Chapman Care Center

In the surveyor’s words

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

• Actual harm, isolatedF689Dec 17, 2021

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from accident hazards. * Resident 1 fell from the shower gurney on 10/23/21, sustaining neck and pelvis (lower part of the torso) fractures and resulting in a transfer to the acute care hospital. Findings: Review of the Manual Shower Bed's Owner's Manual dated 11/2018 showed before each use, check to ensure all casters are properly secured to the device and the device is stable. Do not use device if it appears wobbly or unstable, the casters are rusted or fail to move easily, the fabric appears torn or weak, cracks are observed in the fittings, or the device appears to be compromised in any way. […]

• No harm, potential for more than minimal, patternF812Jan 21, 2026

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure one heavy-duty blender used for puree preparation was air dried and free of water residue prior to storing. * The facility failed to ensure the microwave utilized to warm up the food was in a sanitary condition. […]

• No harm, potential for more than minimal, patternF880Jan 21, 2026

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the infection control practices were maintained in the facility's laundry room when a facility staff's personal clothing was stored in the clean laundry storage area. * The facility failed to ensure the water management program was established and implemented to include the specific implementation of measures to prevent the growth of Legionella (type of bacteria that is naturally found in [NAME] environments) and other opportunistic pathogens; and a way to monitor the measures the… […]

• No harm, potential for more than minimal, patternF812Dec 6, 2024

  Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure four blenders were not stored wet. * The facility failed to ensure a red cutting board had cleanable surface. * The facility failed to ensure the ice machine was maintained in a sanitary condition. * The facility failed to ensure safe storage of the food brought in by the family. These failures had the potential to result in foodborne illnesses for residents receiving kitchen services. Findings: Review of the facility's document titled Diet Type Report dated 12/3/24, showed 69 of 87 residents were receiving food prepared from the kitchen. 1. […]

• No harm, potential for more than minimal, patternF812May 9, 2022

  Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by the following: * The facility failed to ensure the storage containers for dry food were completely sealed without noticeable gaps. * The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface. * The facility failed to ensure the peelers were in sanitary condition and free of food particles. * The facility failed to ensure the kitchen equipment was air dried and free of food particles. * The facility failed to ensure the kitchen utensils were clean and free of food particles. […]