Chaplinwood Nursing Home

Based on observations, staff interviews, and review of the facility's policy titled Labeling and Dating, the facility failed to ensure that expired foods were not available for use. This deficient practice had the potential to place 85 residents who received an oral diet from the kitchen at risk of foodborne illness. Findings include: Review of the facility's policy titled Labeling and Dating, dated April 2024, included, Upon receipt, all items should be inspected and marked with the date it was received into your facility and the date it should be discarded or expired. If the item has a use-by or discard date already printed on it, then you may use this date. During a tour of the kitchen on 6/2/2025 at 9:30 am with the Dietary Manager (DM), the following items were identified: Two jars of grape jelly with an expiration date of 9/25/2024. Two bags of pecan pieces with an expiration date of 4/18/2025. Two bags of chunk light tuna with an expiration date of 5/16/2025. One box of hot cocoa mix with an expiration date of 11/5/2024. Four bags of raspberry gelatin with an expiration date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, the facility failed to maintain clean Packaged Terminal Air Conditioner (PTAC) filters or units for two of 12 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on the 300 Hall. The deficient practice had the potential to place residents residing in the rooms at risk of living in an unsanitary living environment, and a potential for a diminished quality of life. Findings include: Observations on 6/2/2025 at 11:52 am and 6/4/2025 at 9:15 am in room R304 revealed that the PTAC unit filter displayed a thick gray substance. Observations on 6/2/2025 at 11:48 am and 6/4/2025 at 9:15 am in room R303 revealed that the PTAC unit had black substance with debris inside the unit. During a concurrent observation and interview on 6/4/2025 at 9:23 am, the Maintenance Director confirmed that the PTAC unit filter in room [ROOM NUMBER] had a thick gray substance, and the PTAC unit in room [ROOM NUMBER] had a black and gray substance inside the unit. The Maintenance Director stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and resident interviews, record review, and review of the facility policy titled A Comprehensive Patients' Rights Program, the facility failed to ensure one of 33 sampled residents (R) (R82) choices of care were honored. This deficient practice had the potential to place R82 at risk of unmet needs and a diminished quality of life. Findings include: Review of the facility policy titled A Comprehensive Patients' Rights Program, reviewed date 12/27/2024, revealed the Intent section stated, This intent of this center to have an effective Patients' Rights program that recognizes that meaningful support of Patient's Rights. We believe that all staff should understand the importance of treating patients with care and respect, and honoring patients' rights to make personal choices. We also believe that such a program should include patient, family, and all Associates of the nursing home. Review of R82's electronic medical record (EMR) revealed R82 was admitted on [DATE] with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and record review, the facility failed to ensure a respiratory therapy mask was properly stored in a manner to prevent contamination for one of 18 residents (R) (R40) receiving respiratory services. This deficient practice had the potential to increase the risks of spreading microorganisms and place R40 at risk for respiratory infections and a diminished quality of life. Findings include: Review of R40's electronic medical record (EMR) revealed diagnoses including, but not limited to, heart failure, unspecified, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow). Review of R40's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section GG (Functional Abilities and Goals) documented R40 was dependent for activities of daily living (ADLs). Section O (Special Treatments, Procedures, and Programs) documented that R40 received oxygen therapy while a resident. Review of R40's Care Plan revealed a care area dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, documents, and review of facility policy titled Cleaning and Sanitizing, Storage, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner to prevent cross contamination as evidenced by failing to label and date food items, failing to remove expired items from the cooler, failed to ensure all equipment was not in disrepair, and failing to ensure cleanliness of kitchen and dry food storage shelves for 78 of 81 residents receiving an oral diet. Findings include: Policy: Storage - review 12/30/2022 - Intent It is the intent of this center to store food in a manner that maintains quality and safety. Policy: Cleaning and Sanitizing - review 12/30/2022 - Guideline - Cleaning schedules should be implemented and maintained for all areas of the kitchen. Review of the Quality Assurance Event dated 6/27/2023 identified an issue with compliance in the kitchen which included labeling, dating, and cleaning. Staff not taking ownership of tasks was identified as the root cause of the problem and staff education was provided. