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Deficiency Records for The Waters of Cheatham, LLC
View the most recent health deficiencies and inspection results for The Waters of Cheatham, LLC. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for The Waters of Cheatham, LLC. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2026-03-26 | 2026-04-23 | N |
| Post nurse staffing information every day. | Health | 2026-03-26 | 2026-04-23 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2026-03-26 | 2026-04-23 | N |
| Provide activities to meet all resident's needs. | Health | 2026-03-26 | 2026-04-23 | 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 | 2026-03-26 | 2026-04-23 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2026-03-26 | 2026-04-20 | 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 | 2022-04-27 | 2022-06-14 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-04-27 | 2022-06-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-27 | 2022-06-14 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-04-27 | 2022-06-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-27 | 2022-06-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-04-27 | 2022-06-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-27 | 2022-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-27 | 2022-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-27 | 2022-06-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-27 | 2022-05-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-23 | 2019-11-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-23 | 2019-11-12 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-10-23 | 2019-11-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-23 | 2019-11-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-10-23 | 2019-11-12 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-23 | 2019-11-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-23 | 2019-11-12 | 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 | 2019-10-23 | 2019-11-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-23 | 2019-11-12 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-10-23 | 2019-10-31 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-10-23 | 2019-10-31 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-10-23 | 2019-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-23 | 2019-10-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-23 | 2019-10-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-23 | 2019-10-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2026-03-26 | Not Fixed | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2026-03-26 | Not Fixed | N |
| Provide properly protected cooking facilities. | Fire Safety | 2026-03-26 | Not Fixed | N |
| Conduct testing and exercise requirements. | Fire Safety | 2026-03-26 | Not Fixed | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2026-03-26 | Not Fixed | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2026-03-26 | Not Fixed | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2026-03-26 | Not Fixed | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2026-03-26 | Not Fixed | N |