree preparation was observed stored on a countertop shelf while still moist and wet with visible water inside, and the kitchen microwave was observed dirty with dry food residue inside. The DSS verified both findings and stated the blender should have been air dried and the microwave should have been cleaned for infection control purposes. The facility’s diet type report showed 54 of 90 residents consumed food prepared in the kitchen.
Infection Control and Hand Hygiene Failures
Penalty
Summary
The facility failed to implement infection control practices in the laundry area when a staff member’s personal clothing was observed stored in the rack of the clean linen area with clean linens. The facility’s laundry policies stated that linens are to be handled, stored, processed, and transported to prevent the spread of infection, and that careful precautionary procedures must be followed by laundry personnel to prevent spread of infectious disease. During the observation, the Maintenance Director verified that the personal clothing should not have been stored with clean linens. The facility also failed to fully establish and implement its water management program for Legionella prevention. The facility’s Legionella policy described a plan for prevention and referenced a building water system process flowchart and control area monitoring flowchart, but the flowchart did not specify what should be inspected during visual inspections or the acceptable ranges for disinfectant levels and water temperature. The Maintenance Director stated that water temperature was checked, but could not state the acceptable temperature range to prevent Legionella growth and could not show specific control measures being used. The facility also did not test for Legionella on a regular basis. Hand hygiene and wound care practices were not consistently followed during multiple observations. LVN 5 picked up a resident’s bed remote from the floor and then administered medications without performing hand hygiene. LVN 4 touched a trash bag on the medication cart and then prepared medications for two residents without hand hygiene in between. During wound care for another resident, LVN 2 placed a bottle of hand sanitizer that had fallen on the floor back onto the bedside table with wound care supplies and did not perform hand hygiene during the observation. LVN 2 also changed gloves without hand hygiene, touched the wound VAC bag, enteral feeding pump, and bed remote with gloved hands before continuing wound care, failed to sanitize the bedside table, and disposed of a wound VAC canister containing drainage in regular trash. In addition, the facility used black foam padding and black tape on a resident’s lower side rails, and the IP later verified that the foam and tape were not hard surfaces and that the Oxivir wipes used were not appropriate for disinfecting those materials.
Improper Consent for Psychotropic Medication
Penalty
Summary
The facility failed to appropriately obtain consent for a psychotherapeutic medication for one of five sampled residents reviewed for unnecessary medications. Resident 12 was self-responsible and had a history and physical examination showing the resident had the capacity to understand and make decisions, yet the facility obtained informed consent for amitriptyline HCl 10 mg at bedtime from Family Member 1 instead of from the resident. The facility’s Psychotropic Drug Treatment policy stated the resident or representative should be given information about the need for the medication, desired effects, potential side effects, benefits and risks, and treatment goals. The Informed Consent policy stated the attending physician, PA, or NP must obtain informed consent from the resident or responsible party for psychotherapeutic medications and verify consent before administration. The informed consent form for amitriptyline documented that the prescriber discussed the rationale, duration of therapy, side effects and significant risks, and the resident’s right to refuse treatment, but consent was obtained by telephone from Family Member 1 even though the resident had capacity.
Incorrect GT Placement Auscultation by Two LVNs
Penalty
Summary
The facility failed to ensure two of eight LVNs provided services meeting professional standards when they auscultated for GT placement using incorrect stethoscope placement. On 1/20/26, during a medication administration observation with LVN 4, she was observed placing her stethoscope on Resident 29's right lower abdominal area while checking GT placement; LVN 4 later verified and acknowledged the finding. Resident 29 had been readmitted to the facility, had diagnoses including diabetes and status post GT placement, and the H&P dated 5/23/25 stated the resident had no capacity to understand or make decisions. On 1/16/26, during a medication administration observation with LVN 5, she was observed placing her stethoscope approximately four inches to one side of Resident 64's belly button while checking GT placement; LVN 5 later verified and acknowledged the finding.
Improper LAL Mattress Settings for Residents With Pressure Injury Needs
Penalty
Summary
The facility failed to ensure proper pressure ulcer precautions and interventions were provided for four sampled residents reviewed for pressure ulcer care. The deficiency centered on the use of low air loss (LAL) mattresses that were not set consistently with the residents’ body weights. The facility’s policy stated that a LAL mattress should be properly placed and managed when used by a resident. Resident 11 was observed lying on a LAL mattress set at 300 lbs, while the resident’s documented weight was 118 lbs. The physician’s order directed that the mattress could be adjusted to a comfortable setting according to the resident’s body weight every shift. Resident 11 had no capacity to understand and make decisions, had memory problems, severely impaired cognitive skills for daily decision making, and was dependent on staff for activities of daily living. Staff interviews confirmed that the mattress setting should be based on the resident’s weight and that licensed nurses were responsible for checking the setting each shift. Resident 37 was observed on a LAL mattress set at 120 lbs, while the resident’s documented weight was 100 lbs. Resident 37 had memory problems, severely impaired cognitive skills for daily decision making, no capacity to understand and make decisions, and was dependent on staff for activities of daily living. Resident 94 was observed on a LAL mattress set at 350 lbs, while the resident’s documented weight was 199 lbs. Resident 94 had memory problems, severely impaired cognitive skills for daily decision making, no capacity to understand and make decisions, and was dependent on staff for activities of daily living. The Subacute Manager acknowledged the findings for Residents 37 and 94.
GT Feeding Orders Not Followed and Expired Tubing Used
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for two residents reviewed for enteral feeding care. One resident had physician orders for Isosource 1.5 via GT, but the order for 660 mL/990 kcal did not specify an hourly rate. The resident’s care plan and nutritional notes referenced administration at 55 mL per hour for 12 hours, while weekly summaries showed the feeding was being given at 50 mL per hour. During observation, the feeding bag and water flush were hanging at the bedside, and the ADON verified that the order was not specific and that the feeding should have been administered at 55 cc per hour rather than 50 cc per hour. The same resident was observed lying in bed during multiple observations, and dry lips were noted on several occasions. During a concurrent interview, the resident stated her lips usually get dry and that she sometimes forgets to apply Chapstick. The feeding tube and water flush bag were observed hanging on the side of the bed, and the label showed the feeding had started at 0300 hours at 50 mL per hour. The ADON stated that if the enteral feeding order was not specific, the physician should have been called for clarification, and the DON was informed of the findings. For the second resident, the GT feeding formula and water flush bags were observed connected but not turned on, and the bags were dated for a prior time. The ADON stated the formula and water flush bags should be changed every 24 hours and acknowledged they were expired. The DON stated the formula bags were left up until the GT feeding formula was fully consumed, then the nurse should throw everything away and replace the bags and tubing when the next feeding was due. The ADON later stated the facility was treating the tubing like a closed system even though the water flush bag made it an open system, and the manufacturer’s packaging for the feeding set stated not to use it for greater than 24 hours.
Nebulizer Mask Stored Improperly at Bedside
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident 73 when the facility failed to ensure the resident’s nebulizer mask was stored properly. Resident 73 was admitted to the facility and had the capacity to make decisions. The physician’s order included albuterol sulfate 2.5 mg/3 ml solution to be administered via hand held nebulizer as needed for shortness of breath. During observations on 1/14/26 and 1/15/26, the nebulizer mask connected to tubing was seen lying in Resident 73’s basin with other items on the nightstand rather than being stored in a dedicated bag. The tubing was dated 1/9/26. During interview, the ADON verified the mask should not be left in the basin and should be stored in a closed bag, stating that leaving it out can cause contamination and harbor bacteria. The RT, IP, and DON also stated the nebulizer equipment should be washed, allowed to dry, and then placed in a dedicated bag, and that storing it in the basin without a barrier was not appropriate.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, and the observed error rate was 7.41%. During a medication administration observation for a resident with a GT and diagnoses including history of GT dislodgement, post status GT replacement, seizure, history of coffee ground vomit, and stroke, an LVN prepared multiple medications and used dissolved Miralax powder to dissolve and flush the resident’s medications into the GT instead of using the ordered water flushes. The resident had no capacity to understand and make decisions, and the LVN verified the findings during interview. In a separate observation, an LVN administered medications to a resident with no capacity to understand and make decisions, including crushing all medications, but failed to administer the ordered ascorbic acid 500 mg/5 ml, 5 ml twice daily for wound management. In another observation, an LVN administered multiple eye drops into both eyes of a resident with diabetes, anxiety disorder, bipolar disorder, and a left eye prosthesis, even though the order was for one drop in each eye every hour for severe dry eyes. The LVN acknowledged there was no order for multiple eye drops and verified the findings.
Medication carts left unsecured and a drawer surface was not cleanable
Penalty
Summary
Medications were not consistently stored in a secure and cleanable condition in three of six medication carts. During a medication preparation observation for Resident 64, LVN 5 retrieved UTI-Stat Oral liquid from Medication Cart 1 and verified that the bottle did not have an expiration date written on it. LVN 5 stated she would hold the medication because it did not have an expiration date on it. During an observation with LVN 2, the Subacute Treatment cart was left unlocked and unattended in the hallway outside Resident 6's room while LVN 2 went inside the room to provide treatment. The cart contained medications including Santyl ointment and normal saline. In a later inspection of Medication Cart 1 with LVN 1, one drawer pull for a drawer filled with medication was found to have two areas of layered paper tape over a cracked drawer front. LVN 1 stated the drawer pull was cracked underneath the taped areas and verified the paper tape was not a hard, nonporous surface.
Hospice medication changes and visit documentation were not fully communicated or recorded
Penalty
Summary
The facility failed to provide necessary hospice care and services for one resident receiving hospice services. The resident had no capacity to understand and make decisions and was admitted to Hospice A under routine level of care. Hospice A’s current treatment/medication/DME list included gabapentin for nerve pain, hydromorphone for severe pain, and lorazepam for anxiety, but the facility’s order summary report did not show physician orders for those medications. The resident’s discontinued physician orders showed hydromorphone was discontinued after the resident representative was spoken with, gabapentin was discontinued at the resident representative’s request, and lorazepam was discontinued after the order was clarified from a Hospice A nurse. The medical record did not show that Hospice A physician was notified when the facility discontinued these medications. During interview and record review, the ADON verified there was no documented evidence that Hospice A physician had been notified of the medication discontinuations and stated Hospice A physician should have been notified when a hospice resident’s medication was discontinued. The resident’s hospice schedule called for RN/LVN visits twice weekly, CHHA visits twice weekly, and MSW visits every two months. The hospice calendar listed multiple RN, LVN, and CHHA visits, but the hospice flowsheet entries did not identify the staff making the entries and did not show whether several scheduled visits actually occurred. Interviews with CNA 2 and LVN 5 did not confirm the CHHA or the exact hospice visit pattern, and the ADON verified the documentation did not show whether the listed RN, LVN, and CHHA visits occurred as scheduled. The DON was informed and acknowledged these findings.
Medicare beneficiary notices not provided to self-responsible resident
Penalty
Summary
The facility failed to provide the required Medicare beneficiary notices to Resident 12, who was reviewed for beneficiaries. Resident 12 was admitted and later readmitted to the facility, was documented in the admission record as their own responsible party, and the H&P stated the resident had the capacity to understand and make decisions. The record showed a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage and a Notice of Medicare Non-Coverage were dated and signed on 12/22/25, stating the resident's level of care did not meet Medicare coverage requirements and that Medicare would likely not pay for current services after 12/23/25, with appeal rights included. During an interview and concurrent record review, the Business Office Manager stated Family Member 1 signed the forms because he was the resident's responsible party, but the medical record verified the resident was self-responsible and should have been provided and signed the forms.
Failure to Maintain Privacy During Personal Care
Penalty
Summary
Privacy was not maintained during personal care for Resident 4 when LVN 2 provided treatment to the coccyx area. During the observation on 1/20/26 from 0904 to 0945 hours, the privacy curtain was only partially closed and the resident's door remained wide open while care was being given. As a result, Resident 4's buttocks and lower back were exposed from the waist down during the treatment. During an interview on 1/20/26 at 1052 hours, LVN 2 acknowledged that the privacy curtain was partially open and the door was open, and verified the findings.
