Inspection Reports for Chapman Valley Manor

An offsite revisit survey was conducted on 10/18/24 to verify correction of all previous deficiencies cited on 09/18/24.

All deficiencies have been corrected as of the compliance date of 09/24/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited in a prior survey conducted on 2024-09-18. The plan outlines corrective actions to address multiple deficiencies related to forms, medication management, dietary services, hospice coordination, and water management.

The facility identified several deficiencies including incorrect use of CMS forms, improper fentanyl patch management, psychotropic medication renewal issues, dietary preparation concerns, hospice care coordination, and water management risks. The facility has implemented audits, in-services, and monitoring systems to ensure compliance and prevent recurrence.

The inspection was a Health Resurvey to assess compliance with Medicare/Medicaid regulations, including review of Medicaid/Medicare coverage notices, nursing staff competency, medication regimen review, psychotropic medication use, medication errors, food preparation, hospice services coordination, and infection control.

The facility was found deficient in multiple areas including failure to provide correct Medicare ABN forms, inadequate nursing staff competency in medication disposal, failure of consultant pharmacist to identify medication irregularities, improper use of psychotropic medications without required stop dates, medication administration errors crushing extended-release medications, improper preparation of pureed diets, lack of coordinated hospice care plans, and failure to implement a water management program to mitigate Legionella risk.

An offsite revisit survey was conducted on 02/16/24 to verify correction of all previous deficiencies cited on 01/17/24.

All deficiencies have been corrected as of the compliance date of 01/24/24, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was conducted as an abbreviated survey combined with complaint investigations KS00185063, KS00184799, and KS00183046.

The facility was found deficient in ensuring a safe environment to prevent resident falls, resulting in a resident sustaining a broken nasal bone from a fall due to failure to follow fall interventions. Additionally, a significant medication error occurred when the wrong medication was administered to a resident, placing the resident at risk for health complications.

The visit included complaint investigations KS00185063, KS00184799, and KS00183046 as stated in the initial comments.

This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited in a prior inspection related to medication errors.

The facility identified a medication error involving resident R 2, conducted audits, educated staff, and implemented monitoring and competency testing to ensure compliance and prevent recurrence.

An offsite revisit survey was conducted on 04/14/23 to verify correction of all previous deficiencies cited on 03/07/23.

All deficiencies cited in the previous inspection were corrected as of 03/27/23, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited during a prior inspection.

The facility identified multiple deficiencies related to resident care plans, estimated cost notifications, discharge planning, gastrostomy tube care, monitoring of antipsychotics, and infection control. Corrective actions include audits, staff in-service training, policy development, and ongoing monitoring with Quality Assurance/Performance Improvement (QAPI) oversight.

The inspection was a health resurvey conducted at the facility to assess compliance with Medicare and Medicaid regulations.

The facility was found deficient in multiple areas including failure to provide Medicaid beneficiary liability notices with estimated costs, failure to develop comprehensive care plans especially for gastrostomy tube use, failure to develop discharge summaries, inadequate monitoring of tube feeding intake, inappropriate use of psychotropic medications without proper indications, and failure to follow infection prevention and control practices including hand hygiene.

An offsite revisit survey was conducted on 06/13/22 for all previous deficiencies cited on 05/10/22 to verify correction of prior deficiencies.

All deficiencies cited in the previous inspection have been corrected as of the compliance date of 05/19/22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The plan of correction addresses deficiencies cited in a prior survey related to elopement risk assessment accuracy and resident safety measures.

The facility failed to ensure the elopement risk assessment was completed accurately, placing a resident at risk. Corrective actions included medication review, re-education of staff on elopement risk assessments, repair of a door alarm, and implementation of daily safety checks.

The inspection was conducted as a result of a complaint investigation KS00171507 regarding the facility's nursing staff competencies and resident safety.

The facility failed to ensure the Elopement Risk Assessment was completed accurately and/or updated for a resident at risk for elopement, which placed the resident at risk for injuries related to accidents and hazards. The resident exited the building unsupervised, resulting in injury.

The complaint investigation KS00171507 focused on nursing staff competency and resident safety related to elopement risk. The investigation found that the facility inaccurately assessed a resident's elopement risk, leading to an incident where the resident left the facility unsupervised and was injured.

An offsite revisit survey was conducted on 09/30/21 to verify correction of all previous deficiencies cited on 09/02/21.

All deficiencies cited in the previous inspection were corrected as of the compliance date of 09/14/21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited during a prior inspection.

The facility failed to investigate skin tears, update care plans for safe transfers, follow accident procedures, identify and report lack of blood glucose monitoring, and ensure medication availability and monitoring for adverse reactions. The plan outlines corrective actions including staff re-education, care plan updates, monitoring, and policy revisions.

The inspection was a health resurvey conducted to investigate allegations of abuse, neglect, and compliance with care plan and medication regulations.

The facility failed to investigate skin tears of Resident 15, failed to update and revise the care plan for Resident 15 after a change in condition, and failed to provide adequate supervision to prevent accidents resulting in skin tears. Additionally, the facility's consultant pharmacist failed to identify and report lack of blood glucose monitoring and insulin unavailability for Resident 16, placing the resident at risk for hypoglycemia/hyperglycemia.

The visit was complaint-related due to allegations of abuse, neglect, exploitation, or mistreatment. The facility failed to investigate injuries of unknown origin and did not complete required incident reports or investigations.

A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

A Targeted Infection Control Survey/COVID-19 Focused Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 07/07/2020 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.

The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2019-07-02.

All deficiencies cited in the prior inspection were corrected as of the compliance date 2019-07-31, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The visit was a Health Resurvey conducted to assess compliance with regulatory requirements following prior findings.

