Chapel Manor

Inspectors wroteBased on observations, facility policy, and resident and staff interviews, it was determined that the facility failed to provide food and drink that were served at palatable temperatures for one of one meal tray tested on the first floor nursing unit.

Inspectors wroteBased on observations, and interviews with residents, it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment for the main lobby and two out of four nursing units (B and D wing). Findings Include: Observations on June 23, 2026, during a tour on the first-floor nursing unit (B-Wing) revealed the following: -room [ROOM NUMBER]B: Over-bed light inoperable for approximately two months, per an interview with Resident R1. -room [ROOM NUMBER]A: Wallpaper peeling behind the head of the bed; bathroom toilet soiled with feces; ceiling tile displaced exposing pipes; ceiling vent heavily soiled with crusted debris; stained ceiling tiles; night light missing protective cover exposing the light bulb. -room [ROOM NUMBER]: Bathroom ceiling tiles stained. -room [ROOM NUMBER]: Floor mat visibly dirty with a large slit in the center. [...]

Inspectors wroteBased on review of facility policy, review of clinical record, and staff interviews it was determined that the facility failed to develop a comprehensive care plan for one of 34 residents reviewed (Residents R17).

Inspectors wroteBased on review of clinical records, observations, and staff interviews, it was determined that the facility failed to maintain an environment that was free of accidents and hazards for one of six residents and one of four nursing units reviewed (Resident R163, D Wing).

Inspectors wroteBased on review of clinical records and staff interview it was determined that the facility failed to timely assess nutrition status to maintain acceptable parameters of nutritional status for one of eight residents reviewed (R94). Findings Include:Review of Resident R94's Minimum Data Set (MDS -federally mandated resident assessment and care screening) dated May 11, 2026, revealed the resident was admitted to the facility in July 2025 and has diagnoses of hypernatremia (elevated sodium level in the blood), hyperlipidemia (elevated levels of cholesterol and or triglycerides in the blood), dementia (a progressive disorder affecting memory, thinking and the ability to perform daily activities), and malnutrition (inadequate nutritional status resulting from insufficient intake or utilization of nutrients). [...]

Inspectors wroteBased on review of clinical records and interview with staff, it was determined the facility failed to ensure pain assessment was completed prior to administration of PRN (as needed) pain medication for one of two residents reviewed for pain management (Resident 134).

Inspectors wroteBased on observation and staff interview, the facility failed to ensure medications were stored according to required temperature ranges. Findings Include:Review of facility documentation Medication Room Temperature Log states, temperatures are to remain between 36-46 degrees. Observations on June 23, 2026, at 10:30 am, with Nurse Manager, Employee E10, of Wing B Medication Room Refrigerator (located behind the Nurses Station) revealed ten out of thirty-one days in the month of May 2026, May 3, May 4, May 5, May 10, May 11, May 16, May 17, May 29, May 30, and May 31, the refrigerator temperatures were not documented. [...]

Inspectors wroteBased on a review of clinical records, facility policies and facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that two of five residents reviewed were free from abuse.(Resident R1 and Resident R2).

Inspectors wroteBased on the review of clinical records and interview with staff it was determined that the facility failed to accurately document medical diagnosis for one of three residents reviewed (Resident R2). Findings Include:Review of facility policy, Medication Monitoring dated January 2024, stated Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of medical record in order to prevent, identify, report and resolve medication-related problems, medication errors, or other irregularities, their family, and /or resident representative. [...]

Inspectors wroteBased on clinical record review and interviews with facility staff, the facility failed to ensure that a safety device was properly function and monitor for one of one resident (Resident R2).

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure that a resident was treated with respected during a group meeting for one of four residents reviewed (Resident 35).

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff interviews it was determined that the facility failed to conduct a complete and thorough investigation related to a resident fall for one of four residents reviewed (Resident R174). Findings Include: Review of facility policy Abuse Prohibition revised October 24, 2022, revealed the facility will implement an abuse prohibition program which would include investigation of incidents and accidents. Review of Resident R174's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated April 1, 2025, revealed the resident had a Brief Interview for Mental Status (BIMS -a structured interview to assess cognitive function and orientation) score of 14 (intact cognitive response). [...]

Inspectors wroteBased on clinical record review, and staff interview, it was determined that the facility failed to ensure that the residents and/or their representative received written notice notifying them of the transfer and the reason for the move in writing and in the language and manner they understand for two residents reviewed for hospitalizations (Resident R171 and R3).

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff and resident interviews it was determined that the facility failed to develop comprehensive care plan for three of 33 residents reviewed (Resident R26, R102, and R61). Findings Include:Review of facility policy Person-Centered Care Plan revised September 15, 2025, revealed the facility will develop and implement person-centered care plan for each resident with measurable objectives to meet a resident's medical, nursing, mental, and psychosocial needs. The care plan must be customized to each individual patient's preferences and needs. [...]

