CHAPEL HILL NURSING CENTER

Nursing Home Inspector

4511 ROBOSSON ROAD
RANDALLSTOWN, MD 21133
Baltimore County
Phone: 410-922-2443
Provider Number: 215220
Last Inspection: 05/09/2017

About the Nursing Home

Number of Beds: 63
Number of Residents: 51
Beds Available: 12
Percent Occupancy: 81%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

60

Facility 		25

County 		29

MD 		20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 
60

2017		 20

2016		 33

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

5/9/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Potential 3 6/14/2017
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 6/14/2017
 
Failed To: Give notice to the resident before a room or roommate change. Pattern : Potential 3 6/14/2017
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 6/14/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 6/14/2017
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 6/14/2017
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 6/14/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 6/14/2017
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated : Minimal 3 6/14/2017
 
Failed To: Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. Isolated : Minimal 3 6/14/2017
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 6/14/2017
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 6/14/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/14/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 6/14/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 6/14/2017
 
Failed To: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Isolated : Minimal 3 6/14/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 6/14/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 6/14/2017
 

2/29/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 4/15/2016
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Pattern : Minimal 4 4/15/2016
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 4/15/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 4/15/2016
 
Failed To: Give or get specialized rehabilitative services per the patient's assessment or plan of care. Isolated : Minimal 3 4/15/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 4/15/2016
 

11/20/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 1/13/2015
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 1/13/2015
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 1/13/2015
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 1/13/2015
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Minimal 3 1/13/2015
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 1/13/2015
 
Failed To: Post nurse staffing information/data on a daily basis. Pattern : Potential 3 1/13/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Isolated : Minimal 3 1/13/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 1/13/2015
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Minimal 3 1/13/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 1/13/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

8/24/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Isolated : Minimal 3 9/26/2017
 

6/7/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Try to resolve each resident's complaints quickly. Pattern : Potential 3 7/5/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 7/5/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 7/5/2017
 

1/20/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Minimal 4 2/22/2017
 
Failed To: Upon the death of a resident, convey the resident’s personal funds and an accounting of those funds to the appropriate party. Pattern : Minimal 4 2/22/2017
 

12/4/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Minimal 4 2/16/2016
 
Failed To: Upon the death of a resident, convey the resident’s personal funds and an accounting of those funds to the appropriate party. Pattern : Potential 3 2/16/2016
 

10/15/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 10/30/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MD State Avg
Number of Residents 51 103.43 107.44
Registered Nurses 0.93 1.01 0.94
Licensed Practical / Vocational Nurses 0.80 0.91 0.87
Certified Nursing Assistants 1.92 2.40 2.35
Total Staff Hours 3.65 4.32 4.16

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MD State Avg%
of high risk long-stay residents with pressure ulcers 5 6 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 91 93 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 95 96 95
of long-stay residents experiencing one or more falls with major injury 4 3 2
of long-stay residents who have depressive symptoms 1 3 3
of long-stay residents who lose too much weight 7 6 6
of long-stay residents who received an antianxiety or hypnotic medication 31 17 18
of long-stay residents who received an antipsychotic medication 25 12 12
of long-stay residents who self-report moderate to severe pain 1 4 4
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 34 21 21
of long-stay residents whose need for help with daily activities has increased 11 17 17
of long-stay residents with a catheter inserted and left in their bladder 2 1 1
of long-stay residents with a urinary tract infection 3 3 3
of low risk long-stay residents who lose control of their bowels or bladder 54 61 58
of short-stay residents assessed and appropriately given the pneumococcal vaccine 64 81 83
of short-stay residents who had an outpatient emergency department visit 14 8 10
of short-stay residents who made improvements in function 58 67 67
of short-stay residents who newly received an antipsychotic medication 2 1 1
of short-stay residents who self-report moderate to severe pain 8 13 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 60 83 82
of short-stay residents who were rehospitalized after a nursing home admission 21 20 20
of short-stay residents who were successfully discharged to the community 36 53 55
of short-stay residents with pressure ulcers that are new or worsened 0 0 1