Chapman Valley Manor

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 17, 2024

  The facility identified a census of 28 residents with three residents reviewed for falls and accidents. Based on record review, observation, and interview, the facility failed to follow Resident (R) 1's fall interventions, which resulted in a fall from R1's bed and R1 sustained a broken nasal bone. On 01/07/23 at 04:15 PM, staff provided care to R1 but did not replace the fall mat next to R1's bed when they left the room. Certified Medication Aide (CMA) M later found R1 lying on the floor on her stomach with her face in a pool of blood and blood running out of her nose. R1 was transferred to the emergency room where she was diagnosed with a broken nasal bone. […]

• No harm, potential for more than minimal, widespreadF838Aug 12, 2026

  Based on record review and interview, the facility failed to ensure the Facility Assessment included the number of staff required for each unit and each shift, including weekends.Findings Included:- The Facility Assessment, dated 11/04/2025, did not identify the specific staffing levels required for each unit and did not identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) required for each unit, patient acuity, and census. The assessment lacked the staffing levels required for each daily shift and on weekends.On 08/12/2026 at 01:11 PM, Administrative Staff A stated she followed the facility's policy as to what was included in the Facility Assessment. […]

• No harm, potential for more than minimal, widespreadF880Aug 12, 2026

  Based on observations, interviews and record review, the facility failed to ensure adequate infection control practice related to sanitary storage of nebulizer ((a device which changes liquid medication int a mist easily inhaled into the lungs)masks, continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) masks, laundry services and wound care.Findings include:- On 08/10/2026 at 10:23 AM, observation revealed Laundry Aide U removed clothes from the covered cart, placed them in a resident's room without recovering the laundry cart. […]

• No harm, potential for more than minimal, widespreadF880Sep 18, 2024

  The facility had a census of 31 residents. The sample included 12 residents. Based on record review and interviews the facility failed to conduct a risk assessment to identify risks and implement a water management program to mitigate the risk of Legionella disease (Legionella is a bacterium spread through mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella) and other waterborne pathogens. […]

• No harm, potential for more than minimal, patternF880Mar 7, 2023

  The facility had a census of 27 residents. The sample included 12 residents. Based on observation, record review and interview the facility failed to provide adequate hand hygiene when caring for Resident (R) 9 and R 22 during incontinence cares, placing the affected residents at risk for infection. Findings included: - R9's Electronic Medical Record (EMR) documented diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), and osteoarthritis (flexible tissue at the ends of bones wears down). The Quarterly Minimum Data Set, dated dated dated [DATE], documented the resident had severely impaired cognition and required total assistance from staff for transfers, bed mobility. […]