A list of the most recent deficiencies for Chapel Pointe at Carlisle. 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2023-05-11 | 2023-06-26 | 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 | 2023-05-11 | 2023-06-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-05-11 | 2023-06-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-11 | 2023-06-26 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-06-14 | 2022-07-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-14 | 2022-07-08 | 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 | 2022-06-02 | 2022-06-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-02 | 2022-06-26 | 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 | 2022-04-22 | 2022-05-13 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-22 | 2021-09-14 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-22 | 2021-08-21 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-06-22 | 2021-08-21 | 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 | 2021-06-22 | 2021-08-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-22 | 2021-08-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-22 | 2021-08-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-22 | 2021-08-21 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-06-16 | 2021-08-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-16 | 2021-08-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-16 | 2021-08-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-16 | 2021-08-02 | N |
