Chatham Glen Healthcare And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents' Minimum Data Set (MDS) assessments were accurate for 2 of 6 residents reviewed for medication management (Residents #75, and #122). Findings include:1) Review of Resident #122's physician order dated 9/28/2025 read, Furosemide Oral Tablet (Furosemide), Give 20 mg [milligram] by mouth every 12 hours for fluid retention. Order Status: Active. Review of Resident #122's Medication Administration Record for January 2026 documented Furosemide was administered from 1/20/2026 to 1/31/2026.Review of Resident #122's quarterly MDS assessment dated [DATE] revealed the resident was not taking diuretics under Section N- Medications.During an interview on 2/19/2026 at 12:37 PM, the Director of MDS stated, [Resident #122's name] diuretic medication section had been coded incorrectly and needed to be corrected.2) Review of Resident #75's physician order dated 8/12/2025 read, Wellbutrin SR [Sustained Release] Oral Tablet Extended Release 12 hour…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered by physician for 2 of 7 residents reviewed for medication management (Residents #24 and #90), and failed to ensure the intravenous (IV) catheter dressing was changed for 1 of 4 residents reviewed for intravenous therapy (Resident #140). Findings include: 1) During an observation on 2/19/2026 at 8:13 AM, Staff G, Licensed Practical Nurse (LPN), administered Diltiazem HCI (Hydrochloride) ER (Extended Release) 240 mg (milligram) capsule to Resident #24. Electronic health record showed Resident #24's blood pressure documented as 118/54 mmHg (millimeter of mercury) and pulse as 56 beats per minute. Review of Resident #24's physician order dated 12/31/2025 read, Diltiazem HCI ER Coated Beads 240 MG capsule extended release 24 hr [hour], Give 1 capsule by mouth one time a day for HTN [hypertension] hold if SBP [systolic blood pressure] is less than 110 or HR [heart rate] less than 60. Administer whole, do not crush, split or chew. During an interview on 2/20/2026 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were securely stored in 2 of 4 halls. Findings include: 1) During an observation on 2/17/2026 at 10:31 AM, Resident #3 was sitting in her wheelchair in her room next to her bed. On top of her bed, there was Hydrocortisone Cream 1% and Zinc Oxide Ointment. During an interview on 2/17/2026 at 10:31 AM, Resident #3 stated, I use the creams preventively for my back because at times my back will itch. During an interview on 2/17/2026 at 11:52 AM, Staff I, Licensed Practical Nurse (LPN), stated, Residents are not to keep medication in their rooms. It should be secured in the medication cart. During an interview on 2/19/2026 at 12:40 PM, the Director of Nursing stated, Medications should be stored in a lock box. 2) During an observation on 2/17/2026 at 10:06 AM, there was a pill and powdered substance on the floor in Resident #42's room. During an observation on 2/17/2026 at 10:24 AM, there was a medication on the floor, crushed into pieces and powder, in Resident #143's room. During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff used personal protective equipment (PPE) appropriately while providing wound care for 1 of 1 residents observed for wound care (Resident #13) to prevent the possible spread of infection and communicable diseases.Findings include: During an observation on 2/20/2026 at 8:15 AM, Staff F, Licensed Practical Nurse (LPN), started providing wound care for Resident #13. Staff F performed hand hygiene and donned gloves. Wound care supplies were separately stored and labeled with Resident #13's name in plastic bags. Staff F removed 4x4 gauze, collagen, Santyl and iodoform packing strip. Staff F cleaned scissors with alcohol and let the scissors dry prior to cutting iodoform packing strip. Staff F performed hand hygiene and donned gown and gloves. Staff F did not tie top of the gown and shoulders were not covered. Staff F proceeded to adjust Resident #13 in the bed on his left side. Staff F adjusted her gown at the shoulders and then removed old dressing from coccyx region and disposed of the old dressing.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received nutritional supplements for 1 of 9 residents reviewed for nutrition, Resident #43 (Photographic evidence obtained). Findings include: Review of Resident #43's admission record revealed the resident was admitted on [DATE] with diagnoses including combined systolic (congestive) and diastolic (congestive) heart failure (primary diagnosis), respiratory failure, orthostatic hypotension, pulmonary embolism without acute core pulmonale, essential (primary) hypertension, muscle weakness, abnormalities of gait and mobility, protein-calorie malnutrition, hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris, peripheral vascular disease, gastro-esophageal reflux disease without esophagitis, osteoarthritis, and pleural effusion. Review of Resident #43's physician order dated 9/6/2024 showed it read, Mighty Shake with meals for protein supp [supplement] 1 carton= 4 oz [ounces]. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

