Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chatham Hills Subacute Care Center during CMS and state inspections, most recent first.
A resident with ESRD on M/W/F hemodialysis had an order for Gabapentin 100 mg TID, but the 1 PM dose was repeatedly missed because it was scheduled while the resident was out of the facility for dialysis. The MAR and progress notes showed multiple omissions across several months, and staff interviews confirmed the dose timing was not adjusted and there was no documented physician contact regarding the missed doses.
Failure to notify the physician and document abnormal blood sugars: A resident with DM and HTN had orders for finger stick blood sugar checks and to notify the physician if glucose was below 70 or above 250. Review of the eMAR showed multiple blood sugar readings above 250, but the nursing notes did not document physician notification. An LPN stated she would notify the physician and document it, while the RN/UM and DON acknowledged that notifications and documentation were expected but were not found.
CP failed to identify irregularities during MRRs for two residents. One resident with ESRD and dialysis had gabapentin scheduled for a time when the resident was routinely out of the facility, resulting in repeated missed doses that were not addressed in the CP review. Another resident with severe cognitive impairment received PRN Xanax for anxiety, but nursing documentation did not consistently show the behaviors prompting use or failed non-drug interventions, and the CP did not identify the documentation deficiency.
Food Storage and Sanitation Deficiencies: Surveyors observed ice buildup in the walk-in freezer, including ice in direct contact with exposed puff pastry, and a discolored film on an air-drying pot and pan rack. In a unit nourishment pantry, the refrigerator temp log had multiple missing morning and evening entries, and the FSD acknowledged the dept was responsible for monitoring pantry refrigerator temps and that potentially hazardous foods could be stored there.
A survey found a tube feeding pump soiled with yellow and brown substance and two floor mats heavily soiled with black and brown substances in a resident room. An LPN confirmed the mats should have been cleaned by housekeeping or maintenance, and stated nurses were responsible for cleaning the feeding pump; the RN unit manager and DON also confirmed feeding pumps should be cleaned by nurses for infection control purposes.
A resident with severe cognitive impairment, dementia with behavioral disturbance, psychosis, and a history of brain injury received PRN Xanax for anxiety, but the chart did not consistently document the specific behaviors prompting use or the nonpharmacologic interventions attempted first. Staff described the resident as anxious, exit-seeking, restless, and sometimes combative or trying to stand unassisted, yet the EMAR, EBMR, and progress notes did not reliably correlate those behaviors with the PRN administrations, and the RN/UM and DON acknowledged the documentation did not show that interventions had failed.
A resident with schizoaffective disorder and moderate cognitive impairment was receiving olanzapine for the condition, but the care plan did not address either the diagnosis or the antipsychotic medication. The MDS reflected schizophrenia/schizoaffective disorder and antipsychotic use, and both the ADON and DON stated the care plan should have included these items.
Failure to provide written notice of a resident’s hospital transfer to the guardian was identified for one resident who had severely impaired cognition and was dependent on staff for all ADLs. The resident was transferred for evaluation of low BP, rapid HR, and elevated body temp, and the UM, LSW, LNHA, and DON confirmed that written notice was not provided to the guardian as required by facility policy.
Four dependent residents were found with wet or soiled briefs during a surveyor incontinence tour. One resident’s brief and bladder pad were saturated with urine and feces, two residents had briefs saturated with urine, and one resident’s brief was saturated with urine and feces. The residents had diagnoses including UTI, CKD, urinary retention, MS, overactive bladder, AKI, diabetes, and impaired cognition, and their care plans called for staff assistance with toileting hygiene and incontinence checks every 2 hours for some residents. CNA staff confirmed the conditions, and an RN/unit manager stated incontinence rounds should occur 3-4 times per shift.
A resident on Enhanced Barrier Precautions (EBP) did not receive care in accordance with infection control protocols. Two CNAs were observed not wearing the required PPE while providing ADLs, despite signage indicating the need for gloves and gowns. The DON cited the high number of residents on EBP as a challenge for placing supplies at each room, leading to non-compliance with the facility's infection control policy.
The facility failed to ensure staff wore appropriate PPE for residents on Enhanced Barrier Precautions, as observed in two cases. One resident's incontinence check was initially conducted without a gown, and another resident with a gall bladder drain tube had no EBP sign or PPE bin at their door. Both instances violated the facility's EBP policy.
The facility failed to handle potentially hazardous foods safely, as observed by surveyors. In the walk-in freezer, hamburger patties and hot dogs were found without labels or dates, and the inner bags were open. Additionally, outdated cereal boxes were found in the South unit pantry. The facility's policies require all food to be labeled and dated, which was not followed, leading to the deficiency.
The facility failed to clarify duplicate orders for Ferrous Sulfate and did not obtain Pregabalin for pain management for two residents. One resident received both tablet and liquid forms of Ferrous Sulfate simultaneously, while another did not receive Pregabalin for several days due to unavailability from the pharmacy.
The facility failed to serve meals in a dignified manner, with residents at the same table receiving meals at different times over three days. Staff interviews confirmed that residents should be served together, but the new Food Service Director sent trays by room number, not table seating, contrary to the facility's policy.
A facility failed to deliver mail to residents in a timely manner, resulting in a resident missing important Social Security correspondence. The delay occurred due to a covering social worker's unfamiliarity with the mail process during the DSS's maternity leave. The issue was resolved when a new social worker discovered and distributed the undelivered mail.
Two residents in a LTC facility, both severely cognitively impaired and dependent on staff for eating, were not provided with necessary meal assistance. One resident was found with an untouched lunch tray, while another did not receive a lunch tray until it was brought to staff's attention. The facility's policy on resident dining was not adhered to, contributing to this deficiency.
The facility failed to maintain a sanitary environment by not keeping the garbage container area free of debris and trash. During a kitchen tour, a surveyor observed debris and trash around the dumpster area, which the Food Service Director stated was the responsibility of housekeeping. The facility's Waste Management Policy requires the area to be kept clean and clear at all times.
Missed Gabapentin Doses During Dialysis
Penalty
Summary
The facility failed to provide safe, appropriate dialysis-related medication services for a resident with ESRD who was dependent on hemodialysis. The resident had diagnoses including end stage renal disease, dependence on renal dialysis, and a left below-knee amputation, and was cognitively intact with a BIMS score of 15. The resident had an implanted left upper chest wall port-a-cath for hemodialysis and was scheduled for dialysis on Monday, Wednesday, and Friday with a chair time of 10:50 AM. The resident also had an order for Gabapentin 100 mg by mouth three times daily for neuropathy. The medication administration record showed that the 1:00 PM dose repeatedly occurred while the resident was out of the facility at dialysis, and the dose was not administered on multiple dialysis days. In June 2025, 9 of 24 doses were coded as out of facility or other; in July 2025, 13 of 31 doses were coded as out of facility; in August 2025, 12 of 31 doses were coded as out of facility; and in September 2025, 7 of 15 doses were coded as out of facility or other. The corresponding progress notes showed the resident was at dialysis and did not receive the 1:00 PM Gabapentin dose on those dates. During interview, the LPN stated the resident was at dialysis on M/W/F and she was unable to administer the 1 PM dose, and she was not sure what else she should have done, adding that she maybe could have let her supervisor know. The UM/RN stated the nurse should have looked at the dialysis schedule, that the resident would not return for the 1 PM dose, and that the nurse should call the physician every time there was a missed dose and document that contact; she acknowledged there were no progress notes showing the physician was called when the dose was missed. The consultant pharmacist stated a resident on dialysis should not have medications scheduled when they are out of the facility for dialysis and expected the nurse to follow the chain of command to make the necessary change. The facility policies stated medications are to be administered safely and in accordance with prescriber orders, and medication omissions are considered medication errors.
