A list of the most recent deficiencies for Chestertown Nursing and Rehab. 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? |
|---|---|---|---|---|
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-10-04 | 2024-02-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-04 | 2024-02-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-04 | 2024-02-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-10-04 | 2024-02-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-04 | 2024-02-12 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-10-04 | 2024-01-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-04 | 2024-01-17 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-10-04 | 2024-01-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-04 | 2024-01-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-04 | 2024-01-17 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-10-04 | 2024-01-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-04 | 2024-01-17 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-10-04 | 2024-01-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-04 | 2024-01-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-28 | 2023-12-04 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-28 | 2023-12-04 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-09-28 | 2023-12-04 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-09-28 | 2023-12-04 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-09-28 | 2023-12-04 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-09-28 | 2023-12-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-28 | 2023-12-04 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-09-28 | 2023-12-04 | 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 | 2023-09-28 | 2023-12-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-28 | 2023-12-04 | N |
| Post nurse staffing information every day. | Health | 2023-09-28 | 2023-12-04 | 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 | 2023-09-28 | 2023-12-04 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-28 | 2023-12-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-09-28 | 2023-12-04 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-28 | 2023-12-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-28 | 2023-12-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-28 | 2023-12-04 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-09-28 | 2023-12-04 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-09-28 | 2023-12-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-28 | 2023-12-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-28 | 2023-12-04 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-28 | 2023-12-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-28 | 2023-12-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-28 | 2023-12-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-28 | 2023-12-04 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-28 | 2023-12-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-28 | 2023-12-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-28 | 2023-12-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-12-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-09 | 2022-05-31 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-03-09 | 2022-05-31 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-09 | 2022-05-31 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-03-09 | 2022-05-31 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-03-09 | 2022-05-31 | Y |
| Meet other general requirements. | Fire Safety | 2019-04-24 | 2019-06-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-24 | 2019-06-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-04-24 | 2019-06-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-04-24 | 2019-06-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-24 | 2019-06-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-04-24 | 2019-06-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-24 | 2019-06-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-24 | 2019-06-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-15 | 2019-04-15 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-02-15 | 2019-04-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-15 | 2019-04-15 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-02-15 | 2019-04-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-02-15 | 2019-04-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-15 | 2019-04-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-02-15 | 2019-04-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-15 | 2019-04-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-15 | 2019-04-15 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2017-12-07 | 2018-01-12 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2017-12-07 | 2018-01-07 | 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 | 2017-12-07 | 2018-01-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-12-07 | 2018-01-07 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-10-19 | 2017-12-31 | N |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-10-19 | 2017-12-31 | N |
| 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. | Health | 2017-10-19 | 2017-12-31 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-10-19 | 2017-12-31 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-10-19 | 2017-12-31 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-10-19 | 2017-12-31 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-10-19 | 2017-12-31 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-10-19 | 2017-12-31 | 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 | 2017-10-19 | 2017-12-31 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-10-19 | 2017-12-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-12-07 | 2017-12-28 | N |