Inaccurate MDS Coding for Resident Fall History
Penalty
Summary
The facility failed to ensure an accurate MDS assessment was completed for one resident reviewed for falls. Resident 67 was readmitted to the facility and had an unwitnessed fall documented on the SBAR Communication Form. The resident's Fall Risk Assessment showed no falls in the past three months on an admission assessment, then later showed one to two falls in the past three months on another assessment. However, the resident's MDS assessment showed no falls since readmission or the prior MDS assessment. During an interview and concurrent record review, the MDS Coordinator reviewed the resident's record and verified the resident had a fall on 11/14/25 and stated the MDS should have been coded to show the fall.
PASRR Level II Evaluation Not Completed After Psychotropic Medication Change
Penalty
Summary
The facility failed to comply with the Level II categorical determination requirements of DHCS as part of the PASRR process for one sampled resident. Resident 6 had a Level I screening dated 2/25/25 that identified the resident as receiving Buspar and Doxepin, both psychotropic medications. The facility’s policy required periodic review of PASRR status until the case was closed, but the resident’s Level I screening was not accurately completed following the change in status. DHCS later sent a letter dated 2/28/25 stating the resident’s Level II evaluation could not be completed because facility staff were unresponsive to two or more communication attempts within 48 hours of the Level I screening. During interviews, the Subacute Manager verified the findings and stated the failure to complete the Level II evaluation could result in an inability to provide proper care. The DON and ADON confirmed the Level I screening should have triggered a Level II evaluation due to the use of psychotropic medications and the diagnosis of serious mental illness, and acknowledged the facility should have followed up accordingly.
Inaccurate PASARR Level I Screening for Resident Receiving Psychotropic Medications
Penalty
Summary
PASARR Level I screening was not accurately completed for one resident who was readmitted to the facility. The resident’s PASARR Level 1 screening dated 1/16/25 indicated no serious mental illness, but the resident’s H&P dated 1/14/25 documented diagnoses of anxiety and depression. The resident’s Order Summary Report showed physician orders for buspirone 20 mg via GT every eight hours for anxiety and doxepin 75 mg via GT every bedtime for depression. During interview and concurrent record review, the Subacute Manager verified the resident had combative behaviors, received psychotropic medications, and the PASARR Level 1 screening should have been coded as having serious mental illness. The ADON also verified these findings.
Incomplete Post-Fall Neuro Checks
Penalty
Summary
The facility failed to provide the necessary care and services to address falls for two sampled residents, Resident 30 and Resident 67, by not completing physician-ordered post-fall neurological checks for the full 72 hours after unwitnessed falls. For Resident 67, medical record review showed an unwitnessed fall on 11/14/25 with a physician order for neurological checks per facility protocol, and a second unwitnessed fall on 1/1/26 with an order for 72-hour neurological checks. In both instances, the 72 Hours Neuro-Check List began at the time of the fall, but the documented schedule only extended through 63.5 hours rather than the ordered 72 hours. For Resident 30, medical record review showed an unwitnessed fall at 0019 hours on 12/30/25 with a physician order for 72-hour neurological checks due to the fall. The 72 Hours Neuro-Check List again used the same schedule format, but the documented checks ended after 63.5 hours instead of 72 hours. During interviews and concurrent record review, the ADON verified that the neurological checks were not completed for the full ordered period, and the DON verified that the Neuro-Check List schedule was incorrect and did not result in a full 72 hours.
Inaccurate insulin and blood sugar documentation by LVN
Penalty
Summary
The facility failed to ensure that one of four licensed nurses observed had the competencies and skill sets necessary to provide nursing and related services to meet residents' needs. LVN 5 documented administering insulin to six residents at the same time she documented obtaining their blood sugar levels, but she later verified that the insulin was actually given at different times after the residents' meal cart arrived. LVN 5 also acknowledged that she wrote down the wrong room number for one resident's blood sugar result and that the glucometer used did not record the exact time or date of the readings. During the observation, LVN 5 stated she began checking blood sugars around 1130 hours and planned to wait for lunch before giving short-acting insulin. Review of the records showed multiple residents with diabetes were scheduled for insulin coverage, including residents with orders for Humulin R, Humalog, and lispro insulin as sliding scale or corrective insulin. The MARs showed insulin administrations at different times, including 1131, 1138, 1154, and 1156 hours, while LVN 5 later confirmed the meal cart did not arrive until after 1220 hours and that her documentation of simultaneous blood sugar checks and insulin administration was inaccurate.
Medication Administration and GT Medication Preparation Errors
Penalty
Summary
Pharmaceutical services were not followed when insulin administration was documented for six of six residents. On 1/15/26, LVN 5 stated she began obtaining blood sugar checks for Station A residents at 1130 hours and would wait for the lunch cart to arrive before giving short-acting insulin. She showed a handwritten list of room numbers and blood sugar results, but acknowledged one room number was written incorrectly and that the glucometer only displayed results, not the exact time or date the checks were obtained. The meal cart had not arrived by 1220 hours, yet the MARs for multiple residents showed insulin documented as given between 1131 and 1156 hours, which LVN 5 later verified was inaccurate because the insulin had not been administered at the same time the blood sugars were obtained. The facility also failed to follow its enteral tube medication administration policy for Resident 64. The policy required each medication to be administered separately. During observation on 1/16/26, LVN 5 prepared Resident 64's GT medications by mixing Miralax powder in water and then using that dissolved Miralax solution to stir and dissolve crushed medications. She brought six crushed medications, a spoon, and lacosomide into the resident's room, flushed the GT before and after medications, and used the Miralax solution to push the medications through the GT. Resident 64 had diagnoses including history of GT dislodgement, post status GT replacement, seizure, history of coffee ground vomit, and stroke, and had no capacity to understand and make decisions. The order summary required the GT to be flushed with water before medications and with water in between each medication. During the observation, the lacosomide did not go down into the GT, the lacosomide and Miralax solution formed two layers, and LVN 5 used the syringe plunger to force the mixture into the GT. Resident 64 was observed coughing with saliva coming out of his mouth, and LVN 5 was unable to explain why dissolved Miralax powder was used to flush medications into the GT.
