A list of the most recent deficiencies for Complete Care at Chestnut Hill LLC. 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 the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-10-18 | 2022-11-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-18 | 2022-11-11 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-08-18 | 2022-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-18 | 2022-11-04 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-08-18 | 2022-10-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-18 | 2022-10-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-18 | 2022-10-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-08-18 | 2022-09-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-08-18 | 2022-09-30 | 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 | 2022-08-18 | 2022-09-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-18 | 2022-09-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-18 | 2022-09-30 | 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 | 2022-08-18 | 2022-09-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-18 | 2022-09-30 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-18 | 2022-09-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-18 | 2022-09-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-08-18 | 2022-09-30 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2022-08-18 | 2022-09-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-11 | 2020-02-21 | 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 | 2020-02-11 | 2020-02-21 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-02-11 | 2020-02-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-05 | 2019-03-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-02-05 | 2019-03-15 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-02-05 | 2019-03-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-05 | 2019-03-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-02-05 | 2019-03-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-05 | 2019-03-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-02-05 | 2019-03-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-05 | 2019-03-15 | 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 | 2019-02-05 | 2019-03-15 | 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 | 2019-02-05 | 2019-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-02-05 | 2019-03-15 | N |
| Dispose of garbage and refuse properly. | Health | 2019-02-05 | 2019-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-05 | 2019-03-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-05 | 2019-03-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-02-05 | 2019-03-15 | N |
