Chaparral House

In the surveyor’s words

From the most serious findings on record at Chaparral House, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF628Jul 23, 2026

  Based 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… […]

• No harm, potential for more than minimal, patternF550Sep 27, 2024

  Based 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. Findings: During a dining observation on 9/23/24 at 12:53 p.m., in the dining room, Residents 21, 22, and 29 were being assisted by staff during lunch. Registered Nurse (RN) 3 asked Resident 29 if she wanted her bread roll to which Resident 29 replied, yes. RN 3 did not have gloves available to feed the bread roll and RN 3 offered water to Resident 29 instead. […]

• No harm, potential for more than minimal, patternF758Sep 27, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF803Sep 27, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF812Sep 27, 2024

  Based 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). Findings: 1. […]