Chapel Hill Nursing Center

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure professional standards for food service safety was followed. This was evident for 1 of 1 facility kitchen, and 2 of 2 units observed during the facility's recertification survey.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to maintain a safe, clean, comfortable, and homelike environment in good repair. This was evident for 2 of 2 Nursing units and 1 out of 1 dining area reviewed during the annual recertification survey and investigation of complaints; #2713655, #320969, and #320969.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to maintain discharge documentation, ensure the local Ombudsman was notified of the facility's discharges and transfers, and provide the resident/representative with written notification of transfers to the hospital and written notification of the facility's completed bed hold policy upon transfer to the hospital. This was evident for 4 (#42, #8, #50, #52) of 5 residents reviewed for transfers and discharges during the annual recertification survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure handrails were firmly affixed. This was evident for 2 out of 2 nursing units during the facility's recertification survey.

Inspectors wroteBased on observations, record review, and staff interviews, it was determined that the facility failed to ensure the promotion of resident's dignity and residents' rights. It was evident for 2 (#14, #61) out of 4 residents reviewed for Resident Rights during this annual recertification survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure that the resident's representative's rights were being upheld. This was evident for 1 (#61's representative) out of 1 resident representative reviewed during this annual recertification survey.

Inspectors wroteBased on observations, record review, and resident and staff interviews, it was determined that the facility failed to ensure that the recommendations and suggestions of residents were addressed and reported back to the residents. This was evident for 6 out of 6 concerns sent to the facility from the resident council.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to indicate the facility's per diem rate for services no longer covered under Medicare/Medicaid as well as the reason why Medicare/Medicare is no longer covering those services on the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (CMS-10055) form. This was evident for 3 (#3, #5, #64) of 3 residents reviewed during the annual recertification survey for beneficiary notification. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (CMS-10055) form is a required document used by Medicare-certified skilled nursing facilities to notify Medicare beneficiaries that their Part A services may not be covered because they are not considered medically reasonable/necessary or are deemed custodial. [...]

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure the assessments were accurately completed. This was determined for 1 (#14) out of 6 residents reviewed for Minimum Data Set (MDS) assessments during this annual recertification survey.

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to develop and implement comprehensive care plans. This was evident for 2 (#50, #2) of 6 residents reviewed for care planning during an annual recertification survey and investigation of Complaint #2784382.

Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure a person-centered care plan was updated and revised. This was evident: for 2 (#50, #63) out of 3 residents reviewed for care plan revisions during the annual recertification survey and investigation of complaint #320972. A care plan is used to summarize a person's health conditions, specific care needs, and current treatments and outlines what needs to be done to plan, assess, and manage care. Care plans are developed, reviewed, and/or revised by the IDT after the completion of a comprehensive MDS assessment (Admission, Annual, Quarterly, Significant Change) to help to evaluate the effectiveness of the resident's care while in the facility. [...]

Inspectors wroteBased on record review and interviews with a resident and staff, it was determined that the facility failed to ensure a resident attended a scheduled medical appointment and the missed appointment was rescheduled timely. This was evident for 1(Resident #45) out of 2 residents investigated for communication/sensory during the annual recertification survey.

Inspectors wroteBased on review of employee personnel files and interviews with staff, it was determined that the facility failed to ensure required Geriatric Nursing Assistant (GNA) performance reviews were completed every 12 months. This was evident for 2 (GNA #15 and GNA #37) out of 5 employees reviewed for sufficient staffing during the annual recertification survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure:1. Medications were securely stored, this was evident in 1 out of 2 medication carts observed on the Unit 1 hallway during the facilities recertification survey.2. Nutritional supplements were not expired. This was evident in 2 of 2 storage areas for Nepro nutritional supplements observed during the facility's recertification survey.

Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure the menu was followed. This was evident for 1 out of 1 lunch meal tray pass observation conducted by the surveyor during the facility's recertification survey.

Inspectors wroteBased on review of an employee file, online sources, and interview with staff, it was determined that the facility failed to ensure Geriatric Nursing Assistant (GNA) staff had an active, current certification. This was evident for 1 (GNA #15) out of 5 GNAs reviewed for staff qualifications during the annual recertification survey.

Inspectors wroteBased on record review and interviews with staff, it was determined that the facility failed to maintain medical records in accordance with accepted professional standards and practices. This was evident for 1 (Resident #18) out of 2 residents reviewed for communication/sensory during the annual recertification survey.

