Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Global Medical Center D/p Snf during CMS and state inspections, most recent first.
A facility failed to maintain a clean, comfortable, and homelike environment in multiple resident rooms. A GT feeding pole stand was observed with brownish, dirt-like particles, a privacy curtain was hanging off the hook with missing hooks, a resident room ceiling had grayish to black discoloration, and several window blinds were missing panels. CNA, EVS, DSD, and Maintenance staff all verified the conditions.
Failure to Disconnect Residents from GT Extension Tubing After Feedings Completed: Three LPNs failed to disconnect residents from GT extension tubing after enteral feedings reached the ordered dose limit or were completed. Two residents with GTs were observed still connected to extension tubing while the pump was off, and the LPNs stated residents were kept connected until the next scheduled feeding instead of being disconnected when the dose was finished.
Improper medication storage and labeling were observed across several med carts and residents’ bedside areas. Surveyors found dust, rust-like particles, stains, wet liners, exposed wound supplies, expired culture and sensitivity kits, and internal and external meds stored together in the same drawer. An expired Lantus insulin vial was also found on a med cart. In addition, opened bottles of normal saline were left on bedside tables past 24 hours for multiple residents with tracheostomies, and a mixture of vitamin E cream and calazime cream was left unattended on one resident’s bedside table.
Unsafe Handling of Food Brought in From Outside Sources: The facility failed to ensure safe handling of food brought in by visitors for residents. Staff gave inconsistent answers about how long outside food could be kept in a resident’s refrigerator, ranging from 24 hours to 72 hours, while the facility policy required food to be labeled, dated, and discarded within 48 hours unless the manufacturer’s expiration date was present. The DON stated the food should not conflict with the resident’s diet and should be labeled and dated before disposal at 48 hours or by the expiration date.
The facility failed to fully implement its infection prevention and control surveillance program. The IP stated surveillance was only initiated when a resident was prescribed antimicrobials or diagnosed with an infection, and residents with signs and symptoms of infection who were not on antimicrobials were not entered into the McGeer’s Criteria review. The surveillance logs showed only HAIs and CAIs, with no residents recorded as not meeting McGeer’s Criteria, and the IP could not determine how many residents met criteria without receiving antimicrobials.
Uncovered Catheter Drainage Bags: Two residents with indwelling urinary catheters were observed with their drainage bags uncovered at the side of the bed. Staff, including CNAs and an LVN, acknowledged the bags did not have privacy bags and stated they should be placed on privacy bags. One resident had severe cognitive impairment and required total assistance with ADLs, and the other had an order for catheter care every shift.
Missing Informed Consent for Psychoactive Medications: A resident with impaired cognition received duloxetine for depression and valproic acid for mood stabilization without proper informed consent in the record. The duloxetine consent was signed by the MD but not the responsible party, and no consent was found for valproic acid; the DSD and DON verified the missing documentation, and the DON stated the facility’s process was missing informed consent on psychotropic medication use.
Privacy Curtains Not Fully Closed During Resident Care: A resident with a GT and two residents receiving trach suctioning were observed during care with privacy curtains not fully closed. An LVN twice failed to fully close the curtain during GT med administration, and an RT suctioned two residents without fully closing the curtains while staff moved in and out of the room. Staff acknowledged the curtains should have been fully closed for privacy.
A resident received repeated Lovenox and insulin injections at the same abdominal and thigh sites instead of having sites rotated as required by facility P&P and standard practice. An LVN verified the administrations and stated the MAR showed the last site used, while the DSD and DON confirmed the sites were not rotated.
Two residents had low air loss mattress settings that were not aligned with the resident-specific requirements. One resident had a Stage 4 sacral pressure injury, severe TBI, and was bedfast and immobile, yet the mattress pump was set at 450 lbs despite a body weight of 125.4 lbs. Another resident’s air mattress was also observed at the maximum setting, and the chart lacked a specific MD order for the mattress setting; an LPN verified there was no such order.
Failure to provide ordered ROM/restorative care for a resident with cerebral palsy, quadriplegia, and contractures. Staff documented PROM, a PRAFO, a right hand splint, and a right soft hand roll, but the RNA flowsheet did not show a left soft hand roll, and the resident was observed with the left hand in a fist position. RNA staff said there was no order for the left hand roll, but LVN verified the physician order existed and that it was not provided as ordered.
Missing Side Rail Padding for Resident With Seizure Precautions: A resident with seizure disorder and cognitive impairment was observed in bed with elevated upper side rails but no pads in place, despite a physician order for bilateral padded upper side rails for safety/seizure precautions. An LVN acknowledged the pads were not replaced after a bed change, and an RN and the DON later acknowledged the resident should have had padded side rails while in bed.
Failure to Report Sediment in Indwelling Urinary Catheter: A resident with severe cognitive impairment, an indwelling urinary catheter, and a Stage 4 pressure ulcer was observed to have sediment and whitish streaking in the catheter tubing and brown sediment in the drainage bag. The record showed repeated sediment and cloudy urine findings, but there was no documented evidence that the clinician was notified of the abnormal urinary characteristics, despite the DON stating staff should report sediment to the clinician.
GT extension tubing was left connected after tube feedings were completed for two residents. One resident had severe traumatic brain injury and was GT dependent, and another resident had a GT with severely impaired cognitive skills. Surveyors observed both residents still connected to GT extension tubing with the enteral pump off after the ordered formula had finished, and staff interviews showed inconsistent understanding of whether the tubing should be disconnected when the dose limit was reached.
A resident with severely impaired cognition and a Stage 4 pressure ulcer received routine and PRN morphine for pain, but the record showed only limited pain documentation. The MAR and pain scale summary did not consistently show pain assessments before morphine or reassessments after administration, and the LVN, RN, and DON verified the resident was not consistently assessed for pain.
Failure to Monitor Anticoagulant and Psychoactive Medication Use: Two residents had medication-related deficiencies. One resident receiving Lovenox had no physician order or documented monitoring for adverse reactions such as bleeding, despite a care plan calling for bleeding surveillance. Another resident receiving duloxetine and valproic acid had no documented evidence that nonpharmacological interventions were ordered, provided, or monitored, even though the care plan referenced behavioral and depression-related approaches. The DSD and DON verified the missing documentation.
A resident's medical record was inaccurate because the physician's order showed full code status even though the POLST indicated DNR, and the care plan still addressed full code status. The resident also had a contact isolation order for C. Difficile and C. Auris even though staff stated the resident no longer had active C. Difficile; EBP signage was still posted and the DON acknowledged the order should have been discontinued.
The facility failed to prevent LVNs from performing respiratory care tasks outside their scope of practice following regulatory changes, as evidenced by continued LVN involvement in tracheostomy care and respiratory assessments for a resident. Facility policies and procedures were not updated to reflect the new scope limitations, and staff interviews confirmed that LVNs continued these practices due to inadequate RT staffing and lack of updated guidance.
