Deficiency Records for Chatham Health and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Chatham Health and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-22 | 2023-02-21 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-08-22 | 2023-02-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-22 | 2023-02-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-08-22 | 2022-10-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-22 | 2022-10-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-22 | 2022-10-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-22 | 2022-10-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-08-22 | 2022-10-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-22 | 2022-10-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-08-22 | 2022-10-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-22 | 2022-10-31 | 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 | 2022-07-27 | 2022-09-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-27 | 2022-09-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-27 | 2022-09-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-27 | 2022-09-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-27 | 2022-09-14 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-07-27 | 2022-09-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-27 | 2022-09-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-07-27 | 2022-09-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-27 | 2022-09-14 | 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 | 2022-07-27 | 2022-09-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-27 | 2022-09-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-27 | 2022-09-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-27 | 2022-09-14 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-12-12 | 2020-01-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-12-12 | 2020-01-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-12-12 | 2020-01-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-12-12 | 2020-01-23 | 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 | 2018-08-21 | 2018-09-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-08-21 | 2018-09-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-21 | 2018-09-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-08-21 | 2018-09-19 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-08-21 | 2018-09-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-08-21 | 2018-09-19 | 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 | 2018-08-03 | 2018-09-07 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-08-03 | 2018-09-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-03 | 2018-09-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-03 | 2018-09-07 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-08-03 | 2018-09-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-08-03 | 2018-09-07 | 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 | 2018-08-03 | 2018-09-07 | 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 | 2018-08-03 | 2018-09-07 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2018-08-03 | 2018-09-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-08-03 | 2018-09-07 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2018-08-03 | 2018-09-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-08-03 | 2018-09-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-10 | Not Fixed | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-10 | Not Fixed | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-10 | Not Fixed | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-01-10 | Not Fixed | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-10 | Not Fixed | Y |