Inspectors wroteBased on observation and interview with staff, it was determined that the facility failed to ensure clean linen was handled, transported, and stored in a safe and sanitary manner. This was evident for 2 of 2 clean linen transports, and 1 of 1 main supply room observed during the annual recertification survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure maintenance of essential kitchen equipment. This was evident during the surveyors review of the kitchen task during the facility's recertification survey.

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to ensure effective pest control to ensure the environment was free from gnats. This was evident in 1 of 2 units, and 1 of 1 kitchen reviewed for effective pest control during the annual recertification survey.

Inspectors wroteBased on review of employee files and interview with staff, it was determined that the facility failed to maintain an in-service training program to consistently evaluate each Geriatric Nursing Assistant (GNA) based on individual performance of mandatory education and clinical skills competencies of no less than 12 hours per year. This was evident for 4 (GNA #15, GNA #35, GNA #36, and GNA #37) out of 5 employee files reviewed for sufficient staffing during the annual recertification survey.

Inspectors wroteBased on the investigation of the facility reported incident, review of medical records and interview with facility staff, it was determined that the facility failed to follow the specified number of staff support needed when providing care for residents. This resulted in the resident falling out of the bed and suffering a left acute frontal subdural hematoma, which required surgery. This was evident for 1 (Resident #264) out of 9 residents reviewed for accidents during the Medicare/Medicaid recertification survey.

Inspectors wroteBased on observations and interviews with the facility staff, it was determined that the dietary staff 1) Failed to maintain the temperature logs on the refrigerator and freezer, 2) failed to date and label foods stored in the refrigerator and freezer with expiration dates and, 3) failed to put on beard covers while handling the resident's food. These were identified during 2 out of 4 observations of kitchen food service operations during the recertification survey and has the potential to affect all residents.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to provide evidence that all nursing staff had received education on abuse, neglect, and exploitation training annually. This was evident for 6 (nurse #11, #28, #38, and Nurse Aides #35, #39, and #40) of 6 nursing staff training records reviewed during the recertification/complaint survey.

Inspectors wroteBased on observation and an interview with facility staff, it was determined that the facility failed to ensure the environment of resident care was kept clean, comfortable and safe for resident use. This was evidenced by the floor radiator heater in the bathrooms observed with significant damage, rust build up along the floor radiator heaters, end caps were not in place which exposed sharp edges. This was evident for 2 of 5 bathrooms observed during the recertification survey.

Inspectors wroteBased on review of a facility reported incident, record review and staff interview, it was determined that the facility administration failed to ensure that a background check was done to protect residents from abuse, neglect, and theft. This was evident for 4 (Staff #26, # 46,# 47, and #48) of 9 employees reviewed for abuse during the re-certification survey.

Inspectors wroteBased on review of facility records, Medical records, and interview with staff it was determined that the facility staff failed to immediately report an allegation of suspected resident abuse. This was evident for 1 (#37) of 15 residents reviewed for self-reported incidents during this recertification survey.

Inspectors wroteBased on medical record review, facility investigation review, and staff interview, it was determined that the facility failed to 1) thoroughly investigate a resident's allegation of unknown origin of injury, 2) educate all staff to prevent similar elopement episodes in the future, and 3) thoroughly investigate an allegation of abuse, and provide documentation for the incident of an allegation of abuse. This was evident for 3 (Resident #30, #23, #19) of 36 residents reviewed during this recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to notify the resident/resident representative in writing about the bed hold policy when the resident was transferred/discharged from the facility to an acute care facility. This was evident for 1 (resident #51) of 2 residents reviewed who were transferred to an acute care facility during the recertification survey.

Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for one (Resident #257) of three residents reviewed for smoking during the recertification/complaint survey.

Inspectors wroteBased on the medical record review and staff interview, it was determined the facility staff failed to revise the interdisciplinary care plans to meet the resident's needs. This was evident for 2 ( Resident #30, #13) of 9 residents reviewed for abuse and 36 residents reviewed for for care plan timing and revision during the survey process.

Inspectors wroteBased on observations, staff interviews, and record review, it was determined that the facility failed to maintain a functional communication system for a non-English speaking resident (Resident # 51). This was evident for 1 of 1 resident reviewed for communication, including language and other functional communication systems, during the recertification survey.

