A list of the most recent deficiencies for The Waters of Cheatham, LLC. 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? |
|---|---|---|---|---|
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-05-17 | 2023-06-30 | Y |
| 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 |
| 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 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | 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 |
| 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 |
| 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 |
| 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 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-24 | 2022-05-13 | 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 and implement an infection prevention and control program. | Health | 2019-10-23 | 2019-11-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-10-21 | 2019-10-31 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-10-21 | 2019-10-31 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-10-21 | 2019-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-21 | 2019-10-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-21 | 2019-10-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-21 | 2019-10-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-04 | 2019-01-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-04 | 2019-01-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-05 | 2019-01-13 | 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 | 2018-12-05 | 2019-01-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-12-05 | 2018-12-06 | N |