Multiple residents did not receive required monitoring for pain and injury, and physician-ordered PT, OT, and RNA services were missed or undocumented. Staff interviews confirmed that assessments and treatments were not consistently performed, and therapy was deprioritized due to staffing shortages.
Two residents dependent on ventilators experienced lapses in respiratory care, including inadequate monitoring of ventilator circuits and improper handling of oxygen therapy and disposable equipment by non-qualified personnel. One resident was found unresponsive and disconnected from the ventilator without timely intervention or documentation of required checks, while another had emergency interventions performed by a CNA outside their scope of practice. The absence of a dedicated RT and inconsistent adherence to facility policies contributed to delayed care and non-compliance.
A resident with multiple pressure injuries was found on an air mattress set to static mode, contrary to the physician's order for an alternate mode setting. An LVN incorrectly confirmed the static mode as correct, despite the order specifying a five-minute cycle for pressure redistribution.
The facility failed to provide ordered RNA services to two residents with contractures and quadriplegia, as documented in their RNA Flowsheets. The absence of daily ROM exercises and application of orthotic devices, as ordered by physicians, was confirmed by staff interviews and could lead to worsening contractures and muscle stiffness.
The facility failed to properly place low air loss mattress pumps for two residents, leaving them on the floor instead of hanging them on the footboard as recommended. Additionally, a resident with impaired cognition and mobility was observed with only one floor mat beside the bed, despite a physician's order for mats on both sides to prevent falls. Staff acknowledged these deficiencies.
The facility failed to maintain the required head of bed (HOB) elevation for two residents receiving enteral feeding via gastrostomy tubes (GT). Both residents had physician orders to keep the HOB elevated at 30 to 45 degrees during feeding, but observations showed the HOB was not elevated to the required angle. Staff interviews revealed a lack of tools and knowledge to ensure compliance with these orders, posing a risk for complications.
A facility failed to maintain proper IV access for a resident, as they did not obtain a physician's order for IV care and maintenance, nor develop a care plan for the IV access on the resident's lower extremity. The resident, with moderately impaired cognitive skills, was on IV hydration due to abnormal lab results. The absence of a physician's order for IV assessment, dressing change, and site change frequency was confirmed by RN 2 and the CNO.
A facility failed to follow its P&P for pharmaceutical waste disposal when an LVN improperly disposed of a half tablet of fludrocortisone in a sharps container instead of the designated pharmaceutical waste container. The incident involved a resident prescribed fludrocortisone for hypotension, and the LVN was observed during a medication administration session.
The facility did not act on a pharmacist's recommendations for a resident, including discontinuing chlorhexidine and performing a hemoglobin A1c test. The physician's orders remained unchanged, and there was no follow-up by nursing staff, as confirmed by the Director of Pharmacy and RN 1.
A resident did not receive medications as prescribed, resulting in a medication error rate of 8% at the facility. The resident was given an incorrect dose of lactulose and did not receive a scheduled clonidine patch. The LVN acknowledged the errors, which were contrary to the facility's medication administration policies.
The facility failed to properly store medications on two medication carts, leading to potential medication administration errors. Medications such as loperamide liquid, Carboxymethylcellulose eye drops, and Insulin Lantus were found stored together without partitions, contrary to the facility's policy. LVNs verified the findings and acknowledged the need for separate storage.
The facility failed to ensure food safety and sanitation in the kitchen, with issues including unsanitary utensils, staff's personal food in the kitchen refrigerator, and lack of hair restraints. These deficiencies were confirmed by the RD, Dietary Supervisor, and CNO.
The facility's infection control committee failed to meet for one quarter in 2024 due to the absence of the Infection Control Chair, leading to a lapse in discussing infection control statistics and posing a risk for disease transmission.
The facility's assessment was outdated and did not involve direct care staff, residents, or their representatives. It lacked a plan for staffing resources, recruitment, retention, and contingency for staffing needs, as confirmed by the CNO.
The facility lacked a full-time, dedicated Infection Preventionist (IP) to oversee its Infection Prevention and Control Program. The position was vacant since January 2024, and the Director of Infection Prevention/Acting IP was primarily stationed at the acute care unit, spending only limited time at the facility. The CNO confirmed the facility shared IP personnel with the acute care unit and was actively seeking to fill the position.
A resident's protected health information was left visible on an unattended staff computer in a hallway accessible to visitors. The computer, used by a Respiratory Therapist, displayed the resident's name and medications, violating confidentiality policies. An LVN confirmed the breach during an observation.
The facility failed to properly dispose of garbage and refuse, with two waste dumpsters observed overflowing and not closed, potentially causing unsanitary conditions. This was confirmed by the RD, Dietary Supervisor, and CNO, and violated the facility's sanitation policy requiring tightly closed containers to prevent pests.
The facility failed to maintain a homelike environment for four residents, as observed in two rooms with walls in disrepair, including holes, scratches, and unfinished patchwork. The residents were cognitively impaired and not interviewable. The CNO acknowledged the need for repairs.
A facility failed to provide restorative nursing assistant (RNA) services as ordered for a resident with contractures, leading to a potential decline in range of motion (ROM) functions. The resident received inconsistent RNA services due to staffing challenges, with RNA staff often reassigned to CNA duties. The Director of Nursing acknowledged the issue and was working on recruiting additional RNA staff.
Unclean and Poorly Maintained Resident Rooms
Penalty
Summary
The facility failed to provide a homelike, clean, and comfortable environment in several resident rooms. During the initial tour, Resident 23’s GT feeding pole stand was observed with brownish, dirt-like particles on the extendable middle section. CNA 3 was shown the stand and verified that it was dirty, and Environmental Services Staff 1 later confirmed the stand had brownish, dirt-like particles and stated it was dirty and needed to be replaced. Resident 9’s privacy curtain was observed hanging off the hook, with approximately five hooks missing during a medication administration observation. The DSD verified the curtain was partially hanging off the hook, and the Environmental Services Director also acknowledged the condition. In Resident 8’s room, the ceiling corner was observed with grayish to black discoloration, and the window had missing blind panels. The Maintenance Supervisor verified the ceiling discoloration and stated the area had previously been fixed but condensation from roof drainage was seeping through the barrier. The same supervisor also verified missing blind panels in other resident rooms, including a room where three blind panels were missing while residents were present in their beds.