Inaccurate Weight Documentation and Failure to Monitor Significant Weight Changes
Penalty
Summary
The facility failed to maintain accurate clinical records and monitor significant weight changes for one resident. Review of the facility’s weight variance and documentation policies showed that weight gains greater than 3% per week were to be reviewed by the IDT, weekly weights were to be re-evaluated, and clinical records were required to be current, accurate, timely, objective, and descriptive. Medical record review showed conflicting weight documentation for the resident, including an electronic record weight of 165 lbs. on 10/28/25, a weight of 143 lbs. on 11/04/25, and a later weight of 147 lbs. on 1/13/26, while a physical weekly weight record showed 146 lbs. on 10/28/25. The resident’s MDS assessment showed no weight loss or gain in the last month or six months, and the care plan did not address the significant weight loss documented on 11/4/25. The nutrition risk assessment showed the resident was at high risk for malnutrition and dehydration. During interview, the ADON stated weekly weights should be monitored after admission and that significant weight changes required physician notification, RD consultation, and care plan updates, but acknowledged these steps were not completed and that the resident should have been re-weighed to confirm the weight change. The Subacute Manager stated she made a documentation error by entering 165 lbs. instead of 146 lbs. in the EHR and failed to accurately track weight changes.
Arbitration Agreement Not Presented in Resident’s Preferred Language
Penalty
Summary
The facility failed to ensure its Arbitration Agreement was presented to Resident 12 in the resident’s preferred language. Resident 12’s MDS assessment showed Foreign Language 1 as the preferred language and indicated the resident needed or wanted an interpreter to communicate with health care staff. However, the Arbitration Agreement signed by Resident 12 and the Admissions Coordinator was written in English, and the record did not show that an interpreter was used to assist with the agreement. Resident 12 was initially admitted to the facility and later readmitted. During interview, Resident 12 stated she could speak some English but not very well and preferred important documents to be explained in or written in Foreign Language 1. Resident 12 did not recall signing an Arbitration Agreement. The Admissions Coordinator confirmed the agreement was in English, that she did not speak Foreign Language 1, and that the resident’s MDS showed the resident wanted or needed a translator.
QAPI Plan Not Followed for Medication Pass Observations
Penalty
Summary
The facility failed to implement its QAPI plan and its prior Recertification Survey POC for F759 by not ensuring the Pharmacy Nurse Consultant conducted medication pass observations for licensed nurses as required. The facility's 2024 Recertification Survey POC, accepted by the Department on 1/17/25, stated that the Pharmacy Nurse Consultant would conduct medication pass observations for all newly hired licensed nurses, conduct medication pass observations with three licensed nurses per month, and that the DON would report the findings monthly to the QAPI committee for evaluation and further recommendation. Review of the facility's QAPI binders for February through December 2025 showed that in 10 of 11 months, the Pharmacy Nurse Consultant conducted two or fewer medication pass observations per month. The Administrator stated there must have been a miscommunication and that the Pharmacy Nurse Consultant only did medication pass observations for new hires only.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Develop Care Plan for EBP Status with Gastrostomy Tube
Penalty
Summary
A deficiency occurred when the facility failed to develop a care plan problem for a resident who was placed on Enhanced Barrier Precautions (EBP) due to the presence of a gastrostomy tube (GT). The facility's policy requires a comprehensive, resident-centered care plan with measurable objectives and timeframes for each resident, based on their comprehensive assessment. Medical record review showed that the resident was readmitted to the facility and had physician orders to check GT placement and patency every shift, as well as to implement EBP every shift due to the GT. However, review of the resident's care plan did not show any care plan developed to address the EBP status as ordered by the physician. During interviews, the RN confirmed that no care plan was developed for the resident's EBP related to the GT, despite the physician's order and the resident having the GT since readmission. The RN explained that the admitting nurse initiates the baseline care plan, and other RNs or MDS staff add care plans as needed. The DON also confirmed that the care plan should have been initiated after receiving the physician's order for EBP and that MDS staff are responsible for reviewing care plans for completion. Both the DON and Administrator acknowledged the findings.
Food Safety and Sanitation Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, which could potentially lead to foodborne illnesses among residents. During an observation, four blenders were found stored wet, contrary to the USDA Food Code 2022, which requires equipment to be air-dried before storage to prevent microorganism growth. Additionally, a red cutting board was heavily marred and discolored, making it difficult to clean and sanitize, thus posing a risk of transferring pathogenic microorganisms to food. The ice machine was also found in an unsanitary condition, with dry dust and white residue present, despite being cleaned by an outside company. This was verified by the Maintenance Director and the Dietary Services Supervisor (DSS), who acknowledged the oversight in ensuring thorough cleaning. Furthermore, the facility did not follow its policy regarding the storage of food brought in by families. An inspection of the resident refrigerator revealed several items, including jellos, onion dip, cottage cheese, and cheddar cheese, that were improperly labeled or undated. The facility's policy states that such food items should not be stored or reheated and must be consumed or discarded immediately. The Licensed Vocational Nurse (LVN) and DSS confirmed these findings, acknowledging that the items should have been properly labeled and stored according to the facility's policy.
