Deficiency Records for Chapel Woods Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Chapel Woods Health and Rehabilitation. 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 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 |
| 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 |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-12-14 | 2024-01-12 | N |
| Provide activities to meet all resident's needs. | 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 |
| 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 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 |
| 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 |
| 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 |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-05-03 | 2023-06-02 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2023-05-03 | 2023-06-02 | Y |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-05-03 | 2023-06-02 | Y |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-09-13 | 2022-10-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-13 | 2022-10-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-12 | 2022-06-11 | Y |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-06-29 | 2021-08-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-02 | 2021-07-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-02 | 2021-07-28 | 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 | 2021-07-02 | 2021-07-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-02 | 2021-07-28 | 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 | 2021-07-02 | 2021-07-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-02 | 2021-07-28 | 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 | 2021-07-02 | 2021-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-02 | 2021-07-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-02 | 2021-07-28 | N |