The facility failed to discard expired medications in the emergency medication kit and failed to store food in a safe and sanitary manner in the activity refrigerator/freezer, placing residents at risk for ineffective medication use and foodborne illness.

An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 09/24/2018.

All deficiencies have been corrected as of the compliance date of 10/22/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.

The inspection was a Health Resurvey to assess compliance with Medicare/Medicaid regulations, including review of Medicaid/Medicare coverage notices, nutrition/hydration status, drug regimen reviews, food safety, and environmental conditions.

The facility failed to provide Advanced Beneficiary Notices to residents discharged from skilled services, failed to adequately monitor and provide hydration to a resident, failed to identify and act on medication documentation irregularities, failed to maintain sanitary food storage and preparation conditions, and failed to maintain a clean and safe environment in resident halls.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be a 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 10/22/2018.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

All previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date, with no uncorrected deficiencies noted.

The inspection was conducted as a Health Resurvey and Complaint Investigation #113172 to evaluate compliance with resident rights, safety, medication administration, food safety, infection control, and other regulatory requirements.

The facility was found deficient in multiple areas including failure to ensure an effective system to respond to residents' missing personal property, failure to secure chemicals safely, failure to administer medications as ordered, failure to dispose of expired food, failure of the pharmacy consultant to identify medication irregularities, and failure to follow infection control precautions by housekeeping staff.

The inspection included a complaint investigation (#113172) related to missing personal property and other concerns.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective March 29, 2017.

This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited during the inspection conducted on 2017-03-20.

The plan addresses multiple deficiencies including improper disposal of resident property, unsecured chemicals, medication administration errors, expired food disposal, monthly drug regimen reviews, and infection control precautions to prevent transmission of infection.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be at 'E' level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. A plan of correction was required and remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.

This post-certification revisit was conducted to verify that previously identified deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

The report documents that corrections were completed for deficiencies identified under regulations 483.10(e), 483.75(l)(4), 483.15(e)(2), and 483.20(d), 483.20(k)(1) as of 08/31/2015.

A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.

The survey found isolated 'D' level deficiencies that constitute no actual harm but have the potential for more than minimal harm without immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective August 31, 2015.

The inspection was a Health Resurvey to assess compliance with regulatory requirements related to resident privacy, notification of room changes, and development of comprehensive care plans.

The facility was found deficient in maintaining resident privacy during toileting, failing to notify and document room changes for residents, and not developing comprehensive care plans for two residents, including lack of care planning for behavioral medications and individualized activities.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.

The plan addresses deficiencies related to ensuring privacy for dependent residents, documenting notification of room changes in medical records, and having comprehensive care plans for all residents including behavior sheets and individualized activity plans.

A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.

The survey found the most serious deficiencies to be 'F' level deficiencies, widespread, with no harm but with potential for more than minimal harm that is not immediate jeopardy.

This post-certification revisit was conducted to verify that deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.

The report shows that all previously cited deficiencies identified by regulation numbers F0241, F0279, F0281, and F0441 were corrected as of the revisit date.

The inspection was a Health Resurvey to assess compliance with previously cited deficiencies and overall regulatory requirements.

The facility was found deficient in promoting dignity and respect by leaving incontinent pads on recliners not in use, failing to develop a comprehensive care plan for a resident using bilateral side rails, lack of follow-up assessments after administration of as needed medications, and inadequate infection control practices including improper cleaning of resident rooms and failure to disinfect the glucometer between uses.

This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.

All previously cited deficiencies identified by their regulation numbers were corrected as of the revisit date of 05/13/2013.

This document is a Plan of Correction submitted by Chapman Valley Manor in response to deficiencies cited in a prior inspection report.

The plan outlines corrective actions for multiple deficiencies related to physician notification, resident dignity during care, skin assessments, medication management, infection control, and sanitary environment practices.

Routine health facility survey to assess compliance with federal regulations and standards for nursing home care.

The facility was found deficient in multiple areas including failure to notify a resident's physician of a change in skin condition, failure to promote dignity during meals, inadequate monitoring of blood pressure for a resident on medication, improper medication labeling and administration, failure to report drug irregularities, and inadequate infection control practices including improper disinfection of glucometer and improper storage of oxygen tubing.

This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection, specifically addressing maintenance of the call light system.

The facility identified deficiencies related to the call light system and has planned corrective actions including monthly maintenance checks and policy updates to ensure proper functioning.

The inspection was a health facility resurvey to assess compliance with regulatory requirements, specifically focusing on the functionality of the resident call system.

The facility failed to ensure the nurse call system worked effectively and efficiently on 2 of the 3 halls. Observations revealed that several resident bedroom and bathroom call lights failed to signal at the nurse's station and on handheld pagers. Maintenance staff confirmed no routine checks were performed on the call light system.

This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.

The plan addresses multiple deficiencies including improper use of incontinent pads, lack of comprehensive care plans for residents using bilateral side rails, inadequate follow-up on PRN narcotic efficacy by licensed nurses, and insufficient sanitation practices related to resident rooms and glucometer disinfection.

This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.

The facility had deficiencies related to expired medicines in the emergency medication kit and cleanliness issues with refrigerators. The Plan of Correction outlines actions taken to replace expired medications, implement monthly checks, and clean and monitor refrigerators to sustain compliance.

This document is a Plan of Correction submitted by the facility to address deficiencies cited in a prior inspection report.

The Plan of Correction outlines specific corrective actions for multiple deficiencies including skilled nursing discharge procedures, staff competency and education, medication order reviews, kitchen sanitation, and facility maintenance issues.