Chambers Pointe Health Care Center

In the surveyor’s words

From the most serious findings on record at Chambers Pointe Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 4, 2025

  Based on a review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of four residents reviewed (Resident 2) resulting in a fall with a fracture.Findings include:The facility's abuse policy, dated February 20, 2025, revealed that the facility will not tolerate abuse and that facility staff must immediately report all such allegations to the Nursing Home Administrator/Abuse Coordinator.The facility's abuse policy, dated February 20, 2025,revealed that the facility provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of… […]

• Actual harm, isolatedF656Nov 29, 2023

  Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of residents for two of three residents reviewed (Residents 1, 3), resulting in a fall with a head injury. Findings include: The facility's policy regarding assistive devices and equipment, dated September 14, 2023, indicated that devices and equipment that assisted with resident mobility, safety and independence were provided for residents, which included wheelchairs, walkers and canes. […]

• Actual harm, isolatedF689Nov 29, 2023

  Based on review of policies, investigative reports, and clinical records, as well as staff interviews, it was determined that the facility failed to take precautions to prevent injury to a resident caused by not having foot rests on his wheelchair during transport for one of three residents reviewed (Resident 1), resulting in a fall with a head injury. Findings include: The facility's policy regarding assistive devices and equipment, dated September 14, 2023, indicated that devices and equipment that assisted with resident mobility, safety and independence were provided for residents, which included wheelchairs, walkers and canes. […]

• Actual harm, isolatedF600Jun 5, 2023

  Based on review of facility policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of seven residents reviewed (Resident 2), resulting in harm to Resident 2 due to a fall that resulted in fractures. Findings include: The facility's policy regarding abuse and neglect, dated April 13, 2023, indicated that the facility was to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. […]

• Actual harm, isolatedF689Jun 5, 2023

  Based on review of facility policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to provide care using adequate assistance devices to prevent accidents for one of seven residents reviewed (Resident 2), resulting in the resident experiencing a fall and fracture. Findings include: The facility's policy regarding gait belt use, dated April 13, 2023, indicated that gait belts were to be used with residents that could not independently ambulate or transfer for the purpose of safety. Each nursing department employee was to be given a gait belt during orientation. All employees would receive education on the proper use of the gait belt during orientation and annually. […]