Chapel Ridge Health and Rehab

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set [MDS] assessment accurately reflected a level II Preadmission Screening and Resident Review [PASARR] under section A1500 for one (Resident #16) sampled resident, and failed to accurately identify medication class under Section N on the MDS for one (Resident #64) of two sampled residents reviewed for MDS accuracy. Specifically, the facility failed to ensure medications without a physician ' s order were not reflected on the MDS.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff sat at eye level while assisting residents with meals/snacks to promote dignity for 3 (Residents #14, #22, and #31) of 3 sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a Minimum Data Set (MDS) accurately reflected the presence of contractures to bilateral wrists to facilitate planning, coordination, and provision of necessary care for 1 (Resident #66) of 1 sampled residents who had contractures to the wrist.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that residents who required assistance with activities of daily living were regularly provided assistance with grooming to include the shaving of facial hair for 1 (Resident #58) of 1 sampled resident.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure necessary care and services were provided to manage injuries of unknown origin, failure to report and investigated to rule out possible abuse, and the delay in possible treatment for 1 (Resident #22) of 1 sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an order was made for Physical Therapy after the admission Assessment for 1 (Resident #66 ) of 1 sampled resident for contractures of the wrists.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure the environment was as free of potential accident hazards as possible, as evidenced by failure to ensure unlabeled medicine cups containing a white cream like substance was contained and not left out in residents rooms; and failed to ensure residents dependent on staff for transferring, were transferred safely using a gait belt, to prevent potential accidents or possible for falls, for 2 (Resident #22 and #61) of 2 sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the narcotics box was permanently affixed in 1 of 2 medication rooms (D Hall) refrigerator.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation, record review, and interviews, the facility failed to ensure resident standing orders/food preferences were honored to promote good nutritional intake and promote resident's choices for 2 (Resident #22 and #15) of 2 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement program [QAPI] Committee developed and implemented appropriate plans of action to prevent repeated deficiencies for (F812) Food Procurement, Store/Prepare/Serve. This failed practice had the potential to affect 86 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the staff's personal belongings were not stored on the laundry folding table with the resident ' s clothing and blankets. This failed practice had the potential to affect 86 residents.

Inspectors wroteBased on observation, and interview, the facility failed to maintain residential rooms in a safe, clinical condition to provide a homelike manner for safety without signs of damage in 3 (Rooms 203, 208 and 302) rooms.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure foods in the freezer were sealed and contained to minimize the potential for foodborne illness and prevent cross contamination in 1 of 1 kitchen.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure foods stored in the refrigerator were labeled, dated when received, opened, and made; failed to ensure dietary staff washed their hands between dirty and clean tasks, before handling clean equipment or food items to prevent the potential for cross contamination. These failed practices had the potential to affect all 81 residents who received meals from 1 of 1 kitchen (total census: 81) as documented on a list provided by Dietary Manager (DM) on 11/17/2022.

Inspectors wroteBased on record review and interview, the facility failed to ensure that oxygen was addressed on the resident's Care Plan for 1 (R #135) of 6 (R #4, R #14, R #46, R #81, R #135, and R #285) sample residents that had orders for oxygen, according to a list provided by the Administrator on 11/16/22, that smoking was addressed on the Care Plan for 1 (R #55) of 1 (R #55) sample residents who smoked according to a list provided by the Administrator on 11/14/22, and that an Anticoagulant was addressed on the Care Plan for 1 (R #14) of 3 (R #14, R #19, and R #25) of sample residents who received an Anticoagulant according to a list provided by the Registered Nurse Consultant to ensure the residents needs were met.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nebulizer tubing and Continuous Positive Airway Pressure (CPAP)/Bilevel Positive Airway Pressure(BIPAP) mask and tubing were properly stored when not in use to prevent potential contamination that could result in respiratory infection for 1 (R #135) of 2 (R #46, R #135) sampled residents who had physician orders for nebulizer treatments, and failed to ensure oxygen tubing was changed in accordance with Physician Orders for 1 (R #4) of 6 ( R #4, R #14, R #46, R #81, R #135, and R #285) residents who have orders for oxygen, and 1 (R #11 ) of 2 (R #10, R #11) who have CPAP/BIPAP therapy, and failed to ensure that oxygen was set at the prescribed rate ordered by the physician for 1 (R# 135) of 6 ( R #4, R #14, R #46, R #81, R #135, and R #285) sample residents who have orders for oxygen, according to a list [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the water temperatures remained at a temperature below 120 degrees Fahrenheit (F) for 3 (Residents #13, R #80, and R #135) of final sample residents who resided on the 200 Hall and received their showers in the 200-Hall shower room and on the 300 hall. This failed practice had the potential to affect 5 Residents (R #4, R #46, R #55, R #69, and R #73) who were ambulatory or self-propelled and used the 200 Hall Shower according to a list provided by the Director of Nursing [DON] on 11/16/22. 1. On 11/14/22 at 10:44 AM, the Surveyors entered [named] resident room, introduced themselves, walked over to the sink. A Surveyor put a hand under the water which became very hot, asked another Surveyor to check the water, she did and confirmed the water was very hot. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) within 14 days of determining a decline in Activities of Daily Living (ADLs) for 1 (Resident #48) sampled residents. This failed practice had the potential to affect all 81 residents in the facility as documented on the Resident Listing Report which was provided by the Administrator on 11/14/22 at 10:16 AM.