Failure to Disconnect Residents from GT Extension Tubing After Feedings Completed
Penalty
Summary
The facility failed to ensure three of five licensed nurses demonstrated the competencies needed to provide safe nursing care when they did not disconnect residents from GT extension tubing after the GT feeding formula dose limit was reached or after the feeding formula was completed. The facility’s P&P for enteral feeding required staff to review the feeding order, check GT placement and residual, and discontinue tube feeding when the volume dose limit was reached. An in-service dated 2/3/26 also included instructions to disconnect residents from the GT(s). Resident 20 had severe traumatic brain injury and was GT dependent. The physician ordered Vital AF 1.2 via PEG tube at 90 ml/hr daily for a total of 1800 ml/2160 kcals, starting at 0600 hours until the total dose was completed. During observation, Resident 20 was found connected to GT extension tubing with formula dated the prior evening while the enteral pump was off. LVN 7 stated the feeding had completed at 0400 hours and, when asked, said the GT extension tubing should not be disconnected after each dose was completed. Resident 3 had a GT and an order for Vital AF 1.2 via GT at 70 ml/hr for a total of 1400 ml/1680 kcals starting at 0600 hours until total dose was completed. Resident 3 was observed connected to GT extension tubing with formula dated the prior evening and a water bag dated the prior morning while the pump was off. LVN 8 stated the feeding had completed at 0300 hours and that licensed staff would turn off the machine and keep residents connected to the GT extension tubing until the next scheduled feeding. LVN 10 also stated that when GT feedings reached the dose limit, residents would remain connected to the GT extension tubing until the next feeding. RN 2 and the DON stated that when the resident reached the GT formula dose limit, staff were expected to turn off the enteral pump, clear the settings, and disconnect the resident from the GT extension tubing.
Improper medication storage and labeling
Penalty
Summary
The facility failed to provide proper pharmacy services for multiple residents and medication carts by not ensuring medications and biologicals were stored and labeled according to accepted principles. Facility policy required medications to be stored in conditions that maintain integrity and potency, external-use medications to be segregated from internal-use medications, and expired, damaged, or contaminated medications to be removed from regular stock. During inspection, Medication Cart A contained dust, brown rust-like particles, wet cart liners, stains, and exposed wound products, along with expired culture and sensitivity test kits and a stained dermal curette without an expiration date. Medication Cart C was found to have internal and external medications stored together in the same drawer, including chlorhexidine bottles stored with Beneprotein Fiber, sucralfate tablets, and Fleet enema. Resident 3’s Lantus insulin on that cart was dispensed with an open date and was found expired; staff confirmed it should have been discarded and that insulin should be kept for 28 days from the open date. Medication Cart D also had rust on the mid-base of the first drawer, and staff verified the condition of the cart. The facility also failed to ensure opened bottles of normal saline were discarded after 24 hours for Residents 3, 5, 9, 10, 12, 13, 16, 18, 20, and 21. These residents had tracheostomies and physician orders for tracheostomy care with normal saline and suctioning. Surveyors observed opened bottles of normal saline on bedside tables or nightstands, including one undated bottle, and staff confirmed the bottles had been open longer than 24 hours and should have been discarded. In addition, Resident 20, who had severe traumatic brain injury and was in a persistent vegetative state, had a pink paste mixture of vitamin E topical cream and calazime cream left unattended in a disposable medication cup on the bedside table, and the LVN verified it should not have been left there.
Unsafe Handling of Food Brought in From Outside Sources
Penalty
Summary
The facility failed to ensure safe food handling of food brought in for residents from outside sources. The facility’s policy titled "Food from an Outside Source" stated that food stored on the nursing units should be labeled with the resident’s name, medical record number, and date, and discarded within 48 hours unless the manufacturer’s expiration date was present. During interviews, nursing staff gave inconsistent answers about how long outside food could remain in a resident’s refrigerator, with responses ranging from 24 hours to 72 hours, while one RN stated it could remain for three days. The Director of Food and Nutrition Services stated nursing staff should educate visitors bringing food from outside sources, verify the food was not contraindicated to the resident’s diet, and label and date the item before discarding it after two days. The DSD also stated the food should be dated and labeled and could remain within 72 hours, and a CNA stated she was unsure and would ask another nurse, while also stating food items could stay for one day. The DON stated the food items brought by outside sources should not contraindicate the resident’s diet, should be labeled and dated, and should be discarded after 48 hours or the manufacturer’s expiration date.
Infection Surveillance Program Not Fully Implemented
Penalty
Summary
The facility failed to implement its infection control surveillance program for the months of October 2025 through March 2026. Review of the facility’s Infection Prevention and Control Surveillance Logs showed that surveillance was only conducted when residents were prescribed antimicrobial medications and/or diagnosed with an infection, and the logs reflected only residents classified as having HAIs or CAIs. The logs did not show any residents who did not meet McGeer’s Criteria during that period. The IP stated that McGeer’s Criteria was used to determine whether a resident had a true infection, and Loeb’s Criteria was used to determine whether a resident met the minimum criteria for antibiotic use. However, the IP also stated the facility did not initiate McGeer’s Criteria forms for residents who exhibited signs and/or symptoms of infection but were not prescribed antimicrobial medications or were not diagnosed with an infection. When asked how many residents met McGeer’s Criteria without receiving antimicrobials from October 2025 through March 2026, the IP stated she was uncertain because those residents were not included in the surveillance process. The DON was informed and verified these findings.
Uncovered Catheter Drainage Bags
Penalty
Summary
The facility failed to maintain dignity for Resident 6 and Resident 14 by leaving their indwelling urinary catheter drainage bags uncovered at the side of the bed. Resident 6 was observed on 4/6/26 and 4/7/26 with the catheter drainage bag uncovered. Medical record review showed Resident 6 was admitted to the facility and had severe cognitive impairment, requiring total assistance from staff for all ADL care. During interview, CNA 2 acknowledged the drainage bag did not have a privacy bag and stated it should be on a privacy bag. Resident 14 was also observed on 4/6/26 and 4/7/26 with the indwelling urinary catheter drainage bag uncovered at the side of the bed. The medical record showed a physician's order dated 6/6/25 for indwelling urinary catheter care every shift. CNA 1 acknowledged the drainage bag did not have a privacy bag and stated it should be on a privacy bag. LVN 1 later verified that both residents used indwelling urinary catheters and that the drainage bags were not on privacy bags. The DON was informed of these findings during the interview and record review.
Missing Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that Resident 7 was free from unnecessary psychoactive medications and failed to complete informed consent before the use of valproic acid and duloxetine. Facility policy stated that psychoactive medications are to be used only when necessary to treat medical, mood, behavioral, or psychiatric symptoms, and that informed consent must be documented in the medical record before initiation of medications requiring consent. Resident 7’s record showed a BIMS score of 99, indicating the interview could not be completed, and the resident had orders for duloxetine delayed release 90 mg via GT at bedtime for depression manifested by refusal of care and tearfulness/crying, and valproic acid 250 mg via GT twice daily for mood stabilization manifested by angry outbursts. Review of the record showed an informed consent form for duloxetine dated 2/25/26, signed by the MD on 3/4/26, but it did not show that the resident’s responsible party was informed and it was not signed by the responsible party. The medical record did not contain an informed consent for valproic acid, and progress notes did not show that the responsible party was notified or that consent was obtained. The MAR showed the resident received duloxetine from 4/1/26 through 4/8/26 and valproic acid twice daily from 4/1/26 through 4/8/26. During interviews, the DSD and DON verified that the duloxetine consent lacked the responsible party’s signature and that no consent existed for valproic acid; the DON stated the facility’s existing process was missing informed consent on psychotropic medication use and that these consents should have been obtained and completed.
