Deficiency Records for Complete Care at Chestnut Hill LLC
Updated as of January 01, 2022
This is not the most recent data for Complete Care at Chestnut Hill LLC. For the most recent information, click here.
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 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 |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-01-31 | 2018-03-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-31 | 2018-03-05 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-01-31 | 2018-03-05 | 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 | 2018-01-31 | 2018-03-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-01-31 | 2018-03-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-01-31 | 2018-03-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-01-31 | 2018-03-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-31 | 2018-03-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-01-31 | 2018-03-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-01-31 | 2018-03-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-01-31 | 2018-03-05 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-01-31 | 2018-03-05 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-01-31 | 2018-03-05 | 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 | 2018-01-31 | 2018-03-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-01-31 | 2018-03-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-01-31 | 2018-03-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-01-31 | 2018-03-05 | N |
