Deficiency Records for Cheltenham Nursing and Rehab C
Updated as of June 01, 2019
This is not the most recent data for Cheltenham Nursing and Rehab C. For the most recent information, click here.
A list of the most recent deficiencies for Cheltenham Nursing and Rehab C. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-11-06 | 2019-01-30 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2018-11-06 | 2019-01-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-06 | 2019-01-30 | 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 | 2018-11-06 | 2019-01-30 | 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 | 2018-11-06 | 2019-01-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-06 | 2019-01-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-06 | 2019-01-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-11-06 | 2019-01-30 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-11-06 | 2019-01-30 | 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 | 2018-11-06 | 2019-01-30 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-11-06 | 2019-01-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-06 | 2019-01-18 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Develop a communication plan. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Establish methods for sharing information. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-11-06 | 2018-11-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-12 | 2018-07-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-12 | 2018-07-31 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2018-06-12 | 2018-07-31 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-06-12 | 2018-07-31 | Y |
| Have power receptacles that are properly grounded. | Fire Safety | 2018-01-25 | 2018-03-09 | N |
| Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. | Health | 2017-07-20 | 2017-09-01 | Y |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-07-20 | 2017-09-01 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-07-20 | 2017-09-01 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-07-20 | 2017-09-01 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-07-20 | 2017-09-01 | Y |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-07-20 | 2017-09-01 | Y |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-07-20 | 2017-09-01 | Y |
| Dispose of garbage and refuse properly. | Health | 2017-07-20 | 2017-09-01 | Y |
| Give or get specialized rehabilitative services per the patient's assessment or plan of care. | Health | 2017-07-20 | 2017-09-01 | Y |
| Provide or obtain dental services for each resident. | Health | 2017-07-20 | 2017-09-01 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-07-20 | 2017-09-01 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-07-20 | 2017-09-01 | Y |
| Provide or obtain laboratory services only when ordered by the attending physician. | Health | 2017-07-20 | 2017-09-01 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-07-20 | 2017-09-01 | Y |
| Meet other general requirements. | Fire Safety | 2017-03-08 | 2017-04-04 | N |
| Have a correctly designed non-healthcare occupancy area in a health care facility. | Fire Safety | 2017-03-08 | 2017-04-04 | N |
| Use approved construction type or materials. | Fire Safety | 2017-03-08 | 2017-04-04 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2017-03-08 | 2017-04-04 | 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 | 2017-03-08 | 2017-04-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-03-08 | 2017-04-04 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2017-03-08 | 2017-04-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-03-08 | 2017-04-04 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2017-03-08 | 2017-04-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-03-08 | 2017-04-04 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-03-08 | 2017-04-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-03-08 | 2017-04-04 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-08 | 2017-04-04 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-03-08 | 2017-04-04 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2017-03-08 | 2017-04-04 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-03-08 | 2017-04-04 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2017-03-08 | 2017-04-04 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-03-08 | 2017-04-04 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-03-08 | 2017-04-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-03-08 | 2017-04-04 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-08 | 2017-04-04 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2017-03-08 | 2017-04-04 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-03-08 | 2017-04-04 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-03-08 | 2017-04-04 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-08 | 2017-04-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-11-16 | 2016-12-13 | Y |
