Deficiency Records for Chestnut Hill Lodge Health and Rehab Ctr
Updated as of March 01, 2024
A list of the most recent deficiencies for Chestnut Hill Lodge Health and Rehab Ctr. 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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-15 | 2023-07-06 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-05-15 | 2023-07-06 | 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 | 2023-05-15 | 2023-07-06 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-05-15 | 2023-07-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-15 | 2023-07-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-15 | 2023-07-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-05-15 | 2023-07-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-05-15 | 2023-07-06 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2023-05-15 | 2023-07-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-15 | 2023-07-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-15 | 2023-07-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-17 | 2023-06-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-17 | 2023-06-02 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-04-17 | 2023-06-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-17 | 2023-06-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-04-17 | 2023-06-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-17 | 2023-06-02 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-04-17 | 2023-06-02 | N |
| Respond appropriately to all alleged violations. | Health | 2023-04-17 | 2023-06-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-17 | 2023-06-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-17 | 2023-06-02 | 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 | 2023-04-17 | 2023-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-17 | 2023-06-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-17 | 2023-06-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-17 | 2023-06-02 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-04-17 | 2023-06-02 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-04-17 | 2023-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-17 | 2023-06-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-17 | 2023-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-17 | 2023-06-02 | N |
| 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 | 2023-04-17 | 2023-06-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-30 | 2022-12-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-30 | 2022-12-07 | 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 | 2022-09-28 | 2022-11-14 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-28 | 2022-11-14 | Y |
| 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 | 2022-06-01 | 2022-08-08 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-06-01 | 2022-07-15 | 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 | 2022-06-01 | 2022-07-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-06-01 | 2022-07-15 | N |
| Provide appropriate foot care. | Health | 2022-05-31 | 2022-07-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-05-31 | 2022-07-12 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-05-31 | 2022-07-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-31 | 2022-07-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-14 | 2022-02-04 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-08 | 2021-07-16 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-07-08 | 2021-07-16 | 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 | 2021-04-30 | 2021-07-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-30 | 2021-07-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-30 | 2021-07-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-04-30 | 2021-07-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-30 | 2021-06-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-04-30 | 2021-06-18 | 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 | 2021-04-30 | 2021-06-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-04-30 | 2021-06-18 | N |
| 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 | 2021-04-30 | 2021-06-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-30 | 2021-06-18 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-04-30 | 2021-06-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-04-30 | 2021-06-18 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-04-30 | 2021-06-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-30 | 2021-06-18 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2021-04-30 | 2021-06-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-30 | 2021-06-18 | N |
| Have exits that are accessible at all times. | Fire Safety | 2020-12-01 | 2021-02-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-12-01 | 2021-01-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-12-01 | 2021-01-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-12-01 | 2021-01-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-12-01 | 2021-01-30 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-12-01 | 2021-01-30 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-12-01 | 2021-01-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-12-01 | 2021-01-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-12-01 | 2021-01-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-20 | Not Fixed | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-11-20 | Not Fixed | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-02 | Not Fixed | Y |
