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Deficiency Records for Chapel Woods Health and Rehabilitation

View the most recent health deficiencies and inspection results for Chapel Woods Health and Rehabilitation. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Chapel Woods Health and Rehabilitation. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2025-05-13 2025-06-02 Y
Ensure medication error rates are not 5 percent or greater. Health 2025-03-12 2025-04-04 Y
Respond appropriately to all alleged violations. Health 2025-01-23 2025-02-14 Y
Have exits that are accessible at all times. Fire Safety 2024-10-25 2024-11-18 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-10-25 2024-11-18 Y
Provide and implement an infection prevention and control program. Health 2024-10-25 2024-11-18 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-10-25 2024-11-18 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 2024-10-25 2024-11-18 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 2024-10-25 2024-11-18 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-10-25 2024-11-18 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 2024-10-25 2024-11-18 N
Have proper medical gas storage and administration areas. Fire Safety 2024-10-25 2024-11-18 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2024-10-25 2024-11-18 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-10-25 2024-11-18 N
Properly provide smoke detection systems in areas open to corridors. Fire Safety 2024-10-25 2024-11-18 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 2024-10-25 2024-11-18 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2024-10-25 2024-11-18 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-12-14 2024-01-12 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 2023-12-14 2024-01-12 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 2023-12-14 2024-01-12 N
Ensure medication error rates are not 5 percent or greater. Health 2023-12-14 2024-01-12 N
Provide activities to meet all resident's needs. Health 2023-12-14 2024-01-12 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-12-14 2024-01-12 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 2023-12-14 2024-01-12 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-12-14 2024-01-12 N
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Fire Safety 2023-12-14 2024-01-12 N
Have properly located and lighted "Exit" signs. Fire Safety 2023-12-14 2024-01-12 N
Properly provide smoke detection systems in areas open to corridors. Fire Safety 2023-12-14 2024-01-12 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-12-14 2023-12-29 N
Install a fire alarm system that can be heard throughout the facility. Fire Safety 2023-12-14 2023-12-29 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-09-15 2022-10-10 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 2022-09-15 2022-10-10 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-09-15 2022-10-10 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 2022-09-15 2022-10-10 N
Properly provide smoke detection systems in areas open to corridors. Fire Safety 2022-09-15 2022-10-10 N
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Health 2022-09-15 2022-10-10 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 2022-09-15 2022-10-10 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2022-09-15 2022-10-10 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-09-15 2022-10-10 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-09-15 2022-10-10 N

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