Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 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.
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.
A resident fell and sustained a fracture when the shower chair wheels were not locked upon arrival at the shower room. The facility's P&P required locking brakes to prevent falls, but this intervention was not included in the resident's care plan. The incident occurred due to the CNA's failure to lock the shower chair brakes, resulting in the resident falling and sustaining a comminuted fracture of the tibial plateau.
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.
Failure to Lock Shower Chair Brakes Leads to Resident Fall
Penalty
Summary
The facility failed to provide the necessary care and services to prevent a fall incident for a resident. The resident's shower chair wheels were not locked when arriving at the shower room. As the resident removed his cover and leaned forward, the shower chair moved and tilted forward, causing the resident to fall on his left knee and sustain a fracture. The facility's policies and procedures (P&P) for fall risk and prevention of injury, as well as the Falling Start Program, both include locking the brakes on beds, gurneys, or wheelchairs to prevent falls. However, the resident's care plan did not include this intervention, leading to the incident. The resident was readmitted to the facility with diagnoses of paraplegia and had a history of being at high risk for falls due to various factors including impaired mobility and balance problems. The resident's quarterly MDS assessment indicated that he was dependent on chair/bed-to-chair transfer and tub/shower transfers. The incident occurred when the CNA failed to lock the shower chair brakes, resulting in the resident falling and sustaining a comminuted fracture of the tibial plateau. Interviews with the resident, CNA, and ADON confirmed that the shower chair brakes were not locked at the time of the fall.
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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 | — | 3 | 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 | — | 1 | 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 August 2026) and official state health department websites.