CMS Inspection Results for CHELTENHAM NURSING AND REHAB C

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 03/24/2009 Health Survey for CHELTENHAM NURSING AND REHAB C

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Pattern	Minimal harm or potential for actual harm
Get rid of garbage properly.	Pattern	Minimal harm or potential for actual harm
Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm

 

• 03/17/2009 Fire Safety Survey for CHELTENHAM NURSING AND REHAB C

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
automatic sprinkler systems that have been maintained in working order.	Pattern	Minimal harm or potential for actual harm
Building Service Equipment
Deficiency	Scope	Level of Harm
restrictions on the use of portable space heaters.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
properly maintained smoke detectors.	Isolated	Minimal harm or potential for actual harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm

 

• 06/27/2008 Health Survey for CHELTENHAM NURSING AND REHAB C

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that follow each resident's written care plan.	Isolated	Minimal harm or potential for actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm

 

• 06/20/2008 Fire Safety Survey for CHELTENHAM NURSING AND REHAB C

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
automatic sprinkler systems that have been maintained in working order.	Widespread	Minimal harm or potential for actual harm
portable fire extinguishers.	Isolated	Minimal harm or potential for actual harm
Building Contruction
Deficiency	Scope	Level of Harm
a two-hour-resistant firewall in common walls.	Pattern	Minimal harm or potential for actual harm
approved construction type or materials.	Widespread	Potential for minimal harm
Building Service Equipment
Deficiency	Scope	Level of Harm
properly constructed linen or trash chutes.	Pattern	Minimal harm or potential for actual harm
properly protected cooking facilities.	Isolated	Minimal harm or potential for actual harm
heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Pattern	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Isolated	Minimal harm or potential for actual harm
exit stairways and towers that are smoke proof.	Isolated	Minimal harm or potential for actual harm
corridors or aisles that are unobstructed and are at least 8 feet in width.	Isolated	Minimal harm or potential for actual harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
a fire alarm system that can be heard throughout the facility.	Pattern	Minimal harm or potential for actual harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm
Vertical Openings
Deficiency	Scope	Level of Harm
proper stairway enclosures and vertical shafts.	Isolated	Minimal harm or potential for actual harm

 

• 02/04/2008 Fire Safety Survey for CHELTENHAM NURSING AND REHAB C

Building Contruction
Deficiency	Scope	Level of Harm
a two-hour-resistant firewall in common walls.	Pattern	Potential for minimal harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm

 

• 01/28/2008 Health Survey for CHELTENHAM NURSING AND REHAB C

Administration
Deficiency	Scope	Level of Harm
Follow all laws and professional standards.	Pattern	Immediate jeopardy to resident health or safety
Be administered in a way that leads to the highest possible level of well being for each resident.	Widespread	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Widespread	Immediate jeopardy to resident health or safety
Keep temperature levels comfortable and safe.	Pattern	Immediate jeopardy to resident health or safety
Make sure that the nursing home area is safe, easy to use, clean and comfortable.	Widespread	Minimal harm or potential for actual harm
Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm