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Deficiency Records for Chehalem Post Acute
View the most recent health deficiencies and inspection results for Chehalem Post Acute. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Chehalem Post Acute. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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 | 2026-01-15 | 2026-02-03 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2026-01-15 | 2026-02-03 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2025-08-13 | 2025-08-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-03-28 | 2025-04-29 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2025-03-28 | 2025-04-29 | N |
| Post nurse staffing information every day. | Health | 2025-03-28 | 2025-04-29 | N |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2025-03-28 | 2025-04-29 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. | Health | 2025-03-28 | 2025-04-29 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2025-03-28 | 2025-04-29 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2025-03-28 | 2025-04-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2025-03-28 | 2025-04-29 | 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 | 2025-03-28 | 2025-04-29 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2025-03-28 | 2025-04-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2025-03-28 | 2025-04-29 | Y |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-03-28 | 2025-04-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-03-28 | 2025-04-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-03-28 | 2025-04-29 | 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 | 2025-03-28 | 2025-04-29 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2025-03-28 | 2025-04-29 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2025-03-28 | 2025-04-29 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-03-28 | 2025-04-29 | Y |
| 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 | 2025-03-28 | 2025-04-29 | 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 | 2025-03-28 | 2025-04-29 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2025-03-28 | 2025-04-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2025-03-28 | 2025-04-29 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2025-03-28 | 2025-04-29 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-03-28 | 2025-04-29 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-03-28 | 2025-04-29 | 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 | 2025-03-28 | 2025-04-29 | 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 | 2025-03-28 | 2025-04-29 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2025-03-28 | 2025-04-29 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2025-03-28 | 2025-04-29 | 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 | 2025-01-07 | 2025-01-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2025-01-07 | 2025-01-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-01-07 | 2025-01-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-09-19 | 2024-10-07 | Y |
| 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 |
| Have simulated fire drills held at unexpected times. | Fire Safety | 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 |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-12-04 | 2024-01-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-12-04 | 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 | 2023-12-04 | 2024-01-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-12-04 | 2024-01-23 | N |
| Meet other general requirements. | Fire Safety | 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 |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-12-04 | 2024-01-23 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-12-04 | 2024-01-23 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-12-04 | 2024-01-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-12-04 | 2024-01-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-12-04 | 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 | 2023-12-04 | 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 | 2023-12-04 | 2024-01-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-12-04 | 2024-01-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-12-04 | 2024-01-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-10-21 | 2022-11-15 | N |
| 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 | N |
| Keep all essential equipment working safely. | Health | 2022-10-21 | 2022-11-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-21 | 2022-11-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-21 | 2022-11-15 | 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 | 2022-10-21 | 2022-11-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-10-21 | 2022-11-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-21 | 2022-11-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-21 | 2022-11-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-21 | 2022-11-15 | N |