Inspectors wroteBased on clinical records review and staff interviews, it was determined that the facility failed to follow physician orders to place hearing aids in the residents ears each morning and remove them at bedtime for one of one resident reviewed for vision and hearing (Resident R7).

Inspectors wroteBased on review of facility documentation, review of clinical records, observations, and staff interviews it was determined that the facility failed to provide appropriate assistance/supervision for one of four residents reviewed for falls (Resident R174). Findings Include:Review of van driver, Employee E6, personnel file revealed the employee was hired as the facility van driver effective November 4, 2024. Review of van driver, Employee E6, job description for Positions that Involve Transporting Customers/Clients revealed the employee is responsible for assisting residents when boarding and disembarking the vehicle. The employee will operate the vehicle in a safe manner when transporting residents. Review of van driver, Employee E6, personnel file revealed a Vehicle Safety Competency dated November 15, 2024. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff interviews it was determined that the facility failed to monitor and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for one of five residents reviewed (Resident R142). Findings Include: Review of facility policy Weights and Heights dated July 15, 2025, revealed the facility will ensure all patients maintain acceptable parameters of nutrition status. [...]

Inspectors wroteBased on observation, staff interviews, clinical record review, and review of facility policy, it was determined that the facility failed to ensure that a resident was provided with dialysis clamps for one of one resident reviewed receiving hemodialysis. (Residents 15).

Inspectors wroteBased on observation, clinical record review, and staff interview, the facility failed to ensure Resident R1 who required 1:1 supervision received adequate supervision to prevent accidents, which resulted in actual harm to Resident R1 who sustained an unwitnessed fall from bed and sustained a traumatic brain injury for one of five residents reviewed (Resident R1). This deficiency was cited identified as past non-compliance. Findings Include:Review of the facility policy titled Enhanced Patient Supervision: Continuous 1:1, revised September 15, 2025, revealed, When using Continuous 1:1 Supervision, designated staff will be assigned to manage the 1:1 supervision of the patient. The designated staff will only be involved with the delivery of care to this patient and no other patient (where possible, a staff member already known to the patient is recommended to ensure consistency of care). [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide adequate staffing to ensure continuous supervision for Resident R1, who required 1:1 observation as ordered by the physician. This failure resulted in actual harm to Resident R1 who was left unsupervised, sustained a fall from the bed, requiring transfer to the hospital and diagnosis of traumatic head injury for one of five residents reviewed. (Resident R1) Findings Include: Review of facility assessment revealed under section titled, Function - Care Requirements 3. Staff/Personnel required: Consider the specific needs of each resident unit in the facility to adjust as necessary (i.e. number of staff, skill sets). [...]

Inspectors wroteBased on review of clinical records, review of facility policy and interviews with staff and residents, it was determined that the facility failed to ensure complete documentation of Medication Administration Records for two of 10 residents records reviewed (Resident R1 and R4). Review of Facility policy titled Medication Administration: General Guidelines dated January 2025 revealed The individual who administers the medication dose, records the administration on the resident's MAR (Medication Administration Record) immediately following the medication being given. In no case should the individual who administered the medication report off-duty without first recording the administration of any medication. Further review of policy revealed When PRN medication are administered, the following documentation is provided: a. [...]

Inspectors wroteBased on interviews with residents and staff, observations of the laundry department and linen storage areas throughout the nursing units, it was determined that the facility failed to provide sufficient supplies of linen for the bathing and toileting care needs for 12 of 12 residents reviewed. (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11 and R12).

Inspectors wroteBased on interviews with staff and residents and observations of the resident care equipment, it was determined that essential equipment for the mechanical preparation of ice throughout the facility was not being maintained in a safe operating condition.

Inspectors wroteBased on review of clinical record, facility policy, facility documentation, and staff interviews, it was determined the facility failed to ensure Resident R1 was free from neglect by failing to place Resident R1's bed in a safe position after the completion of care. This failure resulted in actual harm to Resident R1 who fell out of bed, sustained a subdural hematoma and an intertrochanteric fracture of left femur (thigh) for one of four residents reviewed for falls (Resident R1).

Inspectors wroteBased on clinical record reviews, interviews with staff, reviews of hospital records and facility policies and procedures, it was determined that the facility failed to permit one of three residents reviewed to return to the facility after hospitalization. (Resident R1)

Inspectors wroteBased on the review of clinical records, facility policies, and interview with staff, it was determined that the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Facility failed to update a resident's comprehensive care plan and discharge plan, as appropriate for one of three residents reviewed (Resident R1) Findings Include: Review of facility policy Discharge and Transfer: [...]

