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Deficiency Records for Chalet of Niles, LLC
A list of the most recent deficiencies for Chalet of Niles, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Chalet of Niles, 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 | 2024-07-03 | 2024-09-06 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-07-03 | 2024-09-06 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-06-20 | 2024-07-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-06-20 | 2024-07-16 | 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 | 2023-10-23 | 2023-11-23 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-23 | 2023-11-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-23 | 2023-11-23 | 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 | 2023-10-25 | 2023-11-10 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-10-25 | 2023-11-10 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-10-25 | 2023-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-25 | 2023-11-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-25 | 2023-11-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-25 | 2023-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-04 | 2023-10-24 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-04 | 2023-10-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-20 | 2023-03-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-20 | 2023-03-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-12-20 | 2023-03-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-20 | 2023-03-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-20 | 2023-03-10 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-12-20 | 2023-03-10 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-12-19 | 2023-02-10 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-12-20 | 2023-01-23 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-12-20 | 2023-01-23 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-12-20 | 2023-01-23 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-12-20 | 2023-01-23 | 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 | 2022-12-20 | 2023-01-23 | 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 | 2022-12-20 | 2023-01-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-20 | 2023-01-23 | 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 | 2022-12-20 | 2023-01-23 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-20 | 2023-01-23 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-12-20 | 2023-01-23 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-12-20 | 2023-01-23 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2022-12-20 | 2023-01-23 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-12-20 | 2023-01-23 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-12-20 | 2023-01-23 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-12-20 | 2023-01-23 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-19 | 2023-01-23 | 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 | 2022-12-19 | 2023-01-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-19 | 2023-01-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-19 | 2023-01-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-12-19 | 2023-01-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-19 | 2023-01-23 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-19 | 2023-01-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-19 | 2023-01-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-19 | 2023-01-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-12-19 | 2023-01-23 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-09 | 2022-10-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-09 | 2022-10-15 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-09 | 2022-10-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-09 | 2022-10-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-21 | 2022-05-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-03-15 | 2022-04-15 | Y |
| Ensure the activities program is directed by a qualified professional. | Health | 2022-03-15 | 2022-04-15 | 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 | 2022-03-15 | 2022-04-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-15 | 2022-04-15 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-15 | 2022-04-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-12-21 | 2022-01-22 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-21 | 2022-01-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-21 | 2022-01-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-21 | 2022-01-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-15 | 2022-01-22 | 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 | 2021-09-15 | 2022-01-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-15 | 2021-11-12 | 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 | 2021-09-15 | 2021-11-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-15 | 2021-11-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-15 | 2021-11-12 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-09-15 | 2021-11-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-09-15 | 2021-11-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-09-15 | 2021-11-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-15 | 2021-11-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-09-15 | 2021-11-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-15 | 2021-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-15 | 2021-11-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-15 | 2021-10-14 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-09-15 | 2021-10-14 | 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 | 2021-09-15 | 2021-10-14 | N |
| Provide activities to meet all resident's needs. | Health | 2021-09-15 | 2021-10-14 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-15 | 2021-10-14 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-15 | 2021-10-14 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-15 | 2021-10-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-15 | 2021-10-14 | N |
| Dispose of garbage and refuse properly. | Health | 2021-09-15 | 2021-10-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-15 | 2021-10-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-15 | 2021-10-14 | N |
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