Chaplinwood Nursing Home

In the surveyor’s words

From the most serious findings on record at Chaplinwood Nursing Home, in the surveyor’s own words.

• Actual harm, isolatedF656Sep 17, 2023

  Based on observation, record review, staff interview, and review of the facility policy 'Patient's Plan of Care' the facility failed to follow the person-centered comprehensive care plan related to using a Hoyer lift for one resident (R) (R73) and related to receiving tube feedings as ordered for two residents (R65 and R8). Actual harm occurred on 7/10/2023 when R73 sustained a distal tibial fracture after being transferred by two Certified Nursing Aides without the use of a Hoyer lift. The sample size was 28. Findings include: 1. […]

• Actual harm, isolatedF689Sep 17, 2023

  Based on observations, interviews, and record reviews the facility failed to ensure that one resident (R 73) of three residents reviewed for accidents was free from injury during transfer. Actual harm occurred on 7/10/2023 when R 73 sustained a distal tibial fracture after being transferred by two Certified Nursing Aides without the use of a Hoyer lift. Findings include: Review of the electronic medical record (EMR) for R 73 revealed diagnoses that included but were not limited to End stage renal disease, Presence of cardiac pacemaker, Dependence on renal dialysis, Chronic obstructive pulmonary disease, unspecified, Atherosclerotic heart disease of native coronary artery without angina pectoris, Muscle weakness (generalized), Need for assistance with personal care, and endocarditis. […]

• No harm, potential for more than minimal, widespreadF812Jun 5, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF812Sep 17, 2023

  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. […]

• No harm, potential for more than minimal, patternF584May 26, 2022

  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 302, 306, 308, 310, and 312), and one resident room on 200-Hall (room 220). The facility also failed to ensure residents rooms were in good repair for rooms 306 and 308 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. […]