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Deficiency Records for Chehalem Post Acute
A list of the most recent deficiencies for Chehalem Post Acute. 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 Chehalem Post Acute. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-09-19 | 2024-10-07 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-12-04 | 2024-01-23 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-12-04 | 2024-01-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-04 | 2024-01-23 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-12-04 | 2024-01-23 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-12-04 | 2024-01-23 | N |
| Post nurse staffing information every day. | Health | 2023-12-04 | 2024-01-23 | 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 | 2023-12-04 | 2024-01-23 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-04 | 2024-01-23 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-12-04 | 2024-01-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-04 | 2024-01-23 | 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 | 2023-12-04 | 2024-01-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-12-04 | 2024-01-23 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-12-04 | 2024-01-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-04 | 2024-01-23 | 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 | 2023-12-04 | 2024-01-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-04 | 2024-01-23 | 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 | 2023-12-04 | 2024-01-23 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-12-04 | 2024-01-23 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-12-04 | 2024-01-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-04 | 2024-01-23 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2023-11-30 | 2024-01-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-30 | 2024-01-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-11-30 | 2024-01-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-30 | 2024-01-23 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-11-30 | 2024-01-23 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-30 | 2024-01-23 | N |
| Meet other general requirements. | Fire Safety | 2023-11-30 | 2024-01-23 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-11-30 | 2024-01-19 | 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 | 2023-11-30 | 2024-01-19 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-11-30 | 2024-01-19 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-11-30 | 2024-01-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-30 | 2024-01-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-11-30 | 2024-01-19 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-10-21 | 2022-11-15 | 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 | 2022-10-21 | 2022-11-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-21 | 2022-11-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-21 | 2022-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-21 | 2022-11-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-21 | 2022-11-15 | Y |
| Keep all essential equipment working safely. | Health | 2022-10-21 | 2022-11-15 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-18 | 2022-11-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-18 | 2022-11-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-18 | 2022-11-15 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-08-20 | 2018-10-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-08-20 | 2018-10-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-08-20 | 2018-10-10 | 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 | 2018-08-20 | 2018-10-10 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-08-20 | 2018-10-10 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-08-20 | 2018-10-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-20 | 2018-10-10 | 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 | 2018-08-20 | 2018-10-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-08-20 | 2018-10-10 | N |
| Provide activities to meet all resident's needs. | Health | 2018-08-20 | 2018-10-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-08-20 | 2018-10-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-08-20 | 2018-10-10 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2018-08-20 | 2018-10-10 | N |
| Post nurse staffing information every day. | Health | 2018-08-20 | 2018-10-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-08-20 | 2018-10-10 | 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 | 2018-08-20 | 2018-10-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-08-20 | 2018-10-10 | 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 | 2018-08-20 | 2018-10-10 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-08-20 | 2018-10-10 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-08-20 | 2018-10-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-08-20 | 2018-10-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-20 | 2018-10-10 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-08-23 | 2018-10-10 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-08-23 | 2018-10-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-08-23 | 2018-10-10 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2018-08-23 | 2018-10-10 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-08-23 | 2018-10-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2018-08-23 | 2018-10-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-08-23 | 2018-10-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-08-23 | 2018-10-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-08-23 | 2018-10-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-23 | 2018-10-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-08-23 | 2018-10-10 | N |
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