Deficiency Records for Chapel Manor
Updated as of July 01, 2020
This is not the most recent data for Chapel Manor. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-08-26 | 2019-11-18 | 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 | 2019-08-26 | 2019-11-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-08-26 | 2019-11-18 | N |
| Be properly staffed | Fire Safety | 2019-08-26 | 2019-11-18 | N |
| Meet other general requirements. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-08-26 | 2019-10-25 | 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 | 2019-08-26 | 2019-10-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
| Have an externally vented heating system. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-08-23 | 2019-10-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-08-23 | 2019-10-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-23 | 2019-10-15 | 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 | 2019-08-23 | 2019-10-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-23 | 2019-10-15 | 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 | 2019-08-23 | 2019-10-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-08-23 | 2019-10-15 | N |
| 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 | 2019-08-23 | 2019-10-15 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-08-23 | 2019-10-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-15 | 2019-04-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-21 | 2019-04-16 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-01-22 | 2019-03-05 | Y |
| Meet other general requirements. | Fire Safety | 2018-07-30 | 2018-09-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-07-30 | 2018-09-13 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-07-30 | 2018-09-13 | 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 | 2018-07-30 | 2018-09-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-30 | 2018-09-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-07-30 | 2018-09-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-30 | 2018-09-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-30 | 2018-09-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-07-31 | 2018-09-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-07-31 | 2018-09-03 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-07-31 | 2018-09-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-31 | 2018-09-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-31 | 2018-09-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-07-31 | 2018-09-03 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-07-31 | 2018-09-03 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-06-15 | 2018-07-30 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-08-24 | 2017-10-10 | 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 | 2017-08-24 | 2017-10-10 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2017-08-24 | 2017-10-10 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2017-08-24 | 2017-10-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-24 | 2017-10-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-08-24 | 2017-10-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-08-24 | 2017-10-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-08-24 | 2017-10-10 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2017-08-24 | 2017-10-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-08-24 | 2017-10-10 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-08-14 | 2017-09-29 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-14 | 2017-09-29 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-14 | 2017-09-29 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-08-14 | 2017-09-29 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-08-14 | 2017-09-29 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-08-14 | 2017-09-29 | N |
