Chapel Ridge Health and Rehab

In the surveyor’s words

From the most serious findings on record at Chapel Ridge Health and Rehab, in the surveyor’s own words.

• Immediate jeopardy, isolatedF609Nov 18, 2022

  Based on interview and record review, the facility failed to ensure injuries of unknown origin were reported to the Office of Long-Term Care (OLTC) and other agencies in accordance with state and federal law, to enable those agencies to provide any necessary oversight of the facility's investigations and protective measures for 1 (Resident # 29) of 3 (Residents #29, #40, and #59) residents who were reviewed for abuse and neglect. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm and/or injury to 81 residents who resided in the facility, according to the Resident Census received from the Administrator on 11/14/22. The Administrator was informed of the Immediate Jeopardy condition on 11/15/22 at 04:18 PM. The findings are: 1. […]

• Immediate jeopardy, isolatedF610Nov 18, 2022

  Based on interview and record review, the facility failed to ensure injuries of unknown origin were thoroughly investigated and documented to demonstrate the facility's efforts to investigate and provide protection and prevention for 1 (Resident #29) of 3 (Resident #29, #40, and #59) residents who were reviewed for abuse and neglect. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm and/or injury to all 81 residents who resided in the facility, according to the Resident Census received from the Administrator on 11/14/22. The Administrator was informed of the Immediate Jeopardy condition on 11/15/22 at 04:18 PM. The findings are: 1. Resident #29 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. […]

• No harm, potential for more than minimal, widespreadF812Nov 18, 2022

  Based 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. The findings are: 1. On 11/14/22 at 10:53 AM, during the initial tour with the Dietary Manager (DM), a square clear storage container labeled chocolate syrup dated 10/10 was found in the 3-door stainless refrigerator. […]

• No harm, potential for more than minimal, patternF550Feb 16, 2024

  Based 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. The findings are: The Annual Minimum Data Set (MDS), dated [DATE], revealed Resident #14 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The resident required set up or clean up assistance for eating. Review of Resident #14's Care Plan, revised on 1/4/2023, revealed the resident had an activity of daily living (ADL) self-care performance deficit related to disease of dementia. Interventions initiated on 8/8/2022 included supervision and set up help by one staff to eat. […]

• No harm, potential for more than minimal, patternF641Feb 16, 2024

  Based 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. The findings are: 1. On 2/12/24 at 2:38 PM, a contracture was observed in the resident ' s right wrist. 2. On 2/14/24 at 1:27 PM, the contracture was observed in the right wrist of Resident #66. 3. Resident #66 had a diagnosis of Unspecified psychosis not due to a substance or known physiological condition. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11-21-2023 documented, Should a brief interview mental status be conducted. […]