Privacy Curtains Not Fully Closed During Resident Care
Penalty
Summary
The facility failed to ensure privacy was provided during care for one sampled resident and two nonsampled residents. Facility policy titled Resident Privacy and Confidentiality, dated 3/2026, stated to always use curtains to provide full visual privacy when caring for the resident. Resident 9 was admitted to the facility and had an H&P dated 9/26/25 showing the resident's general status was unresponsive. During a medication administration observation on 4/7/26, LVN 4 pulled Resident 9's gown to access the GT for medication administration but did not fully close the privacy curtain before exposing the resident's abdominal area. LVN 4 stated she forgot to close the curtain completely. The DSD was informed and stated the curtain should be fully closed during GT medication administration. Resident 9's ADL and Dignity Care Plan showed the resident required total assistance in all areas of ADL and included interventions to provide privacy and dignity. During a second medication administration observation on 4/8/26, LVN 6 again did not fully close the privacy curtain while administering medications via GT and stated she should have closed it. RN 1 later stated the curtain should have been drawn completely for privacy. Resident 23 was admitted to the facility and had an H&P dated 9/26/25 showing the resident was awake and non-communicative. Resident 12 was admitted to the facility and had an H&P dated 7/31/25 showing the resident was neurologically awake but had no other meaningful response. During an observation on 4/7/26, RT 1 suctioned Resident 23 from across the room without fully closing the privacy curtain toward Resident 12's bed and the doorway, then suctioned Resident 12 without fully closing the privacy curtains toward the side of Resident 23. Facility staff were also observed coming in and out of the room replacing supplies. RT 1 acknowledged she did not fully close the privacy curtain during suctioning and stated the curtain was supposed to be fully closed. LVN 4 later verified the privacy curtains for Residents 12 and 23 were not fully closed during suctioning and stated the curtains must be closed during care. The DON was informed and acknowledged the findings.
Failure to Rotate Injection Sites for Lovenox and Insulin
Penalty
Summary
The facility failed to provide the necessary services to attain or maintain the highest practicable well-being for one sampled resident, Resident 2, by not rotating injection sites for Lovenox and insulin administration. Resident 2 had physician orders for Lovenox 40 mg subcutaneously daily and insulin glargine 32 units subcutaneously at 0600 hours and 26 units subcutaneously at 1800 hours. Review of the MARs for March and April 2026 showed repeated use of the same abdominal and thigh injection sites for multiple doses of both medications, including consecutive administrations at the left lower quadrant, left upper quadrant, right lower quadrant, and left thigh. During an interview and concurrent record review, an LVN verified administering the anticoagulant and insulin and stated that injection sites should be rotated and that the MAR would show the last injection site. The DSD stated that the nurse should administer the medications as ordered and rotate injection sites to prevent complications, and then verified that the injection sites were not rotated. The DON was also informed and verified the findings.
Low Air Loss Mattress Settings Not Properly Ordered or Set
Penalty
Summary
The facility failed to ensure the necessary care and services were provided to prevent the risk and development of pressure injuries for two residents. For Resident 20, who had a severe traumatic brain injury, was in a persistent vegetative state, bedfast, completely immobile, and had a Stage 4 sacral pressure injury, staff observed him in bed on a low air loss mattress with the pump set at 450 lbs. The facility’s policy required following the manufacturer’s recommendations for pump settings, and the mattress manual stated the settings should be adjusted to the patient’s weight and comfort. Resident 20’s weight was documented as 125.4 lbs, and the DON stated the pump settings should be based on the resident’s weight. For Resident 2, staff observed the resident asleep in bed on a low air loss mattress that was also set at the maximum 450 lbs. The physician had ordered an air mattress, but the medical record did not show a specific physician’s order for the low air loss mattress setting. During interview, LVN 3 verified the mattress setting was at the maximum level and acknowledged there was no specific physician’s order for the setting of the machine. The DON was informed and verified the findings.
Failure to Provide Ordered Left Hand Roll
Penalty
Summary
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM, and/or mobility was not met for one resident. Resident 24 had diagnoses including cerebral palsy, quadriplegia, and contractures, and was assessed as having severely impaired cognitive skills for daily decision making. Physician orders directed RNA staff to provide gentle PROM to all four extremities daily, apply a left soft hand roll at all times except for ADLs, apply a PRAFO to the left ankle for four hours as tolerated after ADLs, and apply a right soft hand roll the rest of the time except for ADLs. The care plan also included interventions for PROM, hand rolls, and splint use related to the resident's ADL functional status and rehabilitation potential. During observations, Resident 24 was seen lying in bed with a PRAFO on the left ankle and a splint on the right hand, while the left hand remained in a fist position. Review of the RNA flowsheet showed documentation for the PRAFO, right hand roll, right hand/wrist splint, and PROM, but it did not show that a left soft hand roll was provided. RNA staff stated there was no order for a left soft hand roll, while LVN 12 later reviewed the physician orders and verified that the order did exist and that the resident was not provided the left soft hand roll as ordered. The DON was informed and acknowledged the findings.
Missing Side Rail Padding for Resident With Seizure Precautions
Penalty
Summary
The facility failed to provide the necessary care and services to prevent accidents for one of 12 sampled residents, Resident 4, by not ensuring the resident’s upper side rail pads were in place as ordered for safety and seizure precautions. Facility policy titled Seizure Precaution stated that residents with seizure diagnoses were to have side rails padded with anti-trauma pads. On 4/6/26 and 4/7/26, Resident 4 was observed in bed with both upper side rails elevated and no pads in place. Resident 4’s record showed a diagnosis of seizure disorder and moderate cognitive impairment. Physician’s orders included monitoring seizure episodes every shift and placing bilateral padded upper side rails for safety/seizure precautions. The treatment flowsheet for April 2026 showed the bilateral upper side rail padding was implemented, but during an observation and interview, LVN 1 verified the resident had elevated bilateral upper side rails with no pads in place and stated the bed had been changed the day before and the side rail padding had not been replaced. RN 1 and the DON were later informed and acknowledged that Resident 4 should have padded side rails at all times when in bed for seizure precaution.
