Chapel Manor

In the surveyor’s words

From the most serious findings on record at Chapel Manor, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jul 22, 2023

  Based on the review of facility policies and procedures, clinical records, facility documentation, hospital records, review of surveillance camera, observations, interviews with residents and staff, it was determined that the facility failed to provide appropriate staff supervision during resident smoking times and non-smoking times for residents who smoke in the facility and residents with the history of drug abuse. This failure resulted in two residents (Resident R2 and R3) obtaining and abusing illicit drugs and placed residents who smoke in the facility at risk for serious harm, resulting in an Immediate Jeopardy situation for seven of nine residents reviewed. […]

• Immediate jeopardy, isolatedF689Nov 7, 2022

  Based on the review of facility documentations, policies and procedures, clinical records, hospital records, EMS records, observations, and interviews with staff, it was determined that the facility failed to provide appropriate staff supervision and failed to complete a thorough assessment of the resident environment for drug paraphernalia for Resident R355, who was readmitted from the hospital with diagnosis of drug abuse, and tested positive for cocaine in her urine. This failure of the facility to provide appropriate staff supervision and failure to conduct a thorough assessment of resident's room and personal property resulted in the resident able to access drug paraphernalia, possible abuse of controlled substance, leading to a cardiac arrest and subsequent death in the facility. […]

• Immediate jeopardy, isolatedF755Nov 7, 2022

  Based on the review of facility documentation, review of policies and procedures, review of clinical records, review of hospital records, observations, and interviews with staff, it was determined that the facility failed to have enough supply of Narcan available during a potential emergency drug overdose. This failure of the facility to appropriately administer and have enough supply of Narcan available for a resident who was prescribed opiates and had a history of opiate abuse placed Resident R355 at risk for serious injury including death and 3 other residents at risk for serious injury for one of 4 residents reviewed with a history of opioid abuse. […]

• Actual harm, isolatedF689Nov 3, 2025

  Based 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. […]

• Actual harm, isolatedF725Nov 3, 2025

  Based 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). […]