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? |
|---|---|---|---|---|
| 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 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-07 | 2023-01-04 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-11-07 | 2023-01-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-07 | 2023-01-04 | 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 | 2022-11-07 | 2023-01-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-07 | 2023-01-04 | N |
| Keep all essential equipment working safely. | Health | 2022-11-07 | 2023-01-04 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-11-07 | 2023-01-04 | N |
| 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 |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-09 | 2023-01-03 | 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 | 2022-11-09 | 2023-01-03 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-11-09 | 2023-01-03 | 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 | 2022-11-09 | 2023-01-03 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-11-09 | 2023-01-03 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2022-11-09 | 2023-01-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-09 | 2023-01-03 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-09 | 2023-01-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-11-09 | 2023-01-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-11-09 | 2023-01-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-11-09 | 2023-01-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-09 | 2023-01-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-09 | 2023-01-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-31 | 2022-05-13 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-11-29 | 2022-02-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-29 | 2022-02-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-29 | 2022-02-07 | N |
| Meet other general requirements. | Fire Safety | 2021-11-29 | 2022-01-12 | 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 | 2021-11-29 | 2022-01-12 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-11-29 | 2022-01-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-29 | 2022-01-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-11-29 | 2022-01-12 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-11-29 | 2022-01-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-11-29 | 2022-01-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-29 | 2022-01-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-29 | 2022-01-12 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-11-29 | 2022-01-12 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-11-29 | 2022-01-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-22 | 2022-01-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-22 | 2022-01-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-22 | 2022-01-05 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-11-22 | 2022-01-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-05 | 2021-09-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-05 | 2021-09-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-16 | 2021-08-02 | 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 |