Inspectors wroteBased on medical record review and resident and staff interviews it was determined the facility staff failed to ensure that the dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 (Resident #37) of 2 residents reviewed for Activities of Daily Living (ADL) during this recertification/complaint survey.

Inspectors wroteBased on record review and interview with facility staff, it was determined that facility staff failed to communicate and document a concern about a resident with a contracted dentist prior to tooth extraction which resulted in a resident having gum bleeding after the tooth extraction. This was evident for 1(Resident #264) out of 4 complaint investigations reviewed during the Medicare/Medicaid recertification survey.

Inspectors wroteBased on a review of the medical record and interview with staff it was determined that the facility failed to monitor a resident's significant weight changes. This was evident for 1 (#37) of 2 residents reviewed for nutrition during the recertification/complaint survey.

Inspectors wroteBased on the medical record review and staff interview the facility failed to ensure that the use of high-risk psychotropic medication was necessary and justified when staff failed to complete behavior monitoring documentation and utilization of nonpharmacological interventions before administering Anxiolytic medication for the resident (#13). This concern was evident for 1 (Resident #13) of 2 residents reviewed for utilization of unnecessary medication during the recertification survey.

Inspectors wroteBased on observation and the staff interviews, it was determined that the facility failed to properly store medications, as evidenced by failing to ensure that medication was properly labeled and dated. This was evident in two of the two medication rooms and one of the two refrigerators observed during the recertification survey.

Inspectors wroteBased on observation, review of resident's immunizations records, and interviews with residents and facility staff, it was determined that the facility failed to 1) prevent infection in a resident with an indwelling catheter and failed to protect the resident's dignity, 2) perform Tuberculosis screening on all admissions, and 3)ensure that medication administration methods were free from contamination in a manner that minimized the potential spread of infection. This was evidenced by 2 residents (Residents #57 and #207) of 36 residents reviewed during the recertification/complaint survey, and a Registered Nurse (RN) (Staff#43), not sanitizing hands between residents during medication administration during this recertification/complaint survey. [...]

Inspectors wroteBased on record review and interview with facility staff it was determined that the facility failed to have a system in place to ensure that Geriatric Nursing Assistant (GNA) received education about residents' safety and residents' care after an alleged abuse incident. This was found to be evident for two Geriatric Nursing Assistants (GNA #10 and #37) out of 7 GNAs' reviewed for training records reviewed during this recertification/complaint survey.

Inspectors wroteBased on observation, interview and medical record review, it was determined that the facility failed to administer medication according to professional standards of nursing, monitor the administration of medication to residents and crush medications according to standards of nursing practice. This was evident during the observation of staff putting medication in resident food and not monitoring when the resident gets the medication, who gives the medication and how much of the medication the resident receives and if the appropriate staff administered the medication. Resident #11's ten medications were left unattended on his/her tray and Resident #13's five medications were left unattended. Both medications were administered by a geriatric nursing assistant (GNA) and incorrectly crushed. [...]

Inspectors wroteBased on surveyor observation during an initial tour of the facility and an interview with the resident, it was determined that the facility failed to maintain and enhance the dignity of the resident (Resident #37). This occurred in 1 of 6 sampled residents.

Inspectors wroteBased on observation and interviews with the resident and the facility staff, the facility failed to ensure that Resident #90 had an alternative method to wash his/her hands secondary to a resident wheelchair not being able to fit through the bathroom door. This is evident for 1 of 6 residents reviewed during the annual survey.

Inspectors wroteBased on interview with facility staff and the resident it was determined the facility failed to ensure a resident receives his/her packages unopened. This was evident for 1 of 7 residents (Resident #7) reviewed during the annual survey.

Inspectors wroteBased on medical record review and interview with the facility staff, it was determined that the facility failed to provide notice to residents informing them that Medicare may deny payments for procedures or treatments and that residents may be personally responsible for full payment. This was evident in 3 of 3 residents (Resident #33, #243 and #24) reviewed during beneficiary protection notification.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to maintain a safe, functional, and comfortable environment for residents. This was evident for 2 of 7 residents (Resident #7 and #37) reviewed during the annual survey.

