Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Valley Manor during CMS and state inspections, most recent first.
The facility failed to conduct a risk assessment and implement a water management program to mitigate the risk of Legionella disease. Maintenance staff confirmed the absence of routine water management checks, and the facility lacked a system to check for standing water in unoccupied rooms. This oversight placed residents at risk of contracting Legionella disease.
The facility provided the incorrect CMS Form CMS-R-131 instead of the required CMS Form 10055 to two residents when their skilled services ended. This error, acknowledged by Social Services staff, resulted in the residents not receiving necessary information about potential financial liability for services not covered by Medicare, as required by the facility's policy.
A hospice CNA improperly removed a resident's fentanyl patch during a bed bath and discarded it in the trash, failing to follow proper disposal procedures. The nursing staff did not immediately retrieve or dispose of the patch correctly, eventually finding it in a trash can in a shower room. This incident highlights a lack of staff competency in handling powerful opioid medications, placing residents at risk for inadequate care.
A facility failed to ensure a Consultant Pharmacist identified and reported a missing 14-day stop date for a PRN Haldol prescription for a resident with dementia and other conditions. The resident's medication administration records showed multiple administrations of the medication, but the Consultant Pharmacist's reviews did not document the omission, placing the resident at risk for unnecessary psychotropic medications.
A facility failed to ensure a resident's PRN antipsychotic medication, Haldol, had a 14-day stop date, as required. The resident, diagnosed with dementia and other conditions, received the medication multiple times without the necessary stop date. The administrative nurse confirmed the oversight, and the facility's policy emphasized the need for antipsychotics to be used only when medically necessary.
A resident receiving hospice care was administered a crushed extended-release medication through a G-tube, contrary to guidelines. The nurse had raised concerns about this practice, but the order was not changed, leading to a medication error.
The facility failed to prepare pureed diets correctly for three residents, compromising the nutritive value and palatability of their meals. Dietary Staff (DS) BB did not follow a specific recipe, resulting in improperly textured meals. This failure placed the residents at risk for impaired nutrition and decreased quality of life.
The facility failed to coordinate hospice care for two residents, leading to a deficiency in providing appropriate end-of-life care. One resident with esophageal cancer and another with COPD and CHF had care plans that lacked specific instructions on hospice services, including supplies, equipment, and medication details. The facility's policy required coordination with hospice providers, but this was not adequately implemented, placing the residents at risk for inappropriate care.
Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to conduct a risk assessment to identify risks and implement a water management program to mitigate the risk of Legionella disease and other waterborne pathogens. This deficiency was identified during a survey where it was found that the facility did not have a routine system for water management checks. Maintenance Staff U confirmed the absence of routine checks and mentioned that housekeeping staff occasionally flushed water in unoccupied rooms, but not on a regular basis. This lack of routine checks and flushing could contribute to the growth of Legionella bacteria, which poses a risk to residents, especially those over 50 or with weakened immune systems. Additionally, Administrative Nurse E verified that the facility lacked a system to check for standing water in unoccupied rooms or other potential areas that could foster Legionella growth. The facility's Water Management Procedure policy, dated 08/14/24, stated that a program should be developed to reduce the risk of Legionella growth and spread. However, the facility did not adhere to this policy, as they failed to identify building water systems needing control measures, assess the risk of hazardous conditions, and apply control measures to prevent Legionella growth. This oversight placed the residents at risk of contracting Legionella disease.
Incorrect CMS Form Provided to Residents
Penalty
Summary
The facility failed to provide the correct CMS Form 10055, Advanced Beneficiary Notice (ABN), to two residents, identified as R28 and R137, or their representatives. Instead, the facility provided the incorrect form, CMS-R-131, when the residents' skilled services ended. This error was identified during a review of the facility's records and interviews with staff. The incorrect form did not include an estimated cost for continuing services, which is a critical component for residents to make informed decisions about their care. The facility's policy, revised in November 2019, required the use of the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) form CMS 10055 for Part A items and services. However, Social Services staff admitted to providing the incorrect form, unaware of the mistake. This oversight placed the residents at risk for making uninformed decisions regarding their skilled services, as they were not properly informed about their potential financial liability if Medicare did not cover the services.
Inadequate Handling of Fentanyl Patch by Staff
Penalty
Summary
The facility failed to ensure that staff had the necessary knowledge and competency to handle a situation involving a resident's fentanyl patch. A hospice CNA removed a resident's fentanyl patch during a bed bath, claiming it was expired, and failed to dispose of it according to standards of practice and manufacturer instructions. The CNA reportedly discarded the patch in the trash, but it was not immediately retrieved or disposed of properly by the nursing staff. This incident was observed when a licensed nurse, after being informed by the CNA, searched the resident's room and eventually found the patch in a trash can in a shower room across the hall. The patch was then disposed of in a Sharp's container. The report highlights that the facility did not ensure that the staff possessed the skills and competency required to safely monitor and dispose of the fentanyl patch, which is a powerful opioid medication. The FDA provides specific instructions for the disposal of fentanyl patches due to the potential danger they pose if not handled correctly. The failure to follow these instructions placed the residents at risk for inadequate care, as the staff did not respond appropriately to the situation.