Failure to Ensure Safe Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a resident was safe to self-administer medication, specifically lidocaine 5% cream. The resident was observed with the cream at their bedside and stated they applied it themselves, with the nurses being aware of this practice. However, there was no physician's order for the lidocaine cream or for the resident to self-administer it. Furthermore, an assessment had determined that the resident was not a candidate for safe self-administration of medications. The facility's policy requires that residents be assessed by the Interdisciplinary Team (IDT) to determine if self-administration is clinically appropriate. Despite this policy, the resident's medical records did not include a physician's order for the lidocaine cream or for self-administration, and the resident's assessment indicated they were not suitable for self-administration. Interviews with facility staff confirmed these findings, highlighting a lapse in adherence to the facility's policies and procedures regarding medication self-administration.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach and accessible for two residents, which could potentially impact their psychosocial well-being or delay their care. Resident 339 was observed sitting in a wheelchair near the foot of the bed, unable to reach the call light, which was clipped on the right side of the headboard. The resident expressed that the CNA had changed her bed and forgot to place the call light within her reach. Resident 339 was cognitively intact and dependent on assistance for toileting and lower body dressing. Similarly, Resident 45 was observed sitting in bed and unable to reach the call light, which was clipped on the left side rail. The resident attempted to use her right arm to reach the call light but found it too short. Both CNAs verified the observations, and the DSD confirmed that the call light should be within the resident's reach at all times when in bed, chair, wheelchair, or bathroom.
Failure to Conduct PASRR Level II Review for Resident with New Diagnosis
Penalty
Summary
The facility failed to ensure that a resident was referred for a PASRR Level II review after a change in diagnosis from Alzheimer's with psychosis to schizoaffective disorder. This oversight was identified during a review of the resident's medical records, which showed that the resident was initially screened with no diagnosis of a serious mental disorder. However, a subsequent psychiatric evaluation revealed the new diagnosis, and a physician's order was made to administer risperidone for schizoaffective disorder. Despite this change, there was no documented evidence of a referral for a Level II review, which is necessary to determine the appropriate level of care and services for the resident's condition. Interviews with the ADON and DON confirmed the findings, acknowledging that the PASRR Level I Screening did not reflect the resident's new diagnosis. The ADON admitted that the diagnosis was added after the initial screening and that a review should have been conducted to update the PASRR level. The DON also verified that a PASRR resident review should have been performed to ensure the resident received the necessary specialized care. The facility's failure to conduct this review was acknowledged by both the Administrator and the DON during the survey process.
Failure to Follow RD Recommendations for Nutritional Care
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 26, received the necessary nutritional interventions to maintain acceptable parameters of nutritional status. Resident 26 experienced a significant weight loss of 11 pounds over 20 days, which was not adequately addressed by the facility. The Registered Dietitian (RD) made recommendations on September 26, 2024, for an appetite stimulant, snacks three times a day, and a very high-calorie nutritional drink twice a day. However, these recommendations were not followed up with the physician, nor were they discussed in the Interdisciplinary Team (IDT) weight variance meetings. Resident 26 was admitted to the facility with diagnoses including right heart failure, acute respiratory failure, and dysphagia, and had severe cognitive impairment requiring assistance with eating. Despite the RD's recommendations being crucial for maintaining the resident's nutritional status, there was no documentation in the medical record indicating that the physician was notified of these recommendations. The Assistant Director of Nursing (ADON) acknowledged the lack of follow-up and documentation regarding the RD's recommendations. The facility's policy required that residents with weight variances be reviewed by the IDT, and any significant weight changes should be addressed. However, the RD's recommendations were not discussed in the IDT weight variance meetings, as confirmed by the Director of Nursing (DON). The failure to follow up on the RD's recommendations and discuss them in the IDT meetings contributed to the deficiency in providing adequate nutritional care for Resident 26.
Deficiency in Tube Feeding Care and Documentation
Penalty
Summary
The facility failed to ensure that necessary care and services related to gastrostomy tube (GT) feeding were provided for two residents. Specifically, the facility did not update the tube feeding care plans for these residents following revisions to their tube feeding orders. For one resident, the care plan still indicated the use of a different feeding formula and rate than what was currently ordered by the physician. Similarly, the other resident's care plan did not reflect the updated feeding formula and rate as per the physician's latest order. This discrepancy between the care plans and the physician's orders posed a risk for complications related to GT feeding. Additionally, the facility did not ensure that the physician's orders for GT feeding included a start time and specified stop time or the instruction to continue until the dose was complete. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) confirmed that the orders lacked these critical details. The LVN stated that in the absence of specified start and stop times, they would typically begin the feeding at a standard time but acknowledged that the orders should include these details. The DON verified that all orders should have a start time and specify until the dose is complete, which was missing in the orders for the two residents.
Deficiencies in Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide necessary respiratory care and services for several residents, as observed during a survey. For Resident 70, oxygen administration was not performed by a licensed nurse, and the administration was not documented in the Medication Administration Record (MAR). Additionally, a 'No Smoking/Oxygen in Use' sign was not posted outside the resident's door, contrary to the facility's policy and procedure (P&P). The Hospice Aide administered oxygen without consulting a licensed nurse, and the resident's oxygen saturation levels were not adequately reported or documented. Multiple residents, including Residents 23, 37, 51, 76, and 339, did not have the required 'No Smoking/Oxygen in Use' signs posted outside their rooms, as per the facility's P&P. This oversight was verified by various staff members, including registered nurses and licensed vocational nurses, during the survey. The absence of these signs poses a potential risk to the safety and well-being of the residents, especially those dependent on oxygen therapy. Additional deficiencies were noted in the sanitary storage of respiratory equipment. Resident 340's suction equipment and Resident 338's nasal cannula tubing were not stored in a sanitary manner. Furthermore, Resident 588 was not administered oxygen as ordered by the physician, and the suction tubing and canister were not replaced as required. Resident 58's ventilator settings were not monitored as frequently as ordered by the physician, with documentation showing checks every six hours instead of the required four hours. These failures collectively indicate a lack of adherence to physician orders and facility policies, potentially compromising the respiratory health of the residents.
Inaccurate Documentation of Dialysis Site Location
Penalty
Summary
The facility failed to provide the necessary care and services for a resident requiring hemodialysis, specifically by not ensuring the physician's order and plan of care accurately reflected the location of the permacath site. The medical record review for the resident, who was admitted to the facility on an unspecified date, revealed a discrepancy between the documented location of the permacath site and its actual location. The initial nursing history and assessment indicated the permacath site was on the right upper chest, while the physician's order dated 11/26/24 incorrectly noted it on the left upper chest. This error was also reflected in the resident's plan of care dated 11/29/24. During an observation and interview on 12/5/24, the permacath site was confirmed to be on the right upper chest by both LVN 3 and RN 2, who verified the inconsistency in the medical records.