2) Review of Resident #52's Pharmacist's Recommendation to Prescriber dated 8/22/2024 showed it read, Findings/Recommendation: This resident has current orders that might present a potential drug interaction: Omeprazole cap 20 mg- give 20 mg by mouth two times a day for GERD [Gastroesophageal Reflux Disease] administer whole do not crush chew or cut., in addition to Sucralfate. Recommendation: Please consider discontinuation of Sucralfate at this time, unless clinically contraindicated. If concomitant therapy is still warranted at this time, please indicate reason . Prescriber's Response: Disagree. The form did not contain the prescriber's rationale. Review of Resident #52's medical records did not reveal any rationale provided by the provider for the pharmacist's recommendation on 8/22/2024. During an interview on 9/19/2024 at 11:26 AM, the Director of Nursing (DON) stated, I just spoke to the pharmacist, and they will be changing the forms so that the physicians know they must include a rationale. Since it just said comments, I would not think I had to write anything in that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure accurate documentation of nutritional supplement administration and percentage of supplement consumed for 1 of 9 residents reviewed for nutrition, Resident #43. Findings include: Review of Resident #43's admission record revealed the resident was admitted on [DATE] with diagnoses including combined systolic (congestive) and diastolic (congestive) heart failure (primary diagnosis), respiratory failure, orthostatic hypotension, pulmonary embolism without acute core pulmonale, essential (primary) hypertension, muscle weakness, abnormalities of gait and mobility, protein-calorie malnutrition, hyperlipidemia, atherosclerotic heart disease of native coronary artery without angina pectoris, peripheral vascular disease, gastro-esophageal reflux disease without esophagitis, osteoarthritis, and pleural effusion. Review of Resident #43's physician order dated 9/6/2024 showed it read, Mighty Shake with meals for protein supp [supplement] 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration for 2 of 4 reviewed for medication administration, Residents #481 and #101, and during wound care for 1 of 6 residents reviewed for skin conditions, Resident #13 to prevent from possible spread of infection and communicable diseases. Findings include: 1) During an observation on 9/18/2024 at 9:03 AM, Staff B, Licensed Practical Nurse (LPN), opened the medication cart and realized she had no liquid protein in the medication cart. Staff B went to the medication room and used the keypad to open the door. Staff B returned to the medication cart and began to open and pour the liquid protein into a medication cup without performing hand hygiene. Staff B's pen fell on the floor and Staff B picked up the pen. Staff B opened the bottom drawer and removed a Sani wipe container with a purple top and sanitized the pen and her hands with the wipe without using gloves. Staff B proceeded to pour medication for Resident #481. Staff B did not have Miralax on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety in the dry storage food area and in the walk-in freezer in the main kitchen. Findings include: During the initial tour of the kitchen dry good storage area conducted with the Certified Dietary Manager on 5/22/23 at 9:25 AM, a plastic scoop was observed in the oatmeal storage bin lying on top of the oatmeal and a small metal scoop was observed in the brown sugar storage bin on top of the brown sugar. During a tour conducted with the Certified Dietary Manager on 5/22/23 at 9:30 AM of the facility's walk-in freezer, there was a container of fried chicken with the cover opened on the corner, a partially used bag of lasagna sheets not fully closed and a partially used bag of preformed cookie pucs [formed, uncooked cookie dough] not fully closