Chapel View Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Apr 24, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Aug 19, 2022

  Based on interview and record review, the facility failed to provide adequate communication and monitoring of staff for safe transfers to 1 of 12 residents (R)-1 reviewed who required the use of assistive devices for transfers. The facilities failure resulted in harm when R1 suffered a fractured clavicle as a result of falling from a mechanical lift. The lift sling used was the incorrect size and R1 was assisted with only one staff member. The immediate jeopardy began on 8/15/22, when the facility failed to use the correct size sling and use the assistance of two staff members for a mechanical lift transfer and R1 fell to the floor fracturing her clavicle. The Administrator and the director of nursing (DON) were notified of the immediate jeopardy at 3:57 p.m. on 8/19/22. […]

• Actual harm, isolatedF695Apr 16, 2026

  Based 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. Findings include:R3's quarterly Minimum Data Set MDS), dated [DATE], indicated she had diagnoses of morbid obesity with alveolar hypoventilation (a condition where breathing is shallow or slow), hypertensive kidney disease, lymphedema (tissue swelling caused by fluid that is usually drained by the body's lymphatic system), atrial… […]

• No harm, potential for more than minimal, widespreadF880Oct 5, 2023

  INFECTIOUS 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. […]

• No harm, potential for more than minimal, widespreadF812Apr 7, 2022

  Based on observation, interview and document review, the facility failed to have a method to consistently monitor dish machine temperatures to ensure proper sanitation of dishware. This had the potential for food-borne illness and could affect 92 of 93 residents who recieved meals prepared and served by the facility. Findings include: Review of the Food Code 2017 included, Adequate cleaning and sanitization of dishes and utensils using a ware-washing machine is directly dependent on the exposure time during the wash, rinse, and sanitizing cycles. Failure to meet manufacturer and Code requirements for cycle times could result in failure to clean and sanitize. For example, high temperature machines depend on the buildup of heat on the surface of dishes to accomplish sanitization. […]