Deficiencies in Bed Rail Use and Documentation
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 29 and Resident 339, were free from accident hazards associated with the use of elevated side rails. For Resident 29, the facility did not obtain an informed consent or initiate a care plan for the use of bilateral grab bars, which were intended to facilitate bed independence. Despite the resident's capacity to understand and make decisions, the informed consent on file was from a previous admission, and no current consent or care plan was documented. For Resident 339, the facility did not implement the least restrictive alternatives before installing grab rails. Although the resident was cognitively intact and required substantial assistance for bed mobility, the informed consent forms did not indicate who obtained the consent or document any less restrictive alternatives prior to the installation of the grab bars. The ADON confirmed these findings and admitted to obtaining verbal consent without proper documentation of who obtained the signatures on the consent forms. These deficiencies were identified through observations, interviews, and medical record reviews, revealing a lack of adherence to the facility's policy on siderails or bedrails. The failures had the potential to place the residents at risk for entrapment and serious injury, as highlighted by the FDA's Safety Alert on entrapment hazards with hospital bed side rails.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's recommendations were acted upon for two residents. For Resident 6, the Pharmacy Consultant recommended changing the tramadol medication label to indicate it was for pain management rather than severe pain levels (7-10). However, this recommendation was not followed, and the label remained unchanged. There was no documentation explaining why the recommendation was not acted upon, and this was verified by RN 1 during an interview and medical record review. For Resident 29, the Pharmacy Consultant recommended A1C level monitoring every three months until the treatment goal was met, and then every six months. Despite a physician's signature on the recommendation form, there was no date or documentation of a response. Further review showed no A1C level results were completed after the recommendation date, and the DON confirmed there were no physician's orders or nurses' notes indicating follow-up on the recommendation. The DON stated that it was RN 1's responsibility to ensure follow-through on the drug regimen review.
Failure to Monitor for Orthostatic Hypotension in Resident on Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically by not monitoring for orthostatic hypotension, a potential side effect of the medications prescribed. The resident was prescribed Wellbutrin, quetiapine, and trazodone for depression and related symptoms, but there was no evidence in the medical record that the resident was monitored for orthostatic hypotension, which could lead to adverse complications. During an interview, a registered nurse confirmed that there was no order to monitor the resident for orthostatic hypotension, despite the use of psychotropic drugs. This oversight indicates a lapse in the facility's responsibility to monitor the resident's condition and ensure their safety while on these medications.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication administration observation. The cumulative medication error rate was 7.41% when two errors were observed in 27 opportunities. These errors were made by a licensed nurse (LVN 7) who administered medications to a nonsampled resident (Resident 688). The errors included failing to administer Metamucil 4 in 1 Fiber oral packet as ordered by the physician and administering an incorrect dosage of enoxaparin sodium. Resident 688, who was admitted to the facility with a history of DVT prophylaxis, was supposed to receive Metamucil 4 in 1 Fiber oral packet daily for bowel management. However, LVN 7 did not administer this medication because it was not available and pending pharmacy delivery. The Director of Nursing (DON) acknowledged that the medication was not a house supply and should have been ordered in advance by the charge nurse. Additionally, LVN 7 administered 100 mg of enoxaparin sodium instead of the prescribed 10 mg. This error was confirmed during an interview with LVN 7, who acknowledged administering the incorrect dosage. The DON verified the findings and stated awareness of the incident. The facility's policies and procedures for medication administration and ordering were reviewed, highlighting the need for accurate medication administration and timely ordering from the pharmacy.
Medication Administration Error for Anticoagulant
Penalty
Summary
The facility failed to ensure that Resident 688 was free from significant medication errors. During a medication administration observation, LVN 7 administered 100 mg of enoxaparin sodium instead of the 10 mg dose ordered by the physician for DVT prophylaxis. This error was confirmed by LVN 7, who acknowledged administering the incorrect dosage and stated she would inform her RN Supervisor and the DON. The facility's policies and procedures for medication administration require that medications be administered as prescribed and that the medication label be read before administration, which was not adhered to in this instance. Resident 688, who had intact cognition, was admitted to the facility with a history of DVT prophylaxis. The error was discovered during a review of the resident's medical records and confirmed through interviews with LVN 7 and the DON. The DON verified the incident and stated that the ADON was assessing Resident 688. The Pharmacy Consultant and Physician 1 were also informed of the error. Physician 1 noted that the error was a personal mistake by the nurse and suggested in-service training to prevent future occurrences. Resident 688 was transferred to the ER at the family's request for monitoring, although no immediate signs of bleeding were observed.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications across several medication carts and resident rooms. Medication Cart A was left unlocked and unattended in front of the nursing station, allowing unauthorized access to medications. Medication Cart B contained IV medications that were on hold, stored alongside current IV solutions, contrary to the facility's policy that requires such medications to be stored separately. Medication Cart C had multiple issues, including the storage of medications on hold with current medications, mixing of orally administered medications with externally used medications, and damaged bubble packs containing medications. Specifically, Eliquis, an anticoagulant, was stored with other medications despite being on hold. Oral medications like Clearlax were stored with transdermal patches and nasal sprays, and bubble packs of levothyroxine and pantoprazole were found with tears or taped repairs. Additionally, medications were improperly left at residents' bedsides. A bottle of Zenpep was found on Resident 338's bedside table, and a cup of zinc oxide cream was left on Resident 339's bedside table. Furthermore, the label on the bubble pack of tramadol for Resident 6 did not match the physician's order, indicating it was for severe pain management rather than general pain management. These deficiencies were verified by the nursing staff and had the potential to impact the residents' well-being and medication safety.
