Deficiency Records for Chehalem Health and Rehab

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Updated as of March 01, 2024

A list of the most recent deficiencies for Chehalem Health 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?
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2023-12-04 2024-01-23 N
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2023-12-04 2024-01-23 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-12-04 2024-01-23 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2023-12-04 2024-01-23 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-12-04 2024-01-23 N
Post nurse staffing information every day. Health 2023-12-04 2024-01-23 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 2023-12-04 2024-01-23 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2023-12-04 2024-01-23 N
Ensure medication error rates are not 5 percent or greater. Health 2023-12-04 2024-01-23 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-12-04 2024-01-23 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 2023-12-04 2024-01-23 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-12-04 2024-01-23 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-12-04 2024-01-23 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-12-04 2024-01-23 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2023-12-04 2024-01-23 Y
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-12-04 2024-01-23 Y
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 2023-12-04 2024-01-23 Y
Provide timely, quality laboratory services/tests to meet the needs of residents. Health 2023-12-04 2024-01-23 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2023-12-04 2024-01-23 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-12-04 2024-01-23 Y
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. Fire Safety 2023-11-30 2024-01-23 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-11-30 2024-01-23 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-11-30 2024-01-23 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-11-30 2024-01-23 N
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-11-30 2024-01-23 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-11-30 2024-01-23 N
Meet other general requirements. Fire Safety 2023-11-30 2024-01-23 N
Address subsistence needs for staff and patients. Fire Safety 2023-11-30 2024-01-19 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 2023-11-30 2024-01-19 N
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 2023-11-30 2024-01-19 N
Provide properly protected cooking facilities. Fire Safety 2023-11-30 2024-01-19 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-11-30 2024-01-19 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-11-30 2024-01-19 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2022-10-21 2022-11-15 Y
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 2022-10-21 2022-11-15 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-10-21 2022-11-15 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-10-21 2022-11-15 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-10-21 2022-11-15 Y
Provide and implement an infection prevention and control program. Health 2022-10-21 2022-11-15 Y
Keep all essential equipment working safely. Health 2022-10-21 2022-11-15 Y
Conduct testing and exercise requirements. Fire Safety 2022-10-18 2022-11-15 N
Have properly located and lighted "Exit" signs. Fire Safety 2022-10-18 2022-11-15 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-10-18 2022-11-15 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2021-06-15 2021-06-24 Y
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Health 2021-04-22 2021-05-11 Y
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2018-08-20 2018-10-10 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2018-08-20 2018-10-10 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2018-08-20 2018-10-10 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 2018-08-20 2018-10-10 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2018-08-20 2018-10-10 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2018-08-20 2018-10-10 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2018-08-20 2018-10-10 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 2018-08-20 2018-10-10 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2018-08-20 2018-10-10 N
Provide activities to meet all resident's needs. Health 2018-08-20 2018-10-10 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2018-08-20 2018-10-10 N
Provide enough food/fluids to maintain a resident's health. Health 2018-08-20 2018-10-10 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2018-08-20 2018-10-10 N
Post nurse staffing information every day. Health 2018-08-20 2018-10-10 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2018-08-20 2018-10-10 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 2018-08-20 2018-10-10 N
Ensure medication error rates are not 5 percent or greater. Health 2018-08-20 2018-10-10 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 2018-08-20 2018-10-10 N
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2018-08-20 2018-10-10 N
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Health 2018-08-20 2018-10-10 N
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2018-08-20 2018-10-10 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2018-08-20 2018-10-10 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2018-08-23 2018-10-10 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2018-08-23 2018-10-10 N
Address subsistence needs for staff and patients. Fire Safety 2018-08-23 2018-10-10 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2018-08-23 2018-10-10 N
Provide primary/alternate means for communication. Fire Safety 2018-08-23 2018-10-10 N
Establish staff and initial training requirements. Fire Safety 2018-08-23 2018-10-10 N
Conduct testing and exercise requirements. Fire Safety 2018-08-23 2018-10-10 N
Have properly located and lighted "Exit" signs. Fire Safety 2018-08-23 2018-10-10 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2018-08-23 2018-10-10 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2018-08-23 2018-10-10 N
Have simulated fire drills held at unexpected times. Fire Safety 2018-08-23 2018-10-10 N