Failure to Report Sediment in Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide appropriate care and services for the use of an indwelling urinary catheter for one resident who had severe cognitive impairment, an indwelling urinary catheter for incontinence and perineal wounds, and a Stage 4 pressure ulcer. The facility’s urinary catheter management policy directed staff to observe urinary drainage for cloudiness, odor, mucus, blood, or sediment and to report abnormal findings. During observation, the resident’s catheter tubing was noted to have a lot of sediment, and the urinary drainage bag had brown sediment. The drainage bag was dated 4/1/26, and the tubing also had whitish color streaks when later observed with nursing staff and the DON. The resident’s medical record showed repeated documentation of sediment in the urine and cloudy urine on multiple dates, including 3/28/26, 3/30/26, 4/1/26, 4/3/26, and 4/4/26. The record did not show documented evidence that the clinician was notified about the urine characteristics. The DON stated that if sediment was observed in a resident’s Foley catheter tubing, licensed nursing staff should notify the clinician for further orders, and also stated there was no documented evidence that the clinician had been notified regarding the resident’s current urinary characteristics.
GT Extension Tubing Left Connected After Feedings Completed
Penalty
Summary
The facility failed to provide appropriate care and services for the use of gastrostomy tube (GT) feedings for two residents. For both residents, surveyors observed that the GT extension tubing remained connected after the tube feeding formula had been completed. The report states these failures posed the risk of tube clogging, leaking, not functioning properly, and developing bacterial growth (infection). Resident 20 had a history of severe traumatic brain injury and was GT dependent. The resident’s physician orders directed Vital AF 1.2 formula via PEG/GT at 90 mL/hr, with a total dose of 1800 mL, starting at 0600 hours until the total dose was completed. During observation, Resident 20 was found asleep with the head of the bed elevated and still connected to GT extension tubing with the enteral pump off. The resident’s formula had been dated the prior evening, and the LVN stated the feeding had completed earlier but that the GT extension tubing should not be disconnected after each dose. RN 2 and the DON stated that when the dose limit was reached, staff were expected to turn off the pump and disconnect the resident from the GT extension tubing. Resident 3 had a GT and severely impaired cognitive skills for daily decision making. The physician’s orders directed Vital AF 1.2 formula via GT at 70 mL/hr, with a total dose of 1400 mL, starting at 0600 hours until the total dose was completed. During observation, Resident 3 was found in bed with the head of the bed elevated and still connected to GT extension tubing with the enteral pump off. The LVN stated the feeding had completed earlier and that staff would turn off the machine but keep residents connected to the GT extension tubing until the next scheduled feeding. RN 2 and the DON stated that when the dose limit was reached, staff were expected to turn off the pump and disconnect the resident from the GT extension tubing.
Failure to Assess and Reassess Pain After Morphine Administration
Penalty
Summary
The facility failed to provide appropriate pain management for one resident who was receiving morphine for pain control. The resident had severely impaired cognitive skills for daily decision making and a Stage 4 pressure ulcer. Physician orders included monitoring pain every shift, morphine 5 mg via GT every six hours as needed for breakthrough pain, morphine 10 mg via GT every 12 hours for pain management, and acetaminophen 650 mg via GT every four hours as needed for mild pain. Review of the medical record showed morphine was administered on multiple occasions, including routine doses and an as-needed dose for signs and symptoms of pain. The facility's pain scale summary contained only a few documented pre-treatment and post-treatment pain assessments, and the record did not show documentation of pain assessments or reassessments on other dates and times after morphine administration. During interviews, an LVN, an RN, and the DON verified that the resident was not consistently assessed for pain, and the DON stated licensed staff were expected to monitor pain every shift and reassess after pain medication administration.
Failure to Monitor Anticoagulant Use and Document Nonpharmacological Interventions for Psychoactive Medications
Penalty
Summary
The facility failed to provide necessary pharmaceutical services for two residents. For one resident receiving Lovenox for anticoagulation, the medical record showed the medication order but did not show a physician's order for monitoring adverse reactions, and the record also lacked documented evidence of monitoring for adverse reactions such as bleeding. The resident's care plan included monitoring for bleeding and notifying the physician if symptoms developed, but the chart did not contain the required monitoring documentation. During interview and record review, the DSD and DON verified the absence of the physician's order and the lack of documentation for adverse reaction monitoring. For another resident receiving psychoactive medications, the record showed orders for duloxetine for depression manifested by refusal of care and tearfulness/crying, and valproic acid for mood stabilization manifested by angry outbursts. The resident's care plan referenced nonpharmacological approaches for depressed symptoms, but the record did not show that those approaches were actually ordered, provided, or documented. Review of the care plan for valproic acid also failed to show nonpharmacological interventions. The pharmacist's drug regimen reviews for January through March 2026 did not include recommendations specific to the duloxetine or valproic acid use. Facility policy required psychoactive medications to be used only when necessary and to include assessment of environmental causes, attempted alternative interventions, and documentation of behavioral management programs. The policy for high alert medications identified anticoagulants as requiring monitoring for unusual bleeding or other adverse reactions. Interviews with the DSD and DON confirmed there was no documented evidence of nonpharmacological interventions for the psychoactive medications and no physician's order or documentation for monitoring adverse reactions related to the anticoagulant.
Inaccurate Code Status and Isolation Orders in Resident Record
Penalty
Summary
The facility failed to ensure the medical record was accurate for one of 12 sampled residents, Resident 3. Resident 3's physician orders listed a full code status, but the resident's POLST form dated 3/31/26 showed DNR status to allow a natural death and was signed by the physician and the resident's legal decision maker. Resident 3's care plan also addressed full code status and included interventions to inform the family that the order had been placed on the resident's chart and to respect the family decision. During record review and interview, RN 1 verified that Resident 3 had DNR status and stated the physician's order should reflect the resident's current code status. The facility also failed to ensure the physician's order for precautions was accurate. Resident 3's patient orders included an enhanced barrier precaution for C. Auris and a contact isolation precaution due to C. Difficile and C. Auris. However, during observation, EBP signage was posted on the resident's room door, and LVN 6 stated the resident had EBP due to a pressure injury, GT feeding, and an indwelling urinary foley catheter. When asked whether Resident 3 currently had active C. Difficile, LVN 6 stated no. The DON later stated Resident 3 did not have active C. Difficile and the physician's order should have been discontinued to reflect the resident's current precautions.