Failure to Provide Prescribed Therapeutic Diet
Penalty
Summary
The facility failed to provide a prescribed therapeutic diet to a resident, identified as Resident 5, who was on a mechanical soft, finely chopped diet. During a lunch observation, Resident 5 was served large pieces of meat and a half piece of hard toast, which were inconsistent with the ordered diet. The resident's medical records indicated a need for a fortified mechanical soft diet with finely chopped meat and vegetables, and the care plan emphasized the importance of monitoring for choking and swallowing problems. Multiple staff members, including a CNA, RN, DSS, and ADON, were involved in the oversight of Resident 5's meal. The CNA fed the resident, while the RN acknowledged the need for the toast to be chopped due to the resident's high risk for aspiration. The DSS admitted responsibility for ensuring the correct ingredients were served and confirmed the meat was not finely chopped. The ADON, who checked the tray before serving, also confirmed the meal did not meet the prescribed diet requirements, noting the toast was too hard and the meat was not finely chopped.
Improper Storage and Labeling of Food Brought by Visitors
Penalty
Summary
The facility failed to ensure proper storage and labeling of food items brought in by family or visitors for a resident, which could potentially lead to foodborne illnesses. During an inspection, it was observed that a resident had several food items, including an unlabeled and undated container of sliced apples, on their nightstand and inside a small refrigerator in their room. The facility's policy requires that food brought in from outside sources be checked by the dietary department or nursing staff to confirm it does not conflict with the resident's prescribed diet and that non-perishable foods be stored in plastic containers with tight-fitting lids or sealable bags and dated. However, these procedures were not followed, as evidenced by the presence of unlabeled and undated food items. Interviews with facility staff revealed a lack of awareness and adherence to the facility's policy regarding food brought in from outside. A CNA was unaware of the policy, and an LVN stated that residents were allowed to have food from outside as long as there were no dietary restrictions, but fresh fruits should be stored for only one day. The DSD confirmed the findings and noted the absence of a thermometer in the resident's refrigerator, indicating a lack of temperature monitoring. Additionally, the Maintenance Supervisor was unaware of the refrigerator's presence in the resident's room, which was against facility policy, and stated that it should have been reported to the charge nurse or social services department.
Inaccurate Medical Records and Consent Form Deficiencies
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to potential unmet needs due to incomplete medical information. For Resident 64, an error on the History and Physical (H&P) evaluation form was not properly documented according to the facility's policy and procedure (P&P). The incorrect entry was scribbled out instead of being struck through with a line and initialed, as verified by the Director of Nursing (DON). This improper documentation practice was identified during a medical record review and interview with the DON. For Resident 29, there were multiple deficiencies in the medical records. The psychotropic medication consent forms were not properly completed by the physician, as sections regarding disclosure of risks and obtaining informed consent were left unchecked. Additionally, the Medication Administration Record (MAR) incorrectly indicated that trazodone was to be administered via a gastrostomy tube (GT), despite the resident not having a GT. These errors were confirmed during interviews with the DON and a registered nurse (RN), highlighting inaccuracies in the resident's clinical records.
Deficiency in Hospice Care and Documentation
Penalty
Summary
The facility failed to provide necessary care and services for a resident who was under hospice care. The hospice aide improperly administered oxygen to the resident when their oxygen saturation level was at 78%, without notifying the licensed nurse. The facility's policy required that the hospice aide report such observations to the supervising nurse, but this was not done. Additionally, the hospice aide was not evaluated for competency in checking and monitoring the resident's oxygen saturation level, which contributed to the oversight. The facility also failed to ensure that the physician's orders regarding the frequency of hospice staff visits were followed. The medical records for the resident did not show evidence that the scheduled visits by skilled nurses, hospice aides, social workers, and spiritual counselors were carried out as ordered. There were discrepancies in the frequency of skilled nursing visits, and the facility did not clarify these orders. Furthermore, there were missing clinical notes for both skilled nursing and hospice aide visits on several dates, indicating a lack of proper documentation and communication between the hospice provider and the facility. The facility's policies and the agreement with the hospice provider outlined responsibilities for maintaining comprehensive assessments and ensuring timely hospice services. However, the facility did not adhere to these standards, resulting in potential delays in care and communication issues that could affect the resident's well-being. The Director of Nursing verified these findings during interviews and record reviews, confirming the deficiencies in care and documentation.
Infection Control Deficiencies in Linen Handling and Hand Hygiene
Penalty
Summary
The facility failed to implement proper infection control practices, as evidenced by several observations. During the transportation of clean linen, a laundry aide was seen pushing an uncovered linen cart with her arm resting on the inner shelf, directly touching clean towels. This was contrary to the facility's policy, which mandates that linen carts should be covered during transport to prevent contamination. The maintenance supervisor confirmed that the linen cart should have been closed while being moved through the hallway. Additionally, staff failed to perform hand hygiene in critical situations. An RNA was observed assisting two residents with meals without changing gloves or performing hand hygiene between interactions, which was acknowledged by the RNA and the infection preventionist (IP) as a breach of protocol. Furthermore, during a wound treatment observation, an LVN did not perform hand hygiene before and after wearing gloves, despite the facility's policy requiring it. The LVN admitted to the oversight, and the IP confirmed the necessity of hand hygiene to prevent infection spread. The Director of Nursing (DON) and the Administrator were informed and acknowledged these findings.
Failure to Conduct Regular Bed Inspections for Entrapment Risks
Penalty
Summary
The facility failed to conduct regular bed inspections as part of a maintenance program to identify potential entrapment risks for three residents. The FDA Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment outlines seven zones where entrapment can occur, and the facility's policy requires regular inspections to prevent such risks. However, the facility did not adhere to these guidelines, leading to potential safety hazards for the residents. For Resident 339, the facility did not perform the necessary measurements for entrapment zones, despite the resident being at high risk for entrapment due to the use of bilateral grab bars. The maintenance supervisor was unaware of the entrapment assessment requirements and did not conduct individual bed inspections or measurements, relying instead on standard equipment dimensions. This oversight was confirmed during interviews with facility staff, who acknowledged the lack of proper documentation and assessment. Resident 51's bed rails were found to be loose and unstable, posing a risk of entrapment. The maintenance supervisor did not receive reports of the issue and did not perform individualized measurements for the resident's bed. Similarly, Resident 29 used grab bars without an entrapment assessment being conducted, as confirmed by the Director of Nursing and RN 1. These deficiencies highlight the facility's failure to ensure bed safety and compliance with established guidelines.
