Deficiency Records for The Laurels of Chatham
Updated as of May 01, 2020
This is not the most recent data for The Laurels of Chatham. For the most recent information, click here.
A list of the most recent deficiencies for The Laurels of Chatham. 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 that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2020-01-24 | 2020-02-21 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-01-24 | 2020-02-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-24 | 2020-02-21 | 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 | 2020-01-24 | 2020-02-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-24 | 2020-02-21 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install | Health | 2020-01-24 | 2020-02-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-24 | 2020-02-21 | 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 ne | Health | 2020-01-24 | 2020-02-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-01-24 | 2020-02-21 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-01-24 | 2020-02-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-01-24 | 2020-02-21 | N |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2019-08-05 | 2019-08-16 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-12 | 2019-04-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-12 | 2019-04-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-03-12 | 2019-04-03 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-02-14 | 2019-03-29 | 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 | 2019-02-14 | 2019-03-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-02-14 | 2019-03-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-02-14 | 2019-03-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-14 | 2019-03-29 | 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 | 2019-02-14 | 2019-03-29 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install | Health | 2019-02-14 | 2019-03-29 | N |
| Post nurse staffing information every day. | Health | 2019-02-14 | 2019-03-29 | 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 ne | Health | 2019-02-14 | 2019-03-29 | 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 | 2019-02-14 | 2019-03-29 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-02-14 | 2019-03-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-02-14 | 2019-03-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-02-14 | 2019-03-29 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-02-14 | 2019-03-29 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-02-14 | 2019-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-02-14 | 2019-03-29 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-02-14 | 2019-03-29 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-02-14 | 2019-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-17 | 2019-01-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-07-20 | 2018-08-06 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-01-16 | 2018-02-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-01-16 | 2018-02-07 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2017-12-14 | 2018-01-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2017-12-14 | 2018-01-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2017-12-14 | 2018-01-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-14 | 2018-01-11 | 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 | 2017-12-14 | 2018-01-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2017-12-14 | 2018-01-11 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2017-12-14 | 2018-01-11 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2017-12-14 | 2018-01-11 | 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 | 2017-12-14 | 2018-01-11 | 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 ne | Health | 2017-12-14 | 2018-01-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2017-12-14 | 2018-01-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2017-12-14 | 2018-01-11 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2017-12-14 | 2018-01-11 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2017-12-14 | 2018-01-11 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-01-17 | 2017-02-28 | 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 | 2017-01-17 | 2017-02-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-01-17 | 2017-02-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-01-17 | 2017-02-28 | N |