LVNs Performed Respiratory Care Outside Scope After Regulatory Change
Penalty
Summary
The facility failed to ensure that Licensed Vocational Nurses (LVNs) performed their duties within their legal scope of practice when providing care to patients, specifically those with tracheostomies. Despite regulatory changes from the Board of Vocational Nursing and Psychiatric Technicians (BVNPT) effective 10/1/25, which restricted LVNs from performing certain respiratory care tasks, LVNs continued to conduct activities such as pre- and post-nebulizer treatment assessments, tracheostomy care, suctioning, and manipulation of ventilators. These actions were documented in patient records and confirmed through staff interviews, indicating that LVNs were performing tasks outside their authorized scope. The facility's policies and procedures (P&Ps) related to respiratory care and tracheostomy management had not been updated to reflect the new BVNPT regulations. Multiple P&Ps, including those for tracheostomy tube suctioning, speaking valve cleaning, and tracheostomy care, did not specify the limitations imposed on LVNs. Staff interviews revealed that LVNs were aware of the regulatory changes but continued to perform restricted tasks due to insufficient respiratory therapist (RT) staffing. Some LVNs stated they performed these tasks out of necessity when RTs were unavailable, and documentation showed that these practices persisted after the effective date of the new regulations. Interviews with the Director of Nursing (DON), RT Manager, and other staff confirmed that the facility was aware of the changes in LVN scope of practice but had not yet fully implemented the necessary staffing adjustments or policy updates. The DON acknowledged that LVNs were performing respiratory care outside their scope and that the facility's job descriptions and policies were outdated. The RT Manager also noted that the number of RTs was insufficient to meet patient needs, leading to continued reliance on LVNs for restricted respiratory care tasks.
Plan Of Correction
Chapman Global Medical Center Plan of Correction Scope changes of LVN staff, including what respiratory care they can provide and instructing them to notify the charge nurse of any respiratory care needed that falls within the limitations defined by the BVNPT so that an RN can complete these duties. Resident #1 was assessed by the RN to ensure no adverse effects were present from the LVN providing the care to the patient. No issues were identified. By 11/15/25, all LVNs will be educated on the changes to the LVN scope of practice for providing respiratory care from the BVNPT effective 10/1/25 by their supervisor. The education will be done during unit huddles, staff meetings, or online. The DON reviewed the LVN JD and found it outdated. By 11/15/25, the Facility will revise the Job Description, Scope of Practice Policies, and Procedures in accordance with the California Vocational Nursing Practice Act and The Respiratory Care Board Regulations. All LVNs will be educated on the revised JD and will sign the new JD to ensure understanding of the changes.
Failure to Provide Necessary Care, Therapy, and Restorative Services
Penalty
Summary
The facility failed to provide necessary care and services to ensure residents maintained their highest physical well-being, as evidenced by multiple deficiencies in monitoring, documentation, and adherence to physician orders for five sampled residents. For one resident with a right upper arm fracture, there was no consistent monitoring for pain, redness, swelling, or warmth of the extremities, despite care plan interventions requiring such assessments. Documentation was lacking for musculoskeletal assessments and CNA care during specific shifts, and there was no evidence that pain observed by PT staff was reported to nursing. Interviews with staff confirmed that assessments were not completed and that signs of injury were not always checked or documented. The facility also failed to follow physician orders for physical therapy (PT) and occupational therapy (OT) treatments for two residents. Records showed missed PT and OT sessions over several weeks, with the rehabilitation department prioritizing other hospital patients over those in the skilled nursing facility. The Director of Nursing acknowledged the lack of therapy documentation and confirmed that required treatments were not consistently provided as ordered. Additionally, the facility did not provide daily Restorative Nursing Assistant (RNA) services as ordered for four residents. Medical records revealed multiple dates where RNA services, including range of motion exercises and application of orthotic devices, were not performed or documented. Staff interviews indicated that on days with staffing shortages, the RNA was reassigned to CNA duties, resulting in missed restorative care. The Director of Nursing verified that these services were not provided on the specified dates due to staffing issues.
Failure to Provide Safe and Appropriate Respiratory Care for Ventilator-Dependent Residents
Penalty
Summary
The facility failed to provide necessary respiratory care and services for two residents who were dependent on ventilators with tracheostomy tubes. For one resident, the ventilator circuit was not effectively monitored, resulting in the resident being found disconnected from the ventilator and unresponsive. Documentation showed that after being readmitted, the resident was alert and oriented, but there was no evidence of required ventilator checks or suctioning as per physician orders and facility policy. The resident was later found unresponsive, disconnected from the ventilator, and required manual ventilation and a Code Blue response. The ventilator alarm log was found to have inaccurate time settings, and it was unclear if the alarm sounded during the incident. Interviews revealed that there was no dedicated respiratory therapist (RT) in the facility, and the RT assigned was also responsible for the acute care unit, leading to lapses in monitoring and care. For the second resident, the facility failed to ensure that policies and procedures for respiratory care were followed when oxygen therapy and parts of the disposable ventilator circuit were replaced and rinsed by a non-qualified staff member. The resident, who had severely impaired decision-making capacity, experienced a sudden change in condition, turning blue and requiring an increase in FiO2. During the event, a CNA replaced the HME filter and rinsed the T-adapter, and also increased the FiO2, actions that were outside the CNA's scope of practice. The RT was not present at the time, and the nurse on duty did not immediately intervene, instead asking the CNA to assist. The RT manager confirmed that CNAs were not permitted to perform these tasks and that the T-adapter should not have been rinsed. Both incidents were compounded by the lack of a dedicated RT in the facility, with RTs being shared with the acute care hospital. This led to delays in care and interventions, as well as non-compliance with facility policies and procedures regarding ventilator management, suctioning, and equipment handling. Documentation and interviews confirmed that required assessments, monitoring, and interventions were not consistently performed or documented, directly contributing to the deficiencies identified.
Failure to Follow Physician's Order for Air Mattress Setting
Penalty
Summary
The facility failed to provide the necessary care and services to promote the healing of pressure injuries for a resident. The resident, who was admitted with several wounds including a Stage 3 pressure injury to the sacrum and Stage 4 pressure injuries to the left and right hips and right ankle, was observed lying on an air mattress set to the static mode. This setting was contrary to the physician's order, which specified that the air mattress should be set to the alternate mode with a cycle of five minutes to aid in pressure redistribution. During an observation and interview, an LVN incorrectly confirmed that the static mode was the correct setting, despite the physician's order indicating otherwise. This discrepancy was later verified during a follow-up interview and medical record review with the same LVN.
Failure to Provide Ordered RNA Services
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 9 and 11, received Restorative Nursing Assistant (RNA) services as ordered by their physicians. Resident 9, who had a history of contractures and quadriplegia, was supposed to receive daily passive range of motion (ROM) exercises and have specific splints and orthotic devices applied for certain durations. However, the RNA Flowsheet for February 2025 showed no documented evidence that these services were provided on specific days. Similarly, Resident 11, also with a history of contractures and quadriplegia, had orders for daily ROM exercises and the application of orthotic devices, but the RNA Flowsheet indicated missing documentation for several days in February 2025. Interviews with RNA 1 and RN 1 confirmed the absence of documentation and acknowledged that the lack of RNA services could lead to worsening contractures and muscle stiffness. The Chief Nursing Officer (CNO) also verified the missing RNA signatures in the RNA Flow Sheets and expressed expectations for the RNA services to be performed as ordered to prevent further contractures. The failure to provide these services as ordered had the potential to negatively impact the residents' ROM function and overall physical condition.
