Chapel Grove Inn The

Based on observation, record review, and staff interview, the facility failed to ensure infection control standards were maintained during administration of oral medications and lab specimens in medication room/nursing area. This affected two residents (Resident #36 and Resident #48) of two residents reviewed for medication administration. The facility census was 101.

Findings include:

1. Observation on 04/14/25 during medication pass between 8:00 A.M. to 8:20 A.M. Nurse #60 did not wear gloves when removing oral medication, from pre-packaged medication bags. Nurse #60 placed Resident #36's medications in a medication cup. Then she used her ungloved middle finger to remove the Oxybutin reporting the Oxybutin had been discontinued. Nurse #60 gave the remaining oral medications to Resident #36 who swallowed them.

Observation on 04/14/25 during medication pass between 8:00 A.M. to 8:20 A.M. Nurse #60 did not wear gloves when removing Resident #48's oral medications from a pre-packaged medication bag. She used her ungloved middle finger to remove the Gabapentin reporting the strength of the Gabapentin had been changed. While removing the Gabapentin, the medication cup tipped over and spilled all the oral medications onto the top of the medication cart. Nurse #60 used her ungloved bare hand to place all oral medications back into the medication cup. Nurse #60 gave the oral medications to Resident #48 who swallowed them.

Interview on 04/14/25 at 8:20 A.M. Nurse #60 verified she did not wear gloves to remove the discontinued oral medications from the medication cup. Nurse #60 confirmed she did not wear gloves when the oral medication cup tipped and spilled all the oral medications onto the medication cart and she placed them back into the medication cup. Further, Nurse #60 verified she did not discard the oral medications which spilled but gave them to Resident #48.

2. Observation of medication room/nursing area on 04/14/25 at 10:30 A.M. revealed unlabeled and undated food and drinks in the lab specimen only refrigerator in the medication room/nursing area. An unlabeled and undated white styrofoam food container on the left side of the top interior shelf of the refrigerator was not fully closed revealing food and an unlabeled and undated small bowl was on the right side of the top interior shelf which contained food. There was a line of unopened Diet Pepsi 12-ounce cans along the bottom shelf of the refrigerator. There was an unlabeled and undated styrofoam drink cup with a straw in it in the door shelf.

Interview at the time of observation with Nurse #70 verified the label in orange on the front of the refrigerator stated, Lab Specimens Only and confirmed only lab specimens should be in that refrigerator. Nurse #70 verified the food and drink should not be in the lab specimen refrigerator and stated I will remove that now.

Based on observation, interview, and review of facility policy, the facility failed to ensure food was served in a safe and sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 101.

Findings include:

1. Observation on 04/10/25 at 8:26 A.M. of the main kitchen revealed bins labeled rice, sugar, and flour were open and undated. Additionally, the freezer had a tray full of ice cream in styrofoam bowls which were uncovered, unlabeled, and undated.

Interview on 04/14/25 at 8:26 A.M. with Cook # 10 verified the bins did not have a date and ice cream bowls were uncovered, unlabeled, and undated. Cook #10 believed it to be from the previous night.

Observation on 04/14/25 of the main dining room at 11:08 A.M. revealed a buildup of grease on the oven hood vents in the main kitchen. Interview with Dietary Director #30 verified grease on the hood vents. Dietary Director #30 reports maintenance cleans the oven hood vents every six months. Cook #10 confirmed oven hood vents are to be cleaned weekly. Dietary Director #30 reports she did not know the oven hood vents needed cleaned in between visits from maintenance.

Review of Policy and Procedures Dietary Services section Food Storage dated 01/2023 revealed stored foods and beverages should be dated with the date received and/or the date opened.

2. Observation on 04/14/25 at 8:35 A.M. of the kitchen on memory care unit revealed five plates with dried food on them in the refrigerator. The five plates were improperly covered, unlabeled, and undated. Further, there was an open latte cup in the refrigerator door which was unlabeled and undated. There was visible dirt in the refrigerator and a dried, red substance on the interior shelves of the refrigerator. Additionally, the freezer had four pizza rolls laying in the freezer. A pizza rolls bag was open, unlabeled, and undated. A Ben & Jerry's pint of ice cream was open, unlabeled, and undated. The freezer contained visible signs of dirt.

