Deficiency Records for Chapel Hill Nursing Center

A list of the most recent deficiencies for Chapel Hill Nursing Center. 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?
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	Health	2020-02-19	2020-03-31	N
Reasonably accommodate the needs and preferences of each resident.	Health	2020-02-19	2020-03-31	N
Ensure residents have reasonable access to and privacy in their use of communication methods.	Health	2020-02-19	2020-03-31	N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.	Health	2020-02-19	2020-03-31	N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	Health	2020-02-19	2020-03-31	N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	Health	2020-02-19	2020-03-31	N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	Health	2020-02-19	2020-03-31	N
Respond appropriately to all alleged violations.	Health	2020-02-19	2020-03-31	N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	Health	2020-02-19	2020-03-31	N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave.	Health	2020-02-19	2020-03-31	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	2020-02-19	2020-03-31	N
Ensure services provided by the nursing facility meet professional standards of quality.	Health	2020-02-19	2020-03-31	N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	Health	2020-02-19	2020-03-31	N
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.	Health	2020-02-19	2020-03-31	N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.	Health	2020-02-19	2020-03-31	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	2020-02-19	2020-03-31	N
Ensure each resident?s drug regimen must be free from unnecessary drugs.	Health	2020-02-19	2020-03-31	N
Ensure medication error rates are not 5 percent or greater.	Health	2020-02-19	2020-03-31	N
Ensure that residents are free from significant medication errors.	Health	2020-02-19	2020-03-31	N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	Health	2020-02-19	2020-03-31	N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	Health	2020-02-19	2020-03-31	N
Develop and implement policies and procedures for flu and pneumonia vaccinations.	Health	2020-02-19	2020-03-31	N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.	Health	2020-02-19	2020-03-31	N
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.	Health	2020-02-19	2020-03-31	N
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	Health	2020-02-19	2020-03-31	N
Develop and maintain an Emergency Preparedness Program (EP).	Fire Safety	2020-02-20	2020-03-17	N
Meet other general requirements.	Fire Safety	2020-02-20	2020-03-17	N
Inspect, test, and maintain automatic sprinkler systems.	Fire Safety	2020-02-20	2020-03-17	N
Properly select, install, inspect, or maintain portable fire extinguishes.	Fire Safety	2020-02-20	2020-03-17	N
Have a battery powered remote alarm panel in a location accessible by operating personnel.	Fire Safety	2018-08-23	2018-10-25	N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	Health	2018-08-30	2018-09-28	N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	Health	2018-08-30	2018-09-28	N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	Health	2018-08-30	2018-09-28	N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Health	2018-08-30	2018-09-28	N
Provide appropriate treatment and care according to orders, resident?s preferences and goals.	Health	2018-08-30	2018-09-28	N
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.	Health	2018-08-30	2018-09-28	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	2018-08-30	2018-09-28	N
Provide and implement an infection prevention and control program.	Health	2018-08-30	2018-09-28	N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Fire Safety	2018-08-23	2018-09-21	N
Properly select, install, inspect, or maintain portable fire extinguishes.	Fire Safety	2018-08-23	2018-09-21	N
Install smoke barrier doors that can resist smoke for at least 20 minutes.	Fire Safety	2018-08-23	2018-09-21	N
Have an externally vented heating system.	Fire Safety	2018-08-23	2018-09-21	N
Have generator or other power source capable of supplying service within 10 seconds.	Fire Safety	2018-08-23	2018-09-21	N
Have proper medical gas storage and administration areas.	Fire Safety	2018-08-23	2018-09-21	N
Have exits that are accessible at all times.	Fire Safety	2017-05-04	2017-06-15	N
Inspect, test, and maintain automatic sprinkler systems.	Fire Safety	2017-05-04	2017-06-15	N
Ensure that testing and maintenance of electrical equipment is performed.	Fire Safety	2017-05-04	2017-06-15	N
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.	Health	2017-05-09	2017-06-14	N
Reasonably accommodate the needs and preferences of each resident.	Health	2017-05-09	2017-06-14	N
Give notice to the resident before a room or roommate change.	Health	2017-05-09	2017-06-14	N
Provide housekeeping and maintenance services.	Health	2017-05-09	2017-06-14	N
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	Health	2017-05-09	2017-06-14	N
Allow residents the right to participate in the planning or revision of care and treatment.	Health	2017-05-09	2017-06-14	N
Provide necessary care and services to maintain or improve the highest well being of each resident .	Health	2017-05-09	2017-06-14	N
Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene.	Health	2017-05-09	2017-06-14	N
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Health	2017-05-09	2017-06-14	N
Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.	Health	2017-05-09	2017-06-14	N
Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances.	Health	2017-05-09	2017-06-14	N
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Health	2017-05-09	2017-06-14	N
Ensure that residents are safe from serious medication errors.	Health	2017-05-09	2017-06-14	N
Store, cook, and serve food in a safe and clean way.	Health	2017-05-09	2017-06-14	N
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.	Health	2017-05-09	2017-06-14	N
Have a program that investigates, controls and keeps infection from spreading.	Health	2017-05-09	2017-06-14	N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.	Health	2017-05-09	2017-06-14	N
Keep accurate, complete and organized clinical records on each resident that meet professional standards.	Health	2017-05-09	2017-06-14	N

Deficiency Records for Chapel Hill Nursing Center

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