Improper Equipment Placement and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure the proper placement of low air loss mattress pumps for two residents, as per the manufacturer's recommendations. For one resident, the pump was observed on the floor under the bed, contrary to the user manual's instructions to hang it on the footboard. A Licensed Vocational Nurse (LVN) confirmed the incorrect placement and acknowledged it was not supposed to be under the bed. Similarly, another resident's low air loss mattress control unit was also found on the floor, with a Registered Nurse (RN) stating that the hook did not fit the footboard, preventing proper placement. The Chief Nursing Officer (CNO) was informed and acknowledged these findings. Additionally, the facility did not implement the physician's order for floor mats on both sides of a resident's bed, which was necessary for fall prevention. The resident, who had severely impaired cognition and was dependent on staff for mobility, was observed with a floor mat on only one side of the bed. An LVN verified the absence of the second mat and recognized the resident's risk for falls, confirming the need for mats on both sides as per the physician's order.
Failure to Maintain Proper HOB Elevation During Enteral Feeding
Penalty
Summary
The facility failed to ensure appropriate care and services for the use of gastrostomy tubes (GT) for two residents. Resident 3, who had severe cognitive impairment and difficulty swallowing, was observed on multiple occasions with the head of the bed (HOB) not elevated at the required 30-degree angle or higher while receiving enteral feeding. Despite physician orders to maintain the HOB at 30 to 45 degrees during and after feeding, the bed lacked a device to measure the elevation, and staff were unable to confirm the correct angle. Interviews with staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), revealed a lack of knowledge and tools to ensure compliance with the physician's orders. Similarly, Resident 13, who also had difficulty swallowing and was on tube feeding, was observed with the HOB not elevated to the required angle during feeding. The resident's care plan and physician orders specified the need for the HOB to be elevated at 30 to 45 degrees, yet observations showed it was only at a 15-degree angle. Staff interviews confirmed the absence of a device to measure the HOB elevation and acknowledged the failure to comply with the physician's orders. These deficiencies posed a risk for complications related to the use of GT for both residents.
Failure to Maintain IV Access for a Resident
Penalty
Summary
The facility failed to provide the necessary care and services for the maintenance of intravenous (IV) access for a resident, identified as Resident 21. The deficiency was observed when the facility did not obtain a physician's order for the care and maintenance of the IV access, nor did they develop a plan of care for the resident's IV access to the lower extremity. This oversight was noted during an observation on February 10, 2025, when Resident 21 was seen with an IV fluid infusing at 70 ml per hour, but the IV access was not visible due to bed covers. Further investigation revealed that the resident had moderately impaired cognitive skills and was on IV hydration due to abnormal laboratory results. Upon reviewing the medical records, it was found that there was no documented evidence of a physician's order for the IV access assessment, dressing change, or the frequency of changing the peripheral IV access site. Additionally, the resident's plan of care did not address the use and maintenance of the IV access site. Interviews with RN 2 and the Chief Nursing Officer (CNO) confirmed these findings, with RN 2 acknowledging the absence of a physician's order for the necessary IV care and the lack of a developed care plan for the resident's IV use.
Improper Disposal of Medication
Penalty
Summary
The facility failed to properly dispose of unused medication in accordance with its policy and procedures (P&P). During a medication administration observation, a Licensed Vocational Nurse (LVN) was seen disposing of a half tablet of fludrocortisone, a corticosteroid medication, in a sharps container instead of the designated pharmaceutical waste container. The facility's P&P, dated October 2022, specifies that all unusable medications, including partially used tablets, should be disposed of in pharmaceutical waste containers. The incident involved a resident who was prescribed fludrocortisone 0.05 mg daily for hypotension. The LVN obtained a 0.1 mg tablet, cut it in half, administered the required dose, and improperly disposed of the remaining half tablet.
Failure to Act on Pharmacy Consultant's Recommendations
Penalty
Summary
The facility failed to ensure that the Pharmacy Consultant's recommendations from the monthly drug regimen review (MRR) were acted upon for Resident 13, who was reviewed for unnecessary medications. The pharmacist recommended discontinuing chlorhexidine, an antiseptic medication, as it was not recommended for residents on a ventilator, and also suggested performing a hemoglobin A1c level test due to the resident's diagnosis of diabetes. These recommendations were documented in the MRR dated 12/31/24 and 1/28/25, respectively, and were signed by the physician. However, there was no documented response from the physician regarding the approval or disapproval of these recommendations. The medical record review revealed that the physician's order to administer chlorhexidine 0.12% oral rinse twice a day remained active and had not been discontinued. Additionally, there was no evidence that the laboratory order for the hemoglobin A1c level was obtained from the physician. Interviews with the Director of Pharmacy and RN 1 confirmed that the charge nurses failed to follow up with the physician about the MRR recommendations. The Chief Nursing Officer (CNO) was also informed and verified these findings, indicating a lapse in the facility's process for addressing pharmacist recommendations in a timely manner.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 8%. This deficiency was identified through the case of a resident who did not receive their medications as prescribed. Specifically, the resident was supposed to receive lactulose 30 grams via GT daily for elevated ammonia levels and clonidine 0.3 mg/24 hours transdermal patch weekly for muscle spasticity. However, during a medication administration observation, it was noted that the resident was only given 20 grams of lactulose instead of the prescribed 30 grams, and the clonidine patch was not applied at all. The facility's policies and procedures for medication administration, which require verification of the correct medication and adherence to the administration schedule, were not followed. The LVN responsible for administering the medications acknowledged the errors during an interview and review of the resident's medical records. These failures in medication administration had the potential to negatively impact the resident's health, as the prescribed treatments were not delivered as ordered by the physician.
