Chaparral House

Inspectors wroteBased on interview and record review the facility failed to provide proper notice for discharge for four of four sampled residents (Resident 2, 3, 4, and 5) when:Resident 2 received a Notice of Proposed Transfer and Discharge (NPTD, a document given by the facility to the resident indicating an upcoming discharge from the current facility to another location) providing less than 30 days' notice. Resident 5 received a NPTD providing less than 30 days' notice. Resident 3 was not given a 30-day advance written NPTD by the facility. Resident 4 was not given a 30-day advance written NPTD by the facility. These failures could have resulted in Residents 2,5,4 and 3 in not having the opportunities to have an advocate inform them of their right to appeal and could have led to an inappropriate transfer or discharge.1. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure ongoing psychosocial monitoring was provided to Resident 1 after the resident reported a sexual abuse allegation (psychosocial monitoring is the ongoing process of tracking a resident's mental, emotional, and social well-being). This failure had the potential to delay the identification of changes in the resident's emotional or psychosocial well-being. Review of Resident 1's Face sheet (information containing contact details, brief medical history at-a-glance), indicated the resident was admitted to the facility on [DATE] with diagnoses that included depression (persistent feeling of sadness). Review of the nurse progress notes dated 6/24/26 at 5:37 p.m., indicated Resident 1 reported that she was touched inappropriately by a male Certified Nursing Assistant (CNA). [...]

Inspectors wroteBased on interview and record review, the facility failed to notify Resident 1 of her Medicaid 'share of cost' in a timely manner and did not explain it in a way the resident could easily understand (Medicaid is a government-funded health insurance. Medicaid 'share of cost' is the specific dollar amount the insured resident is required to pay out-of-pocket for medical bills each month before Medicaid kicks in to cover the rest of the charges). This deficient practice compromised Resident 1's ability to make an informed decision, potentially leading to financial hardship and psychosocial issues. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely reporting and thorough investigation of an allegation of misappropriation of resident property for one out of three sampled residents (Resident 1). Specifically, the facility did not notify law enforcement as required and document or maintain required lost-and-found logs. This failure resulted in the facility's inability to investigate the reported loss of $5,000, placing Resident 1 at risk for unreported financial exploitation. During a record review of facility's document titled, admission Record, printed 6/2/26, Resident 1 was initially admitted to the facility on [DATE] with multiple diagnoses including hyperlipidemia (high cholesterol in blood), and acute on chronic diastolic heart failure (a condition where the heart does not pump enough blood to meet the needs of the body). [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to maintain a safe, comfortable and homelike environment when Resident 1's bedside table had scratched marks on top and had chipped edges. This failure resulted in Resident 1 feeling angry. On 12/26/25 at 10:40 a.m., an unannounced visit was made at the facility to investigate a complaint allegation. During a phone interview on 12/26/25 at 2:03 p.m., Resident 1 stated when she was living at the facility, her bedside table had scratch marks on top and peeled edges. Further stated she felt angry about this. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors when Resident 1 received the medication Percocet instead of Norco (Percocet is the brand name for oxycodone/acetaminophen and Norco is the brand name for hydrocodone/acetaminophen for pain. Both medications are for pain but have different opioid ingredients. Opioids are very powerful type of drugs used for pain relief). This failure exposed Resident 1 to the risk of adverse medication effects and discomfort. During a review of Resident 1's Face Sheet, it indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included right femur fracture (broken bone in right thigh bone). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat three of three sampled residents (Resident 21, 22, and 29) with dignity and respect when Residents 21, 22, and 29, who needed full assistance with meals, were not offered or fed their bread rolls during lunch. This failure had the potential to affect Residents 21, 22 and 29's psychosocial well-being and nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic drugs (medications that can affect the mind, emotions, and behavior) for three of 38 sampled residents (Residents 8,7 and 10) when: 1. Resident 8 did not have the appropriate indications for the use of Seroquel (Seroquel is an antipsychotic medication; Antipsychotic medications are medications that are used to treat symptoms of psychotic mental disorder such as delusions, hallucinations, paranoia, or confused thoughts), 2. Resident 7 had no rationale for continued use of PRN Ativan beyond 14 days (PRN is short for pro re nata [a Latin phrase], meaning as needed, or as necessary; Ativan is a psychotropic medication used to treat anxiety; psychotropic medications are used to treat mental health disorders), and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu for the soft and bite-sized (foods that are soft, moist, and easy to swallow) and easy to chew diet (soft, tender foods that are easy to chew) for 12 out of 12 residents (Residents 13, 23, 8, 6, 190, 29, 7, 12, 34, 18, 15 and 22) when Residents 13, 23, 8, 6, 190, 29, 7, 12, 34, 18, 15 and 22 did not receive two ounces of gravy for lunch with their chicken on 9/23/24. This failure had the potential for Residents 13, 23, 8, 6, 190, 29, 7, 12, 34, 18, 15 and 22 to have problems chewing and swallowing the food when the established menu was not followed accordingly and had the potential for poor nutrition and to further compromise the medical status of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices when: 1. Can opener had red discoloration on the blade that pierced the can, 2. Under the stove and steam tray line, the floors had a build-up of food crumbs, trash, dust, and grime, 3. The oven had build-up of black grime inside, 4. Dry storage floors had build-up of food crumbs, trash, and dead ants, and 5. Diet Aide 1 (DA 1) did not wear a bear net during meal preparation and service. These failures had the potential to expose 38 medically compromised residents who received food from the kitchen to foodborne illness due to cross-contaminations (the transfer for harmful substances or disease-causing microorganisms to food).

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 8's Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care). PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting; and 3) receive the services they need in those settings.) completed when Resident 8 had diagnosis of brief psychotic disorder (mental disorder that can cause abnormal thinking and perception). [...]

Inspectors wroteBased on observation, interview, and record review, for two (Resident 10 and Resident 11) of thirteen sampled residents, the facility failed to implement its Care Plan, Comprehensive Person Centered policy and procedure when: 1. Facility did not develop care plan to address Resident 10's medical diagnoses of Major Depressive Disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life ) and Insomnia (persistent problems falling and staying asleep), and there was no care plan to address Resident 10's use of Amitriptyline and Trazadone (antidepressant medications, antidepressants are medications used to treat major depressive disorder, some anxiety disorders and chronic pain conditions), and 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident's (Resident 14) long toenails received podiatry (foot care) treatment services as ordered by the physician. This failure had the potential to place Resident 14 at risk for injury and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident 9) of two sampled residents received treatment services to address limitation in range of motion to right upper extremity when Resident 9 had contracture (a condition of shortening and hardening of muscles often leading to deformity and rigidity of joints) of right upper extremity and a resting splint (a device that supports and protects a broken bone or injured tissue) was not applied to right hand as ordered by the physician. This failure had the potential to cause Resident 9's decline in range of motion and risk of decreased muscle strength.

Inspectors wroteBased on interview and record review, the facility failed to have a written contract/agreement with Resident 189's outpatient dialysis provider (dialysis is the process of removing toxins from the kidneys and blood through a machine. The contract/agreement should include all aspects of how Resident 189's dialysis care and needs were to be managed by the dialysis provider outside of the facility). This failure had the potential to result in Resident 189's poor dialysis care management.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (Residents 15 and 21) of 38 sampled residents' call lights were within easy reach. This failure had the potential for the Resident 15 and Resident 21 to not to be able to use the call light when needing assistance.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure four (Residents 4, 28, 41 and 43) of five sampled residents were free from unnecessary drugs when; - Resident 4 was administered two antipsychotic medications, Risperdal and Zyprexa, without adequate clinical indication for use and monitoring for adverse side effects. Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior. - Resident 28 was administered Clozapine an antipsychotic and Sertraline an antidepressant without adequate monitoring for target behavior and adverse side effects. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure storage of food under sanitary conditions when: - Dietary staff's lunch bag was kept in the kitchen refrigerator. - One container of low-fat cottage cheese was opened and not labeled or dated - One bottle of chili garlic sauce open date 2/28/23 - One bottle salad cream opened 8/3/22 - One bottle spicy sauce opened 2/28/23 - 1/2 sliced apple in cup not labeled or dated - Two bottles of jam opened 3/6/23 These failures had the potential to result in food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policy and procedures to prevent abuse, neglect and exploitation of residents and misappropriation of resident property when: 1. Resident 31's statement that a nurse was Tearing [Resident 31] to pieces was not investigated and not reported. This failure had the potential to result in abuse by the same staff who continued to provide care to Resident 31. 2. Facility did not perform background checks for five of five employees. This failure had the potential for allowing potential employees who have been convicted of abuse, neglect and exploitation and misappropriation of resident property to care for the residents.

Inspectors wroteBased on interview and record review, the facility failed to implement their Abuse policy and procedure to investigate and report injuries of unknown origin for one (Resident 4) sampled resident. Resident 4's laceration to the left pinky toe was not investigated for the source of the injury and reported to the required agencies. This failure resulted in Resident 4 being transferred to the emergency room (ER) for sutures and had the potential to place residents at risk for mistreatment, neglect and /or abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of the residents when: 1. For Resident 99, Metformin (diabetic medication), a condition where blood sugar levels are too high) was not available for medication administration. 2. For Resident 149, Fluticasone propionate nasal suspension (for management of nasal symptoms of perennial nonallergic rhinitis in adults, rhinitis is inflammation that causes nasal congestion, runny nose, sneezing and itching) was not available for medication administration. [Reference:https://dailymed.nlm.nih.gov] These failures had the potential to result in an ineffective medication regimen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to be free of medication error rate of five percent or greater when three medication errors were observed out of 31 opportunities. The medication error rate was calculated as follows; three divided by 31, then multiplied by 100, which was equal to 10 percent. This failure had the potential to result in ineffective medication regimen for the affected residents (Residents 99 and Resident 149).

Inspectors wroteBased on interviews and record review, the facility failed to promptly follow-up on a denture evaluation and acquiring full dentures for one (Resident 8) sampled resident in a timely manner. This failure resulted in emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to coordinate care planning in collaboration with the resident, family and hospice care (provisions for the terminally ill) provider for one (Resident 41) sampled resident. This failure had the potential for residents to not receive person-centered care at the end-of-life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide six of 12 Residents (Resident 35, Resident 13, Resident 28, Resident 8, Resident 16, and Resident 9) with dignity and respect when they were not served their lunches at the same time as others seated at their dining table. For Resident 13, utensils were not provided in a timely manner. These failures had the potential to result in Resident 35, Resident 13, Resident 28, Resident 8, Resident 16, and Resident 9 having a decreased quality of life.

Inspectors wroteBased on observation,, interview and record review, the facility failed to ensure two (Resident 19 and Resident 5) of two sampled residents, who were dependent on staff for meals, were not assisted to eat in a timely manner. Resident 19 did not receive meal assistance for ten minutes and had interrupted meal assistance when offered, and Resident 5 did not receive assistance for 35 minutes. This deficient practice resulted in Resident 19 and Resident 5 receiving delayed meal assistance and had the potential for foods to be served cold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored properly when food items were left unlabeled and undated in the kitchen refrigerator, and the dishes and utensils were not cleaned under sanitary conditions when the high temperature dishwasher's final rinse did not reach 180 degrees Fahrenheit (F) according to the policy. These deficient practices placed the residents at risk for developing foodborne illness.