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Deficiency Records for Chapel Manor
A list of the most recent deficiencies for Chapel 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 Chapel 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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Meet other general requirements. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-12-23 | 2025-02-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-12-18 | 2025-02-10 | 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 | 2024-12-18 | 2025-02-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-12-18 | 2025-02-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-12-18 | 2025-02-10 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2024-12-18 | 2025-02-10 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-12-18 | 2025-02-10 | N |
| Post nurse staffing information every day. | Health | 2024-12-18 | 2025-02-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-12-18 | 2025-02-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-12-18 | 2025-02-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-12-18 | 2025-02-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-12-18 | 2025-02-10 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-12-18 | 2025-02-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-12-18 | 2025-02-10 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2024-12-18 | 2025-02-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-10-03 | 2024-11-18 | Y |
| Put firmly secured handrails on each side of hallways. | Health | 2024-10-03 | 2024-11-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-12 | 2024-09-10 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-08-12 | 2024-09-10 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2024-08-12 | 2024-09-10 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-06-13 | 2024-07-10 | Y |
| 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 | 2024-06-13 | 2024-07-10 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-06-13 | 2024-07-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-13 | 2024-07-10 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-05-31 | 2024-07-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-31 | 2024-07-03 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-27 | 2024-06-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-02 | 2024-05-29 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-03-26 | 2024-04-18 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-03-26 | 2024-04-18 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-04-10 | 2024-04-17 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2024-04-10 | 2024-04-17 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-04-10 | 2024-04-17 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-03-27 | 2024-04-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-27 | 2024-04-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-03-27 | 2024-04-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-27 | 2024-04-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-03-27 | 2024-04-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-03-27 | 2024-04-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-03-27 | 2024-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-27 | 2024-04-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-27 | 2024-04-15 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-03-06 | 2024-04-09 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-03-06 | 2024-04-09 | 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 | 2024-03-06 | 2024-04-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-03-06 | 2024-04-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-06 | 2024-04-09 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-03-06 | 2024-04-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-06 | 2024-04-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-06 | 2024-04-09 | 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 | 2024-03-06 | 2024-04-09 | N |
| Provide or obtain dental services for each resident. | Health | 2024-03-06 | 2024-04-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-06 | 2024-04-09 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-03-06 | 2024-04-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-06 | 2024-04-09 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2024-03-06 | 2024-04-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-07 | 2024-04-07 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-07 | 2024-04-07 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-01-18 | 2024-03-15 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2023-09-21 | 2023-11-06 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-21 | 2023-11-06 | 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 | 2023-09-21 | 2023-11-06 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-09-21 | 2023-11-06 | 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 | 2023-09-21 | 2023-11-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-21 | 2023-11-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-21 | 2023-11-06 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2023-09-21 | 2023-11-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-09-21 | 2023-11-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-21 | 2023-11-06 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-09-12 | 2023-11-01 | 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 | 2023-09-12 | 2023-11-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-09-12 | 2023-11-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-12 | 2023-11-01 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-12 | 2023-11-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-12 | 2023-11-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-12 | 2023-11-01 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-09-12 | 2023-11-01 | 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 | 2023-09-12 | 2023-11-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-12 | 2023-11-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-12 | 2023-11-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-12 | 2023-11-01 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-12 | 2023-11-01 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-09-12 | 2023-11-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-05 | 2023-08-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-22 | 2023-08-22 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-07-22 | 2023-08-22 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-11-07 | 2023-01-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-07 | 2023-01-04 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-11-07 | 2023-01-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-31 | 2022-05-13 | 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 | 2023-05-24 | Not Fixed | Y |
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