Interview on 04/14/25 at 8:35 A.M. with Assisted Living (AL) Aide #50 revealed dietary staff clean the refrigerator on the memory care unit. AL Aide #50 verified dietary staff are responsible for the cleaning of the memory care kitchenette area.

Interview on 04/14/25 at 1:50 P.M. with the Director of Nursing (DON) #40 confirmed the refrigerator had five improperly covered plates, unlabeled, and undated, the dried red substance on the interior of the refrigerator shelves and showed visible signs of dirt in the refrigerator. Additionally, DON #40 verified the four pizza rolls lying open in the freezer, the opened, unlabeled and undated pizza rolls bag, and the opened, unlabeled, and undated Ben & Jerry's pint ice cream in the freezer.

Based on observation, interview, and review of housekeeping policies, the facility failed to ensure the memory care unit furniture was maintained appropriately and failed to maintain clean floors on the memory care unit. This affected 35 residents who resided in the memory care unit. The facility census was 101.

Findings include:

1. Observation on 04/14/25 at 8:29 A.M., 11:30 A.M., and 1:40 P.M. revealed the furniture in the memory care unit was not maintained in a homelike manner. Two small cloth couches were observed with brown stains the size of a playing card on one couch and multiple brown stains on the other couch of varying sizes and shapes.

Interview on 04/14/25 at 1:43 P.M. with Assisted Living (AL) Aide #60 verified the brown stains on both small cloth couches. AL Aide #60 stated housekeeping is responsible for cleaning couches.

Interview on 04/14/25 at 4:22 P.M. before exit conference, Executive Director (ED) #80 stated stains are to be expected on the memory care unit.

2. Observation on 04/14/25 at 8:29 A.M., 11:30 A.M., and 1:40 P.M. revealed a dried, sticky substance on the floor at entry to the memory care unit. This dried, sticky substance was approximately six inches by six inches and continued down the length of the entrance hallway to the trash bins to the right of the memory care living area. Observed shoes sticking to the floor during walk down of the hallway and directly in front of Resident Care Coordinator (RCC) area which is near trash bin area. Additionally, brown spots the size of pennies were scattered from one of the small gray, cloth couches down the hallway in a trail. Further, a puddle of a clear liquid as big as a twelve-inch diameter frying pan was in between the two small gray cloth couches in front of a floor lamp. This puddle was a dried sticky substance.

Observation on 04/14/25 at 1:40 P.M. of memory care unit revealed there were three aides. One aide was sitting with a resident painting her fingernails. One aide was standing approximately three feet from first aide and they were talking. The third aide was AL Aide #60 who was standing in the area in front of the RCC area near the trash bins.

Interview on 04/14/25 at 1:43 P.M. with AL Aide #60 verified the dried sticky substance was on the floor at the entry to the memory care unit and continued down the hallway to the trash bins. AL Aide #60 stated, It looks like they dragged the trash bags. It was like this when I got here this morning. AL Aide #60 stated night shift is responsible for mopping the floor. AL Aide #60 confirmed the stains on the small gray cloth couches. AL Aide #60 verified the brown spots the size of pennies was on the floor from the small gray cloth couches down the hallway.

Interview on 04/14/25 at 1:46 P.M. with RCC #20 verified the dried sticky substance at the entrance of the memory care unit which continued to the trash bins. Additionally, RCC #20 confirmed the brown spots the size of pennies on the floor which continued down the hallway. RCC #20 stated she didn't know what the brown spots were. RCC #20 stated night shift aides mop the memory care floor at night on a rotating schedule.

Interview on 04/14/25 at 4:22 P.M. before exit conference Executive Director #80 stated the residents on the memory care unit were eating snack like chocolate ice cream all day. ED#80 verified expectations for aides on memory care is to clean up spills on floor or dirty areas as they happen, but says resident care comes first.

Review of Daily Hall Assignments for the memory care unit dated 04/14/25 revealed Sweep & Mopping Schedule is Monday and Thursday long hall, Tuesday and Friday short hall and common area, and Wednesday and Saturday dining room.

The state published no narrative for this citation.