Improper Medication Storage on Facility's Medication Carts
Penalty
Summary
The facility failed to ensure proper storage, labeling, and disposal of medications on two of its medication carts, posing a risk for medication administration errors. During an observation of Medication Cart A, it was found that a bottle of loperamide liquid, Carboxymethylcellulose 0.5% eye drops, and an Albuterol Sulfate inhaler were stored together in one tray without partitions. Additionally, a vial of Insulin Lantus and a bottle of Calcitonin Sodium Nasal spray were also stored together in another tray without partitions. These findings were verified by LVN 5, who acknowledged that the medications should have been stored separately. Similarly, an observation of Medication Cart B revealed that a vial of Insulin Lantus and a bottle of Carboxymethylcellulose 0.5% eye drops were stored together in one tray without partitions. LVN 6 confirmed these findings and stated that the medications should have been stored separately with partitions. The facility's policy on medication storage and security, as outlined in their Pharmacy Manual, requires that medications be stored in segregated and secure conditions to minimize the potential for errors, theft, or diversion. The failure to adhere to these policies resulted in the identified deficiencies.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to meet food safety and sanitary requirements in the kitchen, as observed during a survey. The deficiencies included the use of food preparation utensils and equipment that were not in good, sanitary, and cleanable working conditions. Specifically, a spatula was found with brown discoloration and heavily worn, two scoops had melted handles and were heavily worn, and three white cutting boards were heavily marred with black discoloration. These findings were verified by the Registered Dietitian (RD) during an observation and interview. Additionally, the facility did not ensure that staff's personal food items were kept out of the kitchen refrigerator, as a dietary aide's personal salad was found stored in the kitchen's reach-in refrigerator. Furthermore, the kitchen staff failed to wear appropriate hair restraints, as observed with a staff member who had sideburns and a mustache without a beard restraint. These issues were acknowledged by the RD, Dietary Supervisor, and Chief Nursing Officer (CNO) during interviews, confirming the facility's non-compliance with food safety standards.
Infection Control Committee Meeting Lapse
Penalty
Summary
The facility failed to implement appropriate infection control practices as required by their policies and procedures. Specifically, the infection control committee did not meet for one quarter in 2024 to discuss infection control within the subacute unit. This lapse occurred because the Medical Doctor, who also served as the Infection Control Chair, was out of the country until January 30, 2025, resulting in the committee missing the November 2024 quarterly meeting. The absence of this meeting prevented the discussion of quarterly infection control statistics, posing a risk for the transmission of disease-causing microorganisms.
Facility Assessment Lacks Comprehensive Staffing Plan
Penalty
Summary
The facility failed to ensure that the Facility Assessment was comprehensive and up-to-date, as required by the revised CMS guidance. The assessment did not actively involve direct care staff, residents, or their representatives in its development. Additionally, it lacked a detailed plan for staffing resources necessary to care for residents, particularly during weekends, and did not include strategies for recruitment and retention of direct care staff or a contingency plan for staffing needs. During an interview and document review, the Chief Nursing Officer (CNO) confirmed that the Facility Assessment was outdated and did not reflect the latest CMS updates. The CNO acknowledged the absence of involvement from key stakeholders in the assessment process and the lack of necessary resources and plans to address staffing needs. This oversight had the potential to impact the facility's ability to meet residents' care needs effectively.
Lack of Dedicated Infection Preventionist
Penalty
Summary
The facility failed to have a full-time, dedicated Infection Preventionist (IP) responsible for the Infection Prevention and Control Program. The organizational chart updated in February 2025 showed the position for Infection Control Supervisor/Infection Control was vacant. According to the QSO-22-19 dated June 29, 2022, Skilled Nursing Facilities (SNFs) are required to have an IP with specialized training onsite at least part-time. However, the Director of Infection Prevention/Acting IP was primarily stationed at the acute care unit and only spent one to two hours at the facility, confirming that there had been no dedicated IP personnel since January 2024. The Chief Nursing Officer (CNO) also verified that the facility shared IP personnel with the acute care unit and was actively interviewing to fill the position.
Resident Health Information Confidentiality Breach
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's protected health information, specifically for one resident. On two separate occasions, a staff computer located in the residents' hallway was left unattended with the resident's personal health information displayed on the screen. This information included the resident's name and scheduled medications, and the computer was accessible to residents' family members and visitors who used the hallway. During an observation and interview, a Licensed Vocational Nurse (LVN) confirmed that the computer was unattended and displaying the resident's personal health information. The LVN noted that the computer was used by a Respiratory Therapist, who should have either logged out or used a paper cover to protect the screen when not present. Despite this expectation, the computer was again found unattended with the resident's information visible, confirming a breach of confidentiality as outlined in the facility's policy and procedures.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as evidenced by two of eight waste dumpsters being observed overflowing with trash and not properly closed. This was identified during an observation and interview with the Registered Dietitian (RD) on February 11, 2025, at 0942 hours. The RD confirmed that the waste dumpster lids should be closed to prevent attracting pests and rodents. Further interviews with the RD, Dietary Supervisor, and Chief Nursing Officer (CNO) on February 13, 2025, confirmed the findings. The facility's policy and procedure on sanitation, dated August 2024, requires food waste to be kept in leakproof, nonabsorbent, tightly closed containers and disposed of as frequently as necessary to prevent nuisance or unsightliness. The failure to adhere to these guidelines had the potential to cause unsafe sanitary conditions and harbor pests and rodents.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike environment for four residents, as observed in Rooms A and B. Resident 23, residing in Room A, was found in a room with a wall behind the bed that had a hole, scratches, and unfinished patchwork. Similarly, Residents 10, 14, and 18, residing in Room B, were observed in a room where the wall behind their beds was in disrepair, with holes, scratches, unfinished patchwork, and peeled paint. These observations were made during a survey, and the residents were not interviewable due to cognitive impairment. The Chief Nursing Officer (CNO) was shown photos of the disrepair and acknowledged the need for repairs in these rooms.
Failure to Provide Ordered RNA Services
Penalty
Summary
The facility failed to provide restorative nursing assistant (RNA) services as ordered for a resident, leading to a potential decline in the resident's range of motion (ROM) functions. The resident, who had a history of contractures, muscle wasting, and atrophy, was supposed to receive daily ROM exercises and the application of bilateral hand splints and PRAFOs as per the physician's orders. However, the RNA services were inconsistently provided, with the resident receiving these services on only a few days throughout the month. Interviews with facility staff revealed that the RNA was often reassigned to work as a certified nursing assistant (CNA) due to staffing challenges, which contributed to the inconsistency in providing the ordered RNA services. The Director of Nursing (DON) acknowledged the issue and stated that the facility prioritized residents' hygiene and activities of daily living (ADL) assistance over RNA services, while also working on recruiting additional RNA staff. This failure to adhere to the physician's orders had the potential to negatively impact the resident's ROM status and increase stiffness in the resident's extremities.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4,103 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Healthbridge Children's Hospital - Orange D/p Snf | 0.7 mi | ★★★★★ | 18 | 0 |
| New Orange Hills | 1.7 mi | ★★★★★ | 25 | 0 |
| The Hills Post Acute | 1.8 mi | ★★★★★ | 29 | 0 |
| Orange Healthcare & Wellness Centre, Llc | 1.8 mi | ★★★★★ | 27 | 0 |
| Town & Country | 2 mi | ★★★★★ | 27 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Chapman Global Medical Center D/p Snf.
100% money-back within 48 hours.
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.