Chapel Woods Health and Rehabilitation

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a cognitively impaired resident was not left outside alone, unsupervised, and after hours for 1 (Resident #1) of 1 sampled resident reviewed for neglect. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of J. The IJ began on 05/04/2025 around 5:45 PM when Resident #1 was left outside, alone and unsupervised, in the courtyard of the secured unit. The Administrator, Director of Nursing, and Nurse Consultant were notified of the IJ on 05/09/2025 at 8:54 AM. A plan of removal was requested. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%) during the medication administration observation of 1 (Resident #7) of 2 (Residents #1 and #7) sampled residents, and one (Resident #8) non-sampled resident who received medications from 1 Registered Nurse (RN) and 2 Certified Med Techs (CMT). Observed 25 opportunities of medication administration and 2 of the 25 medications were not administered in accordance with the physician's orders, resulting in a medication error rate of 8.00%.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure allegations of abuse and neglect were thoroughly investigated for 3 (Residents #1, #4 and #5) of 6 sampled residents reviewed for abuse and 1 (Resident #6) of 1 sampled resident reviewed for neglect.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure dietary staff thoroughly washed their hands and changed gloves when contaminated; expired food items were promptly removed/discarded on or before the expiration or use by date; foods stored in the freezer, refrigerator and dry storage area were covered, sealed, and dated; and hot food item was maintained at the required temperature on the tray above the steam table for one meal observed.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the process for dispensing controlled substances was consistently implemented to decrease the potential for diversion of medications from one of four medication carts from which a random narcotic count was performed.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a pharmacist medication regimen review recommendations were addressed for 3 (Residents #2, #3 and #69) of 5 (Residents #2, #3, #53, #69 and #77) sampled residents who were reviewed for unnecessary and psychotropic medications, and medication regimen reviews (MRRs).

Inspectors wroteBased on observation, record review, and facility policy review, the facility failed to ensure a care plan was revised to reflect the resident's most recent care needs for 1 (Resident #3) sampled resident whose care plan was reviewed.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure toenail care was consistently provided during resident care for 1 (Resident #22) sampled resident reviewed for nail care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared and served according to the planned written menu to meet the nutritional needs of the residents for 1 of 1 meal observed.

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review the facility failed to ensure staff donned the proper Personal Protective Equipment (PPE) while performing high contact resident activities for 1 (Resident #76) sampled resident on Enhanced Barrier Precautions (EBP).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure food items stored in the freezer and refrigerator were covered or sealed to decrease the potential for cross contamination; expired food items were promptly removed/discard by the expiration or use by dates as when it was delivered, door frames, ceiling tiles, ceiling vent floor tiles were free of stains, debris, rust and chipped; 1 of 2 ice machines was maintained in clean and sanitary condition, staff washed their hands, and dietary staff washed their hands and between clean tasks to decrease the potential for food borne illness dirty and clean, before handing food items. The failed practices had the potential to 80 affect residents who received meals from the kitchen.

Inspectors wroteBased on observation during medication administration, record review and interview, the facility failed to ensure physician's orders were followed to maintain a medication error rate of less than 5% to prevent potential complications for one Resident #64. Medication errors were made by 1 Licensed Practical Nurses (LPN) (LPN #2) of 2 LPNs and 1 Medication Assistant Certified (MAC) who administered medications in the facility. The medication error rate was 7.32%. The failed practice had the potential to affect 84 residents who received medications.

Inspectors wroteBased on inspection of the medication room and medication carts on 12/12/2023, the facility failed to ensure medications in 1 of 2 medication rooms were labeled and stored in accordance with State law and accepted standards of pharmacy practice, the facility failed to ensure discontinued or expired medications were removed and placed into an area for destruction to prevent potential administration to residents for 2 of 4 medication carts, and the facility failed to ensure all medications and biologicals were stored in locked compartments with only authorized personnel to have access. These failed practices had the potential to affect all 84 residents who resided in the facility and would receive any physician-ordered medications from the medications room, or the medication carts and 47 residents who are mobile and self-propel around the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure enough food items were prepared and served according to planned written menu for 1 of 1 meal observed. The failed practice had the potential to affect 13 residents who received their meal trays in the unit dining room, 8 residents who received their meal trays in the room on E- Hall, 4 residents who received their meal trays in their room on B-Hall, and 5 residents who received their meal trays in their room on G- Hall from 1 of 1 kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to update the resident care plan to reflect the needs of 1 Resident (Resident #10) sampled resident. Resident #10 had a past diagnosis of Osteomyelitis of lower extremities. On 12/11/2023 at 10:45 AM, Resident #10 was sitting in a wheelchair with bilateral lower extremities with 2+ pitting edema. When questioned about her lower leg swelling, Resident #10 stated she had this problem for years off and on. Progress note dated 10/06/2023 at 10:30 AM documented resident had 2+ pitting edema of lower extremities. At 2:16 it documented to start Lasix 40 mg daily. The Physician's order dated 10/07/2023 documented .Lasix oral tablet 40 mg (milligrams) give one tablet by mouth one time a day for fluid retention. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to invite resident and family to attend care plan meetings for one (Resident #10) sampled residents. Resident #10 had a diagnosis of muscle weakness. The Quarterly Minimum Data Set [MDS] with an assessment reference date [ARD] of 10/12/2023 documented a brief interview of mental status [BIMS] of 14 which indicated resident cognitive. On 12/11/23 at 10:40 AM, Resident #10 was asked if she attended care plan meetings and participated in developing her plan of care, Resident #10 stated she would like to attend care plan meetings but was unaware of when they are and had not been invited to attend. Review of Resident #10's clinical record did not document an invitation to resident or resident's representative to attend the care plan meeting. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nails were trimmed to maintain good hygiene and prevent potential skin tears and infection. This failed practice had the potential to affect all 49 residents in the facility who were dependent or assisted with nail care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide activities for, or invite room bound residents to activities for one (Resident #10) of two (Resident #10 and #25) sampled residents who spend most of their time in their room.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure oxygen was consistently administered at the flow rate ordered by the physician, to minimize the potential for respiratory complications for 1 (Residents #230) of 1 sampled resident who had physician's orders for oxygen therapy. The facility also failed to ensure a nasal cannula was dated to ensure regular change out to prevent potential contamination or infection. The failed practice had the potential to affect 9 residents who had physician's orders for oxygen therapy.