Chapel Woods Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 13, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Oct 25, 2024

  Based 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. The findings are. 1. During a concurrent observation and interview on [DATE] at 10:02 AM, Dietary Aide (DA) #1 removed bananas from the original box and placed them on the counter, contaminating her hands. […]

• No harm, potential for more than minimal, widespreadF812Dec 14, 2023

  Based 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. The findings are: 1. […]

• No harm, potential for more than minimal, widespreadF712May 3, 2023

  Based on interview and record review, the facility failed to ensure that Physician face-to-face visits were conducted, and Physician Progress Notes were documented at least every 60 days identified for 3 (Residents #1, #2, and #3) of 3 residents sampled for the timeliness of Physician Progress Notes. The findings are: 1. Resident #1 was admitted on [DATE] and had diagnoses of Diabetes Mellitus, Thyroid Disorder, and Non-Alzheimer Dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/17/23 documented the resident scored 0 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS). a. The Physician Notes from December 2022 to May 2023 did not document an attending Physician's visit or a Progress Note. […]

• No harm, potential for more than minimal, widespreadF812Sep 15, 2022

  Based on observation and interview, the facility failed to ensure door frames, floor tiles, base boards, ceiling tile and air vents were intact to allow for thorough cleaning and disinfecting; the ceiling tile in the kitchen was free of peeling paint; kitchen floors were free of stains and wax build up to prevent potential contamination of food items and dietary employees washed hands before handling clean equipment and between dirty and clean tasks to decrease the potential for food borne illness. These failed practices had the potential to affect 64 residents (total census: 66) who received meal trays from 1 of 1 kitchen as documented on the list provided by the Dietary Supervisor dated 9/15/2022. […]