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Deficiency Records for Chapel Hill Community
A list of the most recent deficiencies for Chapel Hill Community. 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 Chapel Hill Community. 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-05-21 | 2024-04-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-06-06 | 2023-06-26 | Y |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-06-06 | 2023-06-26 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-06 | 2023-06-26 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-06-06 | 2023-06-26 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-06 | 2023-06-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-07 | 2022-11-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-07 | 2022-11-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-11-07 | 2022-11-22 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-11-07 | 2022-11-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-07 | 2022-11-22 | N |
| Provide activities to meet all resident's needs. | Health | 2022-11-07 | 2022-11-22 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-07 | 2022-11-22 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-07 | 2022-11-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-07 | 2022-11-22 | Y |
| Provide or obtain dental services for each resident. | Health | 2022-11-07 | 2022-11-22 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-11-07 | 2022-11-22 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-11-07 | 2022-11-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-07 | 2022-11-22 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-01 | 2022-11-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-01 | 2022-11-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-12-12 | 2020-01-13 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-12-12 | 2020-01-13 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-12-12 | 2020-01-13 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-12-12 | 2020-01-13 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-12-12 | 2020-01-13 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-12 | 2020-01-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-12 | 2020-01-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-12-12 | 2020-01-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-12-12 | 2020-01-13 | 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 | 2019-12-12 | 2020-01-13 | 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 | 2019-12-12 | 2020-01-13 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-12-12 | 2020-01-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-12-09 | 2020-01-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-12-09 | 2020-01-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-09 | 2020-01-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-12-09 | 2020-01-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-12-09 | 2020-01-13 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-12-09 | 2020-01-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-12-09 | 2020-01-13 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-12-09 | 2020-01-13 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-10-11 | 2018-11-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-11 | 2018-11-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-11 | 2018-11-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-10-11 | 2018-11-19 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-10-11 | 2018-11-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-10-10 | 2018-11-19 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-10-10 | 2018-11-19 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-10-10 | 2018-11-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-10-10 | 2018-11-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-10-10 | 2018-11-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-10-10 | 2018-11-02 | N |
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