Chase Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Sep 27, 2022

  Based on interview and record review, the facility failed to ensure Cardiopulmonary Resuscitation (CPR) was initiated and 911 was called for a Full Code status resident found unresponsive and without vital signs for 1 of 2 residents reviewed for death. (Resident B) The immediate jeopardy began on [DATE], when staff entered Resident B's room at 8:30 a.m., to get her up for breakfast. She was found unresponsive with no blood pressure, no apical or radial pulse, and no respirations. The resident was a Full Code. Registered Nurse (RN) 2 did not initiate CPR or call 911. She stated the resident was beyond resuscitating. The facility policy and procedures indicated staff should perform CPR and call 911 for all unresponsive Full Code residents. […]

• No harm, potential for more than minimal, patternF758Sep 27, 2022

  Based on interview and record review, the facility failed to ensure the diagnoses were appropriate for the use of [CONDITION(S)] medications for 5 of 5 residents reviewed for unnecessary medications (Residents 7, 12, 38, 24 and 40). Findings include: 1. The record for Resident 7 was reviewed on 9/23/22 at 10:34 a.m. Diagnoses included, but were not limited to, Alzheimer's disease, hypertension, impulse disorder, depressive disorder and dementia in other disease with behavioral disturbance and psychotic disorder with delusions. A physician's order, dated 7/28/21, indicated [MEDICATION(S)] (an antipsychotic) 0.5 mg (milligram) by mouth twice a day for psychotic disorder with delusions (typically a symptom of mental disorder). […]

• No harm, potential for more than minimal, isolatedF684Nov 19, 2025

  Based on interview and record review, the facility failed to ensure medications were administered as ordered by the physician and the physician was notified when the medications were not administered for 1 of 5 residents reviewed for quality of care. (Resident 3)Findings include:The clinical record for Resident 3 was reviewed on 11/17/25 at 4:18 p.m. The diagnoses included, but were not limited to, traumatic brain injury, influenza A virus with pneumonia, dementia, borderline personality disorder, and anxiety disorder. 1. […]

• No harm, potential for more than minimal, isolatedF883Nov 19, 2025

  Based on interview and record review, the facility failed to ensure pneumococcal vaccines were provided when requested with a signed consent form for 1 of 5 residents reviewed for immunizations. (Resident 3)Findings include: The clinical record for Resident 3 was reviewed on 11/17/25 at 4:18 p.m. The diagnoses included, but were not limited to, traumatic brain injury, influenza A virus with pneumonia, seizures, dementia, borderline personality disorder, and anxiety disorder.A vaccination summary form indicated Resident 3 received a pneumococcal vaccine, on 8/4/18, and the vaccination was now past due.An informed consent form for a pneumococcal vaccine, dated 7/29/25, indicated the resident consented to receiving the vaccination.The electronic medical record did not include documentation… […]

• No harm, potential for more than minimal, isolatedF641Nov 4, 2024

  Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was coded correctly for 1 of 1 resident reviewed for MDS accuracy. (Resident 28) Finding includes: The clinical record for Resident 28 was reviewed on 10/30/24 at 3:28 p.m. The diagnoses included, but were not limited to bipolar disorder, vascular dementia, intermittent explosive disorder, conduct disorder, and visual hallucinations. An annual MDS assessment, dated 12/14/23, indicated the resident had a diagnosis of bipolar disorder. A quarterly MDS assessment, dated 5/30/24, indicated the resident had a diagnosis of bipolar disorder. A quarterly MDS assessment, dated 8/20/24, indicated the resident had a diagnosis of bipolar disorder. […]