Deficiency Records for Cheltenham Nursing and Rehab C
Updated as of January 01, 2021
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? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2020-10-14 | 2020-12-11 | N |
| Use approved construction type or materials. | Fire Safety | 2020-10-14 | 2020-12-11 | 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 | 2020-10-14 | 2020-12-11 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2020-10-14 | 2020-12-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-10-14 | 2020-12-11 | N |
| Have protected exits that allow the resident to escape the building. | Fire Safety | 2020-10-14 | 2020-12-11 | 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 | 2020-10-14 | 2020-12-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-10-14 | 2020-12-11 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2020-10-14 | 2020-12-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-14 | 2020-12-11 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-10-14 | 2020-12-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-10-14 | 2020-12-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-10-14 | 2020-12-11 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2020-10-14 | 2020-12-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-10-14 | 2020-12-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-10-14 | 2020-12-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-10-14 | 2020-12-11 | 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 | 2020-10-06 | 2020-11-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-10-06 | 2020-11-06 | 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 | 2020-10-06 | 2020-11-06 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-10-06 | 2020-11-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-11 | 2020-01-09 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-10-11 | 2020-01-09 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| Meet other general requirements. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-11 | 2019-12-02 | 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 | 2019-10-11 | 2019-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-11 | 2019-12-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-20 | 2019-10-25 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-20 | 2019-10-25 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-20 | 2019-10-25 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-09-20 | 2019-10-25 | N |
| Dispose of garbage and refuse properly. | Health | 2019-09-20 | 2019-10-25 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-09-20 | 2019-10-25 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-09-20 | 2019-10-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-20 | 2019-10-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-14 | 2019-08-19 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-08-14 | 2019-08-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-07-09 | 2019-07-10 | 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 | 2019-07-09 | 2019-07-10 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-07-09 | 2019-07-10 | Y |
| 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 necessary and PRN use is limited. | 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 |