Inspectors wroteBased on review of facility provided documentation and interview with staff, it was determined that the facility did not provide requested evidence of yearly performance evaluations for three out of five nurse aides reviewed (Employee E20, E21, and E22)

Inspectors wroteBased on observation, review of posted daily nurse staffing data, and staff interviews, it was determined that the facility did not ensure that nursing staffing information was posted on a prominent place readily accessible to residents on two out of two resident floors (First and Second floors)

Inspectors wroteBased on observations, interviews with staff, and review of facility policy, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety related to labeling and dating of food items and food wrapped or in covered containers

Inspectors wroteBased on observation, clinical record review and interview with staff, it was determined that the facility did not ensure the residents record was complete and accurate related to diagnosis and pharmacy review for two of 39 residents reviewed (Resident R98 and R 40).

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public, for four of four nursing units observed (A-Wing, B-Wing, C-Wing and D-Wing nursing units).

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that corridors had firmly secured handrails on three of four nursing units observed (B-Wing, C-Wing and D-Wing nursing units).

Inspectors wroteBased on observations, clinical record reviews and interviews with staff, it was determined that the facility failed to accurately complete MDS assessments for two of 39 residents reviewed (Residents R187 and R96).

Inspectors wroteBased on observations, clinical record review, review of facility documents and staff interviews, it was determined that the facility failed to revise the care plan for Feeding-Related Care, for one of 36 residents reviewed (Resident R124).

Inspectors wroteBased on clinical record review, observations of residents and interviews with staff, it was determined that the facility failed to implement timely interventions for weight management of one of 36 residents reviewed (R181).

Inspectors wroteBased on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of 36 residents reviewed (R158).

Inspectors wroteBased on observation, clinical record review, and interview with staff, it was determined that the facility did not ensure the physician notes were accurately completed related to resident assessment and gastrostomy status for one of 39 residents reviewed (Resident R98).

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one out of five residents sampled. (R 150).

Inspectors wroteBased on observations, review of facility policies, review of facility documentation, clinical record review and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to Transmission Based Precautions for one of 36 residents reviewed (Resident R49).

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that call bell systems functioned properly for one of four nursing units observed (C-Wing nursing unit).

Inspectors wroteBased on review of a meal tray test results, review of facility policy and interviews with resident and staff, it was determined that the facility failed to serve foods that were palatable and at proper temperatures for one of eight nursing floors reviewed. (Unit D)

Inspectors wroteBased on observation and interviews with staff, it was determined that the facility failed to equip corridors with safe handrails on each side, for one of four nursing units observed (Second floor nursing D unit).

Inspectors wroteBased on the review of clinical records, interview with staff and resident, it was determined that the facility failed to provide care and services as ordered by the physician for one of three residents reviewed (Resident R2). Findings Include: During interview with Resident R2 on August 12, 2024, at 10:00 a.m. the resident stated that he should be getting ACE wraps to his lower extremity for swelling. Resident stated he was seen by the physician and recommended he wear compression stockings for lower extremity. Resident stated compression stocking was uncomfortable for him so the physician stated he should wear ACE wraps. Resident stated staff did not assist him for putting the ACE wraps on. Observation of the Resident R2 on August 12, 2024, at 10:00 a.m. revealed that the resident was not wearing ACE wraps or compression stockings to the lower extremity. [...]

Inspectors wroteBased on review of a meal tray test results, review of facility policy and interviews with resident and staff, it was determined that the facility failed to serve foods that were palatable and at proper temperatures for one of eight nursing floors reviewed. (Unit A)

Inspectors wroteBased on clinical record review and resident and staff interview, it was determined that the facility failed to schedule an appointment for outside services in a timely manner for one of 3 residents reviewed (Resident R3).

Inspectors wroteBased on review of select facility policy and procedures, observations, and resident and staff interviews, it was determined that the facility failed to ensure that residents could make choices about aspects of their lives that were significant to them, such as smoking and outdoor fresh air times were provided and or honored consistent with interests of the residents for four of six residents reviewed (Resident R1, R2, R3 and R4).

Inspectors wroteBased on observation, review of facility documentation, interview with staff and residents, it was revealed that the facility failed to ensure a safe, clean and homelike environment for resident for one of four nursing units reviewed, A nursing unit. Findings Include: During an initial tour of the facility on June 12, 2024, Resident R5, requested surveyor to come to his friend's room, A 115 to look at his bathroom. Observation inside resident's bathroom revealed that the ceiling tiles were removed and there was a hole to the ceiling, some of the ceiling tiles had brown colored discoloration. Interview with Resident R5, on June 12, 2024, at 10:00 stated his friend's bathroom had a leak from bathroom from the above floor, it was leaking for almost a month. Facility did not fix it, there was dirty water from the above floor toilet. [...]