Consultant Pharmacist Failed to Report Missing Stop Date for PRN Haldol
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist identified and reported the absence of a 14-day stop date for a PRN Haldol prescription for a resident, which is a requirement according to the facility's policies and procedures. The resident, who had diagnoses including dementia, anxiety, cerebrovascular accident, and major depression, was receiving antianxiety, antipsychotic, and antidepressant medications. The resident's care plan included monitoring for physical aggression and administering medications as ordered. However, the physician's order for Haldol, an antipsychotic medication, lacked a stop date, and the Consultant Pharmacist's monthly reviews did not identify or report this omission. The resident's medication administration records showed that the PRN Haldol was administered on several occasions over two months. Despite the facility's policy requiring the Consultant Pharmacist to review medication regimens and report findings, the reviews conducted from May to August did not document the missing stop date for the Haldol prescription. This oversight was confirmed by an Administrative Nurse, who verified that the Consultant Pharmacist had not notified her of the need for a stop date, placing the resident at risk for unnecessary psychotropic medications.
Failure to Implement 14-Day Stop Date for PRN Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident's as-needed (PRN) antipsychotic medication, Haldol, had a required 14-day stop date. This oversight was identified during a review of the resident's electronic medical record, which showed that the medication was prescribed without a stop date. The resident, who had diagnoses including dementia, anxiety, cerebrovascular accident, and major depression, was receiving antianxiety, antipsychotic, and antidepressant medications. The care plan for the resident included monitoring for physical aggression and administering medications as ordered, but the PRN order for Haldol lacked the necessary stop date. The medication administration records indicated that the resident received the PRN Haldol on multiple occasions over two months. During an interview, the administrative nurse confirmed that the Haldol order did not have a stop date and noted that the consultant pharmacist had not notified her of this omission. The facility's policy on monitoring antipsychotics stated that such medications should only be used when medically necessary, with efforts to minimize unwanted side effects. The absence of a stop date for the PRN antipsychotic medication placed the resident at risk for unnecessary medication use and related complications.
Medication Administration Error with Extended-Release Medication
Penalty
Summary
The facility failed to ensure that a resident remained free from significant medication errors during medication administration. The resident, who had a diagnosis of neoplasm of the esophagus, GERD, hypertension, and diabetes mellitus, was receiving hospice services and required extensive assistance with activities of daily living. The resident's physician had ordered Wellbutrin XL, an extended-release medication, to be administered via a feeding tube for anxiety and depression. However, during a medication pass, a licensed nurse crushed the Wellbutrin XL tablet, removed its coating, and administered it through the resident's gastrostomy tube, contrary to the medication's administration guidelines. The nurse acknowledged having concerns about crushing the extended-release medication and had communicated this to hospice, but the order had not been changed. The facility's medication administration policy clearly stated that long-acting or enteric-coated dosage forms should not be crushed unless there is a specific physician order. The administrative nurse confirmed that the extended-release medication should not have been crushed and indicated that the physician would be contacted to change the medication form. This oversight placed the resident at risk for adverse reactions from the medication.
Failure to Prepare Pureed Diets Correctly
Penalty
Summary
The facility failed to correctly prepare pureed diets for three residents who required modified textured food, which compromised both the nutritive value and palatability of their meals. During an observation, Dietary Staff (DS) BB was seen preparing pureed diets without following a specific recipe. DS BB blended chicken fried steak with beef base, water, and bread to a thin consistency, and then pureed cabbage with vegetable base, water, and bread. Additionally, DS BB attempted to puree a chocolate and vanilla marble birthday cake with milk, resulting in a runny liquid that required thickener to achieve the correct texture. DS BB admitted to not following a pureed recipe and later found a recipe book in the kitchen with the correct amounts needed for the appropriate pureed texture. The facility's policy on texture and consistency-modified diets, dated 2017, stated that such diets should be individualized and prepared according to professional standards, with input from a speech-language pathologist, physician, and registered dietician nutritionist. The failure to adhere to these standards placed the affected residents at risk for impaired nutrition and decreased quality of life.
Failure to Coordinate Hospice Care for Residents
Penalty
Summary
The facility failed to ensure a coordinated plan of care for two residents receiving hospice services, which placed them at risk for inappropriate end-of-life care. Resident 19, diagnosed with esophageal cancer, GERD, hypertension, and diabetes, was cognitively intact and required extensive assistance with activities of daily living. Although the care plan noted the resident's need for hospice services due to a terminal prognosis, it lacked specific instructions on the services provided by hospice, including supplies, medical equipment, medications, and contact information for the hospice provider. The facility had a hospice care plan in a communication book, but it did not detail the care provided. Resident 29, with diagnoses of COPD and CHF, was mildly cognitively impaired and dependent on staff for most activities of daily living. The care plan documented the resident's mood issues related to end-stage COPD and CHF and the receipt of hospice services. However, it did not include interventions related to the equipment, supplies, medications provided, or the frequency of hospice visits. The hospice agreement indicated that a hospice care plan should be developed in cooperation with the facility's interdisciplinary care team, but this coordination was lacking. The facility's policy on the coordination of hospice services required a written agreement with hospice providers specifying the care and services to be provided and the process for communication. The policy also mandated that the facility and hospice provider coordinate a plan of care to meet the resident's needs and goals, with input from the resident's attending physician and representative. Despite these requirements, the facility failed to coordinate care between the facility and the hospice provider for both residents, leading to a deficiency in providing appropriate end-of-life care.
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All 10 risk areas, ranked with evidence
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Illustrative
What surveyors actually found near you
We read the 41 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chapman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Enterprise Estates Nuring Center | 7.5 mi | ★★★★★ | 20 | 0 |
| Tallgrass Healthcare Campus | 9.2 mi | ★★★★★ | 8 | 1 |
| Memorial Hospital Ltcu (village Manor) | 10.7 mi | ★★★★★ | 0 | 0 |
| Wakefield Care And Rehab | 16.3 mi | ★★★★★ | 13 | 0 |
| Legacy At Herington | 21.1 mi | ★★★★★ | 0 | 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.