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? |
|---|---|---|---|---|
| Respond appropriately to all alleged violations. | Health | 2021-09-24 | 2021-10-12 | Y |
| 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 |