Inspectors wroteBased on observations, medical record review and interviews with facility staff it was determined the facility failed to report an injury of unknown origin to the state regulatory office. This was found to be evident for 1 (Resident # 15) that was reviewed for general skin condition during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to complete a thorough investigation for a resident injury with an injury of unknown origin. This was found to be evident for 1 resident (Resident #15) reviewed for abuse during the facility's annual survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure residents or their responsible party, received written notification of a transfer to the hospital, including appeal rights and Ombudsman contact information. This was found to be evident for 3 out of 3 residents (Residents #20, # 240 and #22) reviewed for hospitalization during the investigative stage of the survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that residents or residents' responsible party (RP) were given written notification of the facility bed-hold policy when they were being transferred out of the facility to a hospital. This was found to be evident for 2 out of 3 residents (Residents #20 and #240) reviewed for hospitalization during the survey investigation.

Inspectors wroteBased on medical record review, interviews with family and staff it was determined the facility failed to: 1.) review and update the care plan in relation to the resident's Activities of Daily Living (ADL) care plan based on the resident's current status and needs or include family preferences for dining and getting out of bed or follow the interventions for bladder incontinence and 2.) revise a care plan to specify how frequent staff is to monitor a resident who is at risk for falls. This was evident for 2 of 21 residents (Resident #32 and #21) reviewed for care plan updates during the survey investigation.

Inspectors wroteBased on observations, tour of the facility, medical record review as well as review of other pertinent documentation and interview of facility staff it was determined the facility failed to: 1.) provide a safe and hazard-free environment for 1 of 1 resident (Resident #37) reviewed for accidents and 2.) ensure a resident at risk for falls received increased monitoring by staff according to the care plan interventions (Resident #21). This was found to be evident for 1 of 1 resident reviewed for falls during the facility's annual survey.

Inspectors wroteBased on medical record review and interview with facility staff it was determined that a facility physician failed to sign monthly orders timely and when the physician first visited the resident when the orders were written. This was evident during the medical record review of Resident #2.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to have a completed psychiatric consult on the chart and further provide additional psychiatric services to a resident due to a resident's payor source. This was evident during the review of 1 of 5 residents (Resident #13) for unnecessary medications.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility pharmacist failed to identify and act on a medication irregularity. This was identified during the review of 1 of 1 resident (Resident #14) reviewed for insulin usage.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility staff failed to follow physician orders by discontinuing the wrong diabetic medication on a resident that was dependent on insulin. This was identified during the review of 1 of 1 resident (Resident #14) reviewed for insulin usage.

Inspectors wroteBased on observation and medical record review it was determined that the facility failed to administer medications and maintain an error rate of less than 5% by following physician orders. This was evident during the observation of medication pass completed by 1 licensed nurse during the administration of 26 medications, in addition to administration of 5 medications that were observed for a total of 31 medication opportunities that resulted in 10 errors for an error rate of (32%) for Resident #11 and Resident #13.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility staff failed to follow physician orders and promptly identify a medication error involving diabetic medication for a resident that was dependent on insulin for daily functioning. This was identified during the review of 1 of 1 resident (Resident #14) reviewed for insulin usage.

Inspectors wroteBased on observations and interviews with the facility staff it was determined the facility staff failed to store foods properly in the dry storage area. This was found to be evident during an initial tour of the facility conducted during the facility's annual survey.

Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to: 1.) maintain accurate documents related to the care of resident (Resident #37) and 2.) provide documentation that a resident was monitored for aggressive behaviors and was sent for an evaluation for those behaviors according to the resident care plan (Resident #13). This was found to be evident for 2 of 24 residents (Resident #37 and #13) reviewed during the facility's annual survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to: 1.) ensure that each resident or responsible party (RP) received education regarding benefits and risk and document that the residents or the responsible party were provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunization prior to administration. This was evident for 4 residents (Resident #23, #25, #21 and #28) reviewed for immunization.

Inspectors wroteBased on observation during the initial tour it was determined that facility staff failed to maintain an effective pest control program so that the facility was free of pests.

Inspectors wroteBased on the review of facility reported incidents and further review of employee records, including interview with facility staff, it was determined that the facility failed to have documentation that Geriatric Nursing Assistance's (GNA) were given annual abuse training. This was evident during the review of 3 of 4 employee records reviewed (Staff # 16, #17 and #18).

Inspectors wroteBased on the review of facility reported incidents and further review of employee records, including interview with facility staff, it was determined that the facility failed to have documentation that Geriatric Nursing Assistance's (GNA) were given in-service training related to abuse and dementia care upon hire. This was evident during the review of 1 of 2 new employee records reviewed (Staff #16).

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that residents and or visitors were aware of where the state inspection results were located. This was found to be evident during observations during the facility's annual Medicare/Medicaid survey.