Failure to Implement Fall Risk Care Plan
Penalty
Summary
The facility failed to implement the care plan for a resident identified as high risk for falls. The care plan, dated April 15, 2024, included an intervention to use a yellow-colored ID band to signify the resident's high fall risk status. However, during an observation on December 5, 2024, the resident was found without the yellow ID band, which was a required intervention according to the facility's fall risk prevention policy revised in July 2018. This oversight was confirmed during an interview with LVN 11, who acknowledged the absence of the ID band and subsequently applied it to the resident's wrist. The resident, admitted to the facility earlier in the year, had a history of cognitive deficits, impaired safety awareness, weakness, polypharmacy, impaired mobility, a high fall risk score, and a seizure disorder, all contributing to their high risk for falls. Despite these documented risks, the facility did not adhere to the care plan intervention of using a yellow ID band, which was intended to alert staff to the resident's fall risk status. The Director of Nursing also verified the care plan's requirement for the ID band during an interview, confirming the deficiency in implementing the resident's fall prevention measures.
Failure to Promote Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that resident care was provided in a manner that promoted dignity and respect for a resident identified as Resident 70. During observations, a CNA was seen standing over Resident 70 while assisting with eating, rather than sitting beside the resident or at eye level, as required by the facility's policy. The CNA acknowledged standing over the resident and explained that sitting would make it too high to feed the resident. However, the facility's policy, as confirmed by the DSD, mandates that staff should be seated beside the resident or at eye level to promote dignity during meal assistance. Resident 70, who was admitted to the facility with a moderate cognitive impairment, required substantial to maximal assistance for eating, as indicated in the MDS. The failure to adhere to the facility's policy had the potential to negatively impact the resident's feelings of self-worth and well-being.
Improper Placement of Catheter Bag in Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, specifically by not ensuring that the catheter bag was placed below the bladder level. This oversight was observed during a survey when the resident's catheter bag, filled with yellowish urine, was positioned higher than the bladder. According to the facility's policy and procedure for indwelling catheter use, the catheter and tubing must remain patent, with the drainage bag kept below the bladder level to maintain unobstructed urine flow and prevent backflow, which could lead to a urinary tract infection. The resident in question had a physician's order for an indwelling urinary catheter due to obstructive uropathy, with a care plan in place to address the risk of infection. The care plan included interventions to keep the catheter below the bladder level. During an interview, an LVN confirmed the improper placement of the catheter bag and acknowledged that placing the bag above the bladder could result in urine backflow, potentially causing a urinary tract infection. This failure to adhere to the care plan and facility policy posed a risk to the resident's health.
Failure to Monitor Blood Pressure Before Administering Antihypertensive Medication
Penalty
Summary
The facility failed to adequately monitor the blood pressure of Resident 341 before administering metoprolol, an antihypertensive medication, as prescribed by the physician. Resident 341 had a physician's order to receive metoprolol 25 mg every Monday, Wednesday, and Friday in the evening, with instructions to hold the medication if the systolic blood pressure was less than 110 mmHg. However, a review of the Medication Administration Record (MAR) for November and December 2024 revealed that the medication was administered on three occasions without documented evidence of blood pressure monitoring prior to administration. An interview and concurrent medical record review with RN 2 on December 5, 2024, confirmed these findings. This oversight had the potential to negatively affect Resident 341's health condition and well-being, as the necessary precautionary measure of checking blood pressure was not followed.
Failure to Timely Report Suspected Abuse
Penalty
Summary
The facility failed to implement its policy and procedure for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act. This deficiency occurred when an activity staff member witnessed a family member hitting a resident on the head with her hand but did not immediately report the incident to the Charge Nurse. The facility's policy, revised in August 2018, mandates that staff notify the Charge Nurse as soon as possible, who would then inform the Administrator and Director of Nursing immediately. However, the activity staff member reported the incident to the social services staff nearly 22 hours later, which delayed the investigation and mandatory reporting. The incident involved a resident with severe cognitive impairment and dementia, who was unable to recall the event when interviewed. The resident was in the activity room when a family member aggressively intervened during a moment of confusion, resulting in the alleged abuse. Another resident corroborated the account, stating they witnessed the family member hitting the resident's head. The Administrator acknowledged the delay in reporting and confirmed that the staff should have reported the abuse allegation immediately.
Failure to Provide Correct Diet as Ordered
Penalty
Summary
The facility failed to provide a resident with the correct diet as ordered by the physician, which was a regular diet with no added salt. The resident, who had a diagnosis of hypertension, was observed eating a meal that included a salt packet, contrary to the physician's order. The dietary card, diet order form, Kardex, and food cart log all incorrectly indicated a regular diet without specifying the no added salt requirement. The Licensed Vocational Nurse (LVN) responsible for verifying the resident meal trays admitted to an oversight in ensuring the meal matched the physician's order. The LVN had returned the list of physician's orders to the kitchen and failed to verify the resident's lunch was consistent with the physician's order. Upon review, the LVN confirmed that the resident's lunch tray did not meet the prescribed dietary requirements. The Dietary Services Supervisor (DSS) was responsible for transcribing the dietary orders onto the Kardex and dietary cards. The DSS confirmed that the resident's diet order form, Kardex, food cart log, and dietary card all contained incorrect information, failing to reflect the no added salt requirement. The DSS stated there was no set interval for reviewing the physician's orders for resident diets, which contributed to the oversight.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Garden Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Park Care Center | 0.9 mi | ★★★★★ | 4 | 0 |
| The Grove Post Acute | 1 mi | ★★★★★ | 3 | 0 |
| Alta Gardens Care Center | 1.2 mi | ★★★★★ | 39 | 0 |
| Pacific Haven Subacute And Healthcare Center | 1.5 mi | ★★★★★ | 3 | 0 |
| Coventry Court Health Center | 1.6 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.