Failure to Notify Physician and Document Out-of-Range Blood Sugars
Penalty
Summary
The facility failed to ensure that an LPN followed the physician order to notify the physician when a resident’s blood sugar was less than 70 or greater than 250 for a resident with Type 2 diabetes mellitus and hypertension. The resident’s record showed a care plan for diabetes management, an order for finger stick blood sugar checks twice daily before breakfast and before dinner, and an order to notify the physician if the blood sugar was below 70 or above 250. The resident also had an insulin sliding scale order for insulin aspart before meals and at bedtime. Review of the August through September 2025 eMAR showed multiple blood sugar readings above 250, including readings of 299, 260, 258, 277, 307, 297, 319, 315, 358, 284, 355, 342, 288, 269, and 334. Review of the nursing progress notes did not show documentation that the physician was notified when these blood sugar values were above the ordered parameters. During interview, an LPN stated that if there was an order to notify the physician for blood sugar below 70 or above 250, she would notify the physician and document it in the progress note, but also stated, "Usually the nurse practitioner is here, and we just tell her," and acknowledged that if it was not documented, it was not done. The RN/UM stated that nurses were expected to inform the physician if blood sugar was below 70 or above 250 and then document it in the progress note, but she did not see notes showing that the physician had been notified for out-of-range blood sugars. The DON stated that nurses should document communications with doctors so everyone was on the same page and acknowledged that the nurses should have called the physician when blood sugars were out of parameters and documented the communication. The DON also stated there should not have been two blood sugar orders and that nurses should have called the doctor for clarification.
CP Failed to Identify Medication Omissions and Inadequate PRN Psychotropic Documentation
Penalty
Summary
The Consultant Pharmacist (CP) failed to identify and address medication irregularities during monthly drug regimen reviews for a resident receiving gabapentin for neuropathy and for another resident receiving PRN Xanax for anxiety. The facility policy stated that the CP performs medication regimen reviews for every resident and reviews the medical record to prevent, identify, report, and resolve medication-related problems, including omissions of ordered medications. For the resident with end stage renal disease who was dependent on dialysis, the record showed a physician’s order for gabapentin 100 mg three times daily for neuropathy, with the 1 PM dose repeatedly missed because the resident was out of the facility for dialysis treatments. The resident stated they were scheduled for dialysis transport at 10 AM on Monday, Wednesday, and Friday and returned at about 4 PM. The eMAR showed 41 missed 1 PM doses between 6/7/25 and 9/15/25. The CP completed drug regimen reviews on multiple dates, but the facility’s Nursing Summary Reports showed no recommendation identifying or addressing that the gabapentin was scheduled for administration while the resident was away from the facility. For the resident with traumatic brain injury, dementia, psychosis, and severe cognitive impairment, the record showed PRN Xanax orders for anxiety and multiple administrations of the medication. However, the nursing documentation did not consistently explain the behaviors that prompted the medication or document failed non-pharmacologic interventions. The EBMR contained inconsistent behavior entries, including blank fields, X’s instead of counts, and entries that did not correlate with the dates Xanax was given. Nursing staff and the DON acknowledged that the behavior documentation and progress notes did not correlate with the need for the PRN Xanax, and the CP stated he did not look at behavior documentation and made no recommendation regarding the inadequate documentation for the PRN psychotropic use.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain proper food service sanitation practices and to properly store potentially hazardous foods. During a kitchen tour, the walk-in freezer was observed with a solid piece of ice on the floor near a rack under the fan. An opened cardboard box of puff pastry had ice buildup on top, and when the box was opened, two solid pieces of ice were in direct contact with the exposed puff pastry. The Food Service Director stated this was not safe practice. In the same area, a hard plastic rack used for pots and pans that were air drying had a pinkish brown dry film on the surfaces between the tines, and the Food Service Director acknowledged the discoloration. In the south nursing unit nourishment pantry, the refrigerator temperature log showed inconsistent monitoring and documentation. The log required temperatures to be recorded in the morning and evening, but entries were missing for multiple mornings and evenings over several days. During interview, the Food Service Director stated he had recently learned that his department was responsible for monitoring and recording pantry refrigerator temperatures, and he acknowledged that potentially hazardous foods could be stored in those refrigerators and that temperatures needed to remain in acceptable ranges for food safety. Facility policies reviewed by surveyors stated that freezer temperatures should be checked at least twice a day and that food must be stored in a clean, dry area free from contaminants.
Soiled feeding pump and floor mats in resident room
Penalty
Summary
The facility failed to maintain the resident's environment, equipment, and living area in a safe, sanitary, and homelike manner in 1 of 2 nursing units observed. In room [ROOM NUMBER], the surveyor observed a tube feeding pump soiled with a yellow and brown substance, along with two floor mats that were heavily soiled with black and brown substances. The report identified that the pump was used to move formula through the feeding tube into the stomach at a controlled rate. On a later observation, the tube feeding pump was no longer in the room, but the floor mats remained heavily soiled with a brown and black substance. An LPN confirmed the mats were soiled and stated they should have been cleaned by housekeeping or maintenance staff. The LPN also confirmed that nurses were responsible for ensuring the tube feeding pump was cleaned properly and stated the pump had been removed from the room. The RN unit manager and the DON both confirmed that feeding pumps should be cleaned by nurses for infection control purposes.
Inadequate documentation for PRN Xanax use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary administration of PRN Xanax, an anti-anxiety psychotropic medication, because the record did not adequately document the behaviors that justified use of the medication or the non-drug interventions that were attempted and failed before administration. The deficiency involved one resident who had diagnoses including traumatic subdural hemorrhage, aphasia, generalized muscle weakness, dysarthria, anarthria, gait and mobility abnormalities, unspecified psychosis, dementia with behavioral disturbance, and Alzheimer’s disease. The resident’s MDS reflected a BIMS score of 3, indicating severely impaired cognition. The resident’s care plan identified psychotropic medication use related to behavior management and directed staff to monitor and record targeted behaviors such as pacing, wandering, disrobing, inappropriate responses, and violence or aggression, and to document nonpharmacologic interventions such as conversation, hand massage, diversional activities, music therapy, redirection, reassurance, deep breathing, relaxation techniques, or moving the resident to a quieter environment. The EMAR showed multiple PRN Xanax administrations for anxiety, but the corresponding nursing documentation did not consistently explain what behaviors were present or what interventions had been tried before the medication was given. In several instances, the notes only stated that the resident was anxious, restless, or that redirection was unsuccessful, while other notes documented delirium and inattention without linking those entries to the PRN use. Survey interviews with CNA, LPNs, the RN/UM, DON, and consultant pharmacist showed that staff recognized the resident could become agitated, yell, want to go home, ask repeatedly to use the bathroom despite having a catheter, and sometimes try to stand or walk unassisted. However, the RN/UM and DON acknowledged that the EBMR and progress notes did not correlate with the Xanax administrations and did not show that nonpharmacologic interventions had failed. The EBMR also contained inconsistent behavior entries, including blank fields, zeros, and X’s, and some dates showed behavior entries without Xanax administration. The psychiatric progress note described periods of anxiety, exit-seeking behaviors, poor safety awareness, and no overt aggression, and the Xanax order was changed to every 6 hours PRN.
Failure to Include Schizoaffective Disorder and Antipsychotic Use in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for Resident #3 that addressed schizoaffective disorder and the use of antipsychotic medication. Resident #3 was admitted with diagnoses that included schizoaffective disorder, and the comprehensive admission MDS with an assessment reference date of 8/23/25 showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. The MDS also reflected a diagnosis of schizophrenia, which included schizoaffective disorder, and that the resident was receiving antipsychotic medication. A physician order dated 8/19/25 directed olanzapine 10 mg at bedtime for schizoaffective disorder. Review of the care plan with a start date of 8/19/25 showed that it did not address the diagnosis of schizoaffective disorder or the use of an antipsychotic medication. During interview, the ADON stated that both the diagnosis and the antipsychotic medication should absolutely have been addressed on the care plan, and the DON later stated that Resident #3 should have had a care plan addressing schizoaffective disorder and the use of an antipsychotic medication.
Failure to Provide Written Notice of Hospital Transfer to Guardian
Penalty
Summary
The facility failed to ensure that written notice of a resident’s transfer to a hospital was provided to the resident’s mother, who was listed in the admission record as the emergency contact and court-appointed guardian, for 1 of 4 residents reviewed. Resident #102 was admitted with diagnoses including post-operative care of a surgical wound of the right buttock, an antibiotic-resistant infection of the surgical wound site, and a history of a ruptured aneurysm in the brain. The admission MDS dated 3/14/2025 reflected severely impaired cognition and dependence on staff for all ADLs. The resident was transferred to the hospital on 3/18/2025 at 10:00 AM for further evaluation of low blood pressure, rapid heart rate, and elevated body temperature. During interviews, the Unit Manager confirmed she did not provide written notice of the transfer to the guardian, and the Licensed Social Worker also confirmed she had not provided written notice. The LNHA and DON confirmed the facility had not provided written notice that the resident was transferred to a hospital to the guardian. The facility policy, Emergency Transfer or Discharge, stated that in an emergency transfer or discharge to a hospital or other related institution, the facility will notify the representative or other family member.
Delayed Incontinence Care for Dependent Residents
Penalty
Summary
The facility failed to ensure timely incontinence care for dependent residents on the South unit. During an incontinence tour, the surveyor observed four residents in bed with soiled or wet briefs: one resident’s brief and bladder pad were saturated with urine and feces, two residents had briefs saturated with urine, and one resident’s brief was saturated with urine and feces. CNA #1 confirmed the conditions of the briefs during the observations. The residents involved had diagnoses and care needs indicating dependence on staff for toileting and personal hygiene. One resident had diagnoses including urinary tract infection, chronic kidney disease, and urinary retention, with an MDS showing intact cognition, dependence on staff for personal hygiene, frequent bladder incontinence, and always incontinent bowels. Another resident had multiple sclerosis and an overactive bladder, with severely impaired cognition and dependence on staff for personal hygiene and bowel and bladder incontinence. A third resident had acute kidney failure and diabetes mellitus, with intact cognition and dependence on staff for toileting hygiene and frequent bladder and bowel incontinence. The fourth resident had acute kidney failure with tubular necrosis and diabetes mellitus, with severely impaired cognition and dependence on staff for personal and toileting hygiene and frequent bowel and bladder incontinence. Each resident’s care plan included interventions for staff assistance with ADLs and toileting hygiene, and some plans directed staff to check the resident every 2 hours for incontinence. During interviews, CNA #1 stated incontinence care should be provided every 2 hours on all shifts and that it did not appear to have been done. The RN/unit manager stated that incontinence rounds should be conducted 3-4 times on all shifts. The staffing coordinator reported that the CNAs assigned to the affected residents were responsible for 17 residents each on the 11-7 AM shift.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) while providing Activities of Daily Living (ADLs) care for a resident on EBP. The resident, who was admitted with diagnoses including surgical aftercare following surgery on the digestive system, was observed in a room with an EBP sign indicating the need for gloves and a gown during high-contact care activities. However, two Certified Nurse Aides (CNAs) were observed not wearing the required personal protective equipment (PPE) while providing care and handling soiled linens. Interviews with the CNAs revealed a lack of awareness and understanding of the EBP requirements, with one CNA stating the absence of a PPE cart as the reason for not donning PPE. The Director of Nursing (DON) acknowledged the issue, citing the high number of residents on EBP as a challenge for placing supplies at each room. The facility's policy mandates the use of gloves and gowns during high-contact activities for residents on EBP, but this was not adhered to, increasing the risk of infection spread.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) to reduce the transmission of multidrug-resistant organisms (MDROs). This deficiency was observed for two residents on two different units. In one instance, the Infection Preventionist (IP) did not initially wear a gown while performing an incontinence check on a resident, despite the EBP sign indicating the need for both gloves and a gown. The IP acknowledged the mistake and corrected it after the surveyor pointed it out. The resident had been admitted with diagnoses including secondary malignant neoplasm of the breast and hemothorax, and had a physician order for EBP due to the risk of MDROs. The care plan also specified the need for gown and gloves during high-contact activities, which was not initially followed by the IP. In another instance, a resident with a gall bladder drain tube did not have an EBP sign or PPE bin at their door. The surveyor observed the resident multiple times without the required signage or PPE bin. During an incontinence check, the Registered Nurse/Unit Manager (RN/UM) only wore gloves and not a gown, despite handling the resident's biliary drain tube. The resident had been admitted with diagnoses including acute cholecystitis, immunodeficiency, and obstruction of the bile duct, and had a physician order for EBP due to the risk of MDROs. The care plan also specified the need for gown and gloves during high-contact activities, which was not followed by the RN/UM. The facility's policy on Enhanced Barrier Precautions required the use of gown and gloves for high-contact activities and the posting of signs indicating the type of precautions and PPE required. The policy also mandated that PPE be available outside the resident rooms. The RN/UM and the Director of Nursing (DON) acknowledged the lapses in following the EBP protocol during meetings with the survey team. The facility's failure to adhere to its own EBP policy was evident in the observations and interviews conducted by the surveyors.
Deficient Food Handling and Storage Practices
Penalty
Summary
The facility failed to handle potentially hazardous foods and maintain sanitation in a safe and consistent manner, as observed during a survey. In the walk-in freezer, a box of hamburger patties and a box of hot dogs were found without labels or dates, and the inner plastic bags were open to the air. The Food Service Director (FSD) acknowledged that these items should have been labeled with received and opened dates, and the bags should have been closed. Additionally, a fry basket contained an item resembling a french fry, despite no fried foods being prepared for breakfast that day. Further inspection revealed outdated food items in the South unit pantry, including a box of corn flakes with a date of May 1, 2023, and a box of rolled oat cereal with a date of February 14, 2023. The facility's policies on food receiving and storage, as well as refrigerator and freezer management, require all food to be covered, labeled, and dated, with supervisors responsible for ensuring food items are not expired. These policies were not adhered to, contributing to the deficiency.
Failure to Clarify Medication Orders and Obtain Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not clarifying duplicate physician's orders for Ferrous Sulfate and failing to obtain a medication for pain for two residents. For Resident #63, the facility had duplicate orders for Ferrous Sulfate in both tablet and liquid form, which were both administered on the same day. The LPN acknowledged that the Ferrous Sulfate 325 mg tablets should have been discontinued but did not address why both forms were administered simultaneously. For Resident #133, the facility failed to administer Pregabalin capsules for pain management from 9/6/23 to 9/13/23 due to the medication being unavailable from the pharmacy. The facility documented that they were awaiting a delivery from the pharmacy and a prescription from the physician. Despite notifying the physician, the medication was not provided during this period, resulting in the resident not receiving their prescribed pain management. The facility's policies for medication administration and physician orders require that any orders needing clarification be addressed with the physician and that any concerns about medication dosages or potential adverse consequences be communicated. However, these policies were not followed, leading to the deficiencies observed by the surveyors.