Inspectors wroteBased on the review of clinical records, facility policies, and interview with staff, it was determined that the facility failed to develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Facility failed to update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities for one of one residents reviewed for discharge planning process. (Resident R5) Findings Include: Review of facility policy Discharge Planning Process: [...]

Inspectors wroteBased on the review of clinical records, interview with resident and staff, it was determined that the facility failed to administer the medications as ordered by the physician for One of One resident reviewed. (Resident R1). Findings Include: Review of facility policy General Dose Preparation and Medication Administration, revealed that Prior to administration of medication, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 4.1 Facility staff should: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident, as set forth in facility's medication administration schedule. [...]

Inspectors wroteBased on review of clinical records and facility provided documentation, and interview with staff, it was determined that the facility failed to provide the required advanced notice, through a Notice of Medicare Non-Coverage (CMS 10123), regarding termination of Medicare services for one of four residents reviewed. (Resident R2) Findings Include: Review of Resident R2's clinical record revealed the resident was given two Notices of Medicare Coverage (NOMNC) cms-10123 during the month of May. Continued review of the resident's clinical record revealed the resident was given a Notice of Medicare Non-Coverage (NOMNC) cms-10123 on May 13, 2024 at 8:30 a.m. with a last day of coverage listed as the same day May 13, 2024. Resident R2 and his representative did not receive appropriate notice to appeal the denial on Medicare services. On May 31, 2024 at 1:15 p.m. [...]

Inspectors wroteBased on review of facility policy, observations, review of clinical record, and interviews with residents and staff, it was determined the facility failed to ensure the environment was free of potential accidents and hazards related to medication administration for one of seven residents reviewed. (Resident R1) Findings Include: Review of the facility policy titled, General Dose Preparation and Medication Administration with a revision date on January 1, 2022 states under dose preparation 3.10 Facility staff should not leave medications or chemicals unattended. Under medication administration, 5.10 Observe the resident's consumption of the medication(s). [...]

Inspectors wroteBased on review of facility documents, clinical record reviews, and interviews with facility staff, it was determined that the facility failed to ensure the timely delivery of cancer medication from pharmacy for one of six resident records reviewed. (Resident R3)

Inspectors wroteBased on staff interviews, and the review of clinical records, it was determined that the facility failed to ensure that residents were informed of the discontinuation of a medication for one out of four residents reviewed (Resident R3).

Inspectors wroteBased on observations, interviews and the review of clinical records, it was determined that the facility failed to ensure that behavioral health care services were attained for two out of four residents reviewed (Resident R1 and Resident R2).

Inspectors wroteBased on resident and staff interviews, and review of clinical records, it was determined that the facility failed to ensure the timely delivery of an anti-anxiety medication for one out of four residents reviewed (Resident R3).

Inspectors wroteBased on review of facility documentation, ombudsman communications, clinical records and interview with resident, ombudsman and staff, it was determined that the facility failed to put forth sufficient efforts to promptly resolve resident complaints/grievances reported by ombudsman for one of three residents reviewed. (Resident R1)

Inspectors wroteBased on the review of facility policy, clinical records, interviews with resident and staff, it was determined that the facility failed to provide care and services as outlines by the comprehensive care plan met the professional standards of quality related to the appropriate use of electric wheelchair by Resident R1 who had a history of dangerously using electric wheelchair and placing staff and residents at risk for injuries for one of three residents reviewed. (Resident R1) Findings Include: Review of facility policy, Motorized Mobility Devices: use, dated August 7, 2023, revealed that, In accordance with the Americans with Disabilities Act, Title II, Part 35, Nondiscrimination on the Basis of Disability in State and Local Government Services, Use of other power-driven mobility devices: [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff and resident interviews, it was determined that the facility failed to maintain resident dignity for two of five residents reviewed (Resident R2 and R4). Findings Include: Review of facility policy Resident Rights, effective November 2016, revealed the resident has a right to a dignified existence inside the facility. Further review of facility policy revealed the facility must treat each resident with respect and dignity, and care for each resident in a manner, and in an environment, that promotes maintenance, or enhancement, of quality of life, recognizing each resident's individuality. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure that each resident was involved in developing the care plan and making decisions about his or her care for two of five records reviewed (Resident R1 and R3). Findings Include: Review of facility policy Person-Centered Care Plan, revised October 24, 2022, revealed person-centered care means to focus on the resident as the point of control and support the resident in making their own choices and having control over their daily life. The policy states that the resident has the right to participate in the development and implementation of the person-centered care plan. [...]

Inspectors wroteBased on observation of the storage room located on the basement level of the facility and review of facility documents, it was determined that the facility failed to maintain an effective pest control program.