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to ensure a homelike environment as evidenced by slow draining sinks, missing paint from walls and bathrooms, holes in walls, dust buildup in vents, loose sink, brown staining in ceiling, staining on floors, stained privacy curtain, rust on base of overbed table, and missing privacy curtain on one (200 hall) of four halls. Findings include: Observations on 9/15/2023 revealed the following: 1. At 9:26 am in the bathroom of room [ROOM NUMBER] there was a loose sink, panel behind toilet loose with hole showing, dust buildup in vents, and stains in ceiling upon walking in the room. 2. At 9:39 am in room [ROOM NUMBER] behind bed A there was a hole in the wall, staining on privacy curtain for Bed B, and staining on floor at head of bed B. 3. At 11:33 am in room [ROOM NUMBER] there was no privacy curtain for bed A, missing paint from walls in bathroom, dust buildup in vent in bathroom, and buildup on floor at head of bed A. 4. At 12:12 pm in room [ROOM NUMBER]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and review of facility policy titled Abuse Prohibition the facility failed to ensure two residents (R57 and R41) of 81 residents were free from verbal abuse by staff. Findings include: Review of policy titled Abuse Prohibition, with a review date of 12/20/2022 revealed the following: Intent: It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse or misappropriation of any patient and/or their property. The procedures herein established standards of practice for protection of patients and for identification and prevention of abuse. 1. Review of the electronic medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, and review of the facility policy 'Enteral Nutrition Management', the facility failed to provide enteral nutrition and hydration according to physician orders for two of four residents (R) (R65 and R8) receiving tube feeding in the facility. Findings include: 1. Review of the facility policy 'Enteral Nutrition Management' with a review date of 12/30/2022 revealed it is the intent of this center to provide nutritionally complete enteral or parenteral feedings, as ordered by the physician, for the nourishment of patients who are unable to meet estimated nutritional needs orally. Review of the 7/6/2023 Quarterly Minimum Data Set (MDS) Assessment for R65 revealed a BIMS score of 99 indicating severely impaired cognition, no behaviors, is totally dependent upon staff for all Activities of Daily Living (ADL) with two-person physical assist, has active diagnoses of hyponatremia, anxiety, Diabetes Mellitus (DM), is receiving tube feeding, and receives an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and facility policies review titled Preventive Maintenance Schedules, and Physical Plant Maintenance, the facility failed ensure that the facility was maintained in a clean, safe, and sanitary condition on two of three halls observed. Specifically, the facility failed to ensure that used bath basin were properly labeled and stored in five residents' rooms on 300-Hall (room [ROOM NUMBER], 306, 308, 310, and 312), and one resident room on 200-Hall (room [ROOM NUMBER]). The facility also failed to ensure residents rooms were in good repair for rooms [ROOM NUMBERS] which had water noted on the bathroom floor from a water leak that was not addressed. Findings include: On 5/24/22 at 9:42 a.m. observation of room [ROOM NUMBER] bathroom revealed bath basin on back of toilet unlabeled with unlabeled urinal inside. On 5/25/22 at 8:56 a.m. second observation of room [ROOM NUMBER] bathroom revealed bath basin on back of toilet urinal hanging on towel rack unlabeled. On 5/24/22 at 9:45 a.m.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interview, the facility failed to ensure the medication error rate was less than five per cent (5%). A total number of 35 medication opportunities were observed, and there were three errors for two of four residents (R) (R#54) and (R#72) by two of three certified medication aides (CMA) observed giving medications, for an error rate of 8.57%. Findings include: On 5/25/22 at 7:07 a.m., Certified Medication Aide (CMA) FF was observed giving R#54 her morning medications. Observation revealed that medicines given included Aspirin 81 mg (milligrams) chewable 1 tablet, Cranberry Extract 450 mg 1 tablet, Loratadine 10 mg 1 tablet, Vitamin C 500 mg 1 tablet, Vitamin D3 25 mg 5 tablets, Aripiprazole 5 mg 1 tablet, Losartan Potassium 100 mg 1 tablet, Memantine HCL 10 mg 1 tablet, Metoprolol Succinate 50 mg 1 tablet, and Venlafaxine HCL 37.5 mg 1 tablet. After all of the resident's morning medications had been prepared, CMA FF counted the number of pills in the cup, and verified during interview that what she prepared was all of the medications…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and review of facility policy titled Transmission-Based Precautions (TBP), the facility failed to ensure proper disposal of contaminated Personal Protective Equipment (PPE), for one of two residents (R) (#24) on TBP. Specifically, the facility failed to ensure that biohazard container was available for staff use. Findings include: Review of the clinical record revealed R#24 was admitted to the facility on [DATE]. On 5/14/22, R#24 was discovered to have shingles and was started on Valacyclovir 1 gram daily for five days and placed on isolation. Observation on 5/25/22 at 9:56 a.m. revealed Certified Nursing Assistant (CNA) BB exiting R#24's room with used PPE in hand and placed it in soiled trash cart located on the hall. Continued observation on 5/25/22 at 10:06 a.m. revealed no biohazard container in residents' room. Interview with Director of Nursing (DON) on 5/25/22 at 10:08 a.m. confirmed that there was not a biohazard container in the resident's room. The expectation is that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.