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Deficiency Records for Chapman Valley Manor
A list of the most recent deficiencies for Chapman Valley Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Chapman Valley Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2024-01-17 | 2024-01-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-17 | 2024-01-10 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Develop a communication plan. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Use approved construction type or materials. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-04 | 2023-04-26 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-03-07 | 2023-03-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-07 | 2023-03-27 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-03-07 | 2023-03-27 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-03-07 | 2023-03-27 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-07 | 2023-03-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-07 | 2023-03-27 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-05-10 | 2022-05-19 | Y |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-10-12 | 2021-11-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-10-12 | 2021-11-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-10-12 | 2021-11-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-12 | 2021-11-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-12 | 2021-11-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-12 | 2021-11-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-12 | 2021-11-17 | N |
| Respond appropriately to all alleged violations. | Health | 2021-09-02 | 2021-09-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-02 | 2021-09-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-02 | 2021-09-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-09-02 | 2021-09-14 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-02 | 2021-09-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-07-02 | 2019-07-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-02 | 2019-07-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-11 | 2019-07-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-06-11 | 2019-07-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-06-11 | 2019-07-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-11 | 2019-07-03 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-06-11 | 2019-06-11 | N |
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