Chapel View Health Care Center

Inspectors wroteBased on interview and document review, the facility failed to follow practitioner orders for 1 of 3 residents (R3) reviewed for respiratory care when R3 was sent to an off-site appointment without oxygen, resulting in a change in her condition requiring hospitalization. The noncompliance that began on 1/27/26 was corrected prior to the start of survey when the facility implemented a corrective action plan on 1/27/26. This is issued in past noncompliance.

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain resident equipment in a clean and sanitary manner for 1 of 1 resident (R4) whose wheelchair was soiled. In addition, the facility failed to maintain resident equipment cleanliness of intravenous (IV) poles for 2 of 4 residents (R40 and R98) reviewed for tube feeding.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure results of complaint investigations were available for review. This had the potential to affect all 83 residents residing in the facility, as well as family, visitors, and staff.

Inspectors wroteBased on observation, interview, and document review the facility failed to implement infection control strategies for respiratory protection to mitigate the risk and spread of Influenza A. As a result, the facility developed an outbreak where 13 residents (R1, R2, R3, R4, R5, R6, R7, R9, R13, R8, R10, R11 and R12) tested positive for Influenza A. Five residents (R1, R2, R5, R10 and R15) were sent to ED and admitted to hospital, These practices resulted in an immediate jeopardy (IJ) due to the likelihood of spread to the remaining 80 residents in the facility. The IJ began on 3/31/25, when the facility failed to implement ongoing monitoring, screening of residents with respiratory symptoms and implement transmission-based precautions and was identified on 4/18/25. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and appropriately monitor 2 of 3 residents (R5, R13) with acute illnesses including but not limited to influenza that resulted in hospitalization reviewed for change of condition.

Inspectors wroteBased on interview and document review the facility failed to ensure a system to ensure physician orders were accurately transcribed to prevent and/or mitigate risk of medication errors for 1 of 2 residents (R17) reviewed for medication errors. The facility's failures resulted in R17 received ibuprofen 66 times not in accordance with physician orders.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident was free from a significant medication error for 1 of 3 residents (R15) reviewed for medication errors.

Inspectors wroteBased on interview and document review, the facility failed to ensure physician orders for laboratory studies had been obtained in a timely manner for 3 of 3 residents (R5, R13, R15) who had physician ordered labs.

Inspectors wroteBased on interview and document review, the facility failed to promptly notify the ordering physician of an abnormal laboratory result for 1 of 3 residents (R13) who had laboratory orders.

Inspectors wroteBased on interview and document review, the facility failed to maintain a complete, accurately documented, and readily accessible medical record in accordance with accepted professional standards and practices for 1 of 1 resident (R5) reviewed for documentation.

Inspectors wroteBased on observation, interview, and document review, the facility failed to appropriately complete a thorough self administration assessment on 3 of 4 (R2, R3 and R4) sampled residents (who preferred not to administer their own medication) by ensuring residents who were left while the administration was occurring unattended, were found competent to leave their masks and/on or turn off the nebulizer appropriately when finished.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and discuss risks and benefits prior to installation of grab bars for 1 of 1 residents (R194) observed to have grab bars affixed to their bed.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed and appropriate personal protective equipment (PPE) was worn as required during high contact care for 2 of 3 residents (R193, R9) who required EBP and were reviewed for infection control.

Inspectors wroteBased on interview and record review, the facility failed identify the preference for health care directives for seven of ten residents (R1, R2, R3, R4, R6, R7, and R10) reviewed for advanced directives.

Inspectors wroteBased on interview and record review, the facility could not ensure staff were properly trained in basic life support (BLS) including cardiopulmonary resuscitation (CPR) to provide BLS/CPR to residents requiring such care for 18 of 62 licensed staff records registered nurse(RN)-A, RN-B, RN-C, RN-D, RN-E, RN-F, RN-G, RN-H, RN-L, licensed practical nurse (LPN)-A, LPN-B, LPN-C, LPN-D, LPN-E, LPN-F, LPN-G, LPN-H, and LPN-I) when reviewed for BLS/CPR training. The facility contacted licensed staff for proof of BLS/CPR Certification and obtained five more staff BLS/CPR certifications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident bathing preferences were honored for 1 of 2 residents (R3) who voiced concerns about bathing routines.

Inspectors wroteBased on interview, observation, and document review, the facility failed to revise a comprehensive care plan for 1 of 3 residents reviewed (R3) for services provided per plan of care.

Inspectors wroteBased on interview and document review, the facility failed to ensure adequate supply and administration of ordered medications for 1 of 1 resident (R1) reviewed for pharmacy services.

Inspectors wroteINFECTIOUS DISEASE SURVEILLANCE Based on observation, interview, and document review, the facility failed to implement an ongoing surveillance program for infectious disease tracking of new admissions that could affect all 90 residents and all staff at the facility, ensured hand hygiene and infection control was completed for 2 of 3 resident (R27 & R46) observed for incontinent cares and hand hygiene was completed during catheter cares to minimal risk of infection for 1of 1 residents (R27) reviewed for infection control practices. During an interview on 10/4/23 at 12:33 p.m., the facility infection preventionist (IP) stated the facility conducts infection surveillance for tracking and trending infections via spreadsheets. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure the required Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), was not provided to 1 of 3 residents (R111) who continued to reside in the facility upon termination of Medicare A benefits.

Inspectors wroteBased on interview and document review the facility failed to ensure a level I Pre-admission Screening and Resident Review (PASRR) level I was completed and accurate prior to admission to the facility for 2 of 3 residents (R2, R22) reviewed for pre-admission screening (PAS).

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide oral care for 1 of 1 residents (R14) reviewed for activities of daily living for dependant residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper catheter care and maintenance to reduce the risk of urinary tract infections (UTIs) for 2 of 2 (R27, R75) residents reviewed for catheters.

Inspectors wroteBased on observation, interview, and document review, the facility failed to administer oxygen in accordance with the provider orders for 1 of 1 residents (R14) reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess the resident for risk of entrapment, review risks and benefits of bed rails with the resident or their representative, and obtain informed consent for 1 of 1 residents (R21) reviewed for bilaterial grab bars on their bed.

Inspectors wroteBased on interview and document review, the facility delayed the necessary care and treatment to manage symptoms of pain, anxiety, and agitation for 1 of 3 residents (R2) reviewed for quality of care. R2 was restless, yelling out for help, and not provided the prescribed medications to alleviate discomfort. R2's care plan dated 7/14/23, indicated R2 required staff to monitor her degenerative joint disease (inflammation and joint damage) and if the condition worsened to update her medical providers for additional medication. R2's care plan dated 7/17/23, indicated she was alert, oriented, and able to make her needs known. The planned intervention was to update her medical provider if she developed worsening symptoms not resolved by the current treatment plan. [...]