Failure to Serve Meals Dignifiedly
Penalty
Summary
The facility failed to ensure that residents were served their meals in a dignified manner during meal service, as observed by surveyors over three consecutive days. On the first day, a staff member was seen feeding one resident while another resident at the same table was not eating or being fed. Additionally, several tables had residents who were served their meals at different times, with some residents waiting for their meals while others at the same table were already eating. The meal trays did not arrive on the same cart, leading to staggered serving times. This pattern continued over the next two days, with residents at the same table being served meals at different times, sometimes with a delay of several minutes. Interviews with facility staff, including an LPN and the Administrator, confirmed that residents at the same table should be served together to maintain dignity. The Administrator attributed the issue to the new Food Service Director, who was sending trays by room number rather than by table seating. The facility's Resident Dining Policy, dated April 14, 2024, indicated that rounds and audits should be conducted to ensure residents at each table are served together, highlighting a failure to adhere to this policy.
Failure to Deliver Resident Mail Timely
Penalty
Summary
The facility failed to provide timely delivery of mail to residents, including on Saturdays, which resulted in a significant delay in a resident receiving important correspondence. This deficiency was identified during a resident council group meeting where a resident reported not receiving mail from November 2023 until mid-March 2024. The resident was expecting a letter from Social Security, which was delayed, leading to a disqualification due to a missed deadline. The facility had to intervene to rectify the situation and secure the resident's Social Security services. The delay in mail delivery was attributed to a lack of awareness and action by a covering social worker who was unfamiliar with the mail delivery process during the Director of Social Services' maternity leave. The business office manager sorted the mail, but important mail was not delivered to residents in a timely manner. When a new social worker started in mid-March, they discovered the undelivered mail and distributed it to the residents. The facility's policy stated that mail should be delivered daily, but this was not adhered to, leading to the deficiency.
Failure to Provide Meal Assistance to Dependent Residents
Penalty
Summary
The facility failed to consistently provide meal assistance to residents who were dependent on staff for activities of daily living. This deficiency was observed in two residents, Resident #32 and Resident #10, during a survey. Resident #32, who was severely cognitively impaired and dependent on staff for eating, was observed with an untouched lunch tray, indicating that no assistance was provided. The resident's medical records showed a diagnosis of cerebral infarction, hemiplegia, hemiparesis, and dysphagia, requiring a specific diet and assistance with meals. Despite these needs, the resident was left unattended with a meal tray that had not been opened or consumed. Similarly, Resident #10, who also had severe cognitive impairment and required supervision for eating, did not receive a lunch tray until it was brought to the attention of the staff by the surveyor. The resident expressed hunger and confirmed not having eaten, which was corroborated by the absence of a lunch tray on the bedside table. The resident's medical records indicated a diagnosis of dysphagia and malnutrition, necessitating a puree solids diet and nectar thickened liquids, along with supervision during meals. The staff's failure to ensure the resident received and was assisted with their meal was a clear oversight. The facility's policy on resident dining was reviewed, which stated that audits are conducted to ensure residents' dining needs are met. However, during a meeting with the survey team, the facility's administration acknowledged that no patient should be missed for meal pass, and no additional information was provided regarding audits as per the dining policy. This lack of adherence to the policy contributed to the deficiency observed in the care of Residents #32 and #10.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain a sanitary environment by not keeping the garbage container area free of debris and trash. During an initial kitchen tour, a surveyor observed debris and trash, including cardboard and paper, around the dumpster area. The Food Service Director indicated that housekeeping was responsible for maintaining this area. The facility's Waste Management Policy, dated January 3, 2024, specifies that the area around the container should be kept clean and clear at all times. This deficiency was identified during a survey conducted on May 22, 2024, and was confirmed through an interview with the Administrator on May 29, 2024, who stated that the area was cleaned immediately after the surveyor's observation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chatham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Acres Rehabilitation And Healthcare | 1.7 mi | ★★★★★ | 9 | 0 |
| Spring Grove Rehabilitation And Healthcare Center | 2.7 mi | ★★★★★ | 18 | 0 |
| Cheshire Home | 2.8 mi | ★★★★★ | 8 | 0 |
| Florham Park Rehabilitation And Healthcare Center | 3 mi | ★★★★★ | 7 | 0 |
| Continuing Care At Lantern Hill | 3.9 mi | ★★★★★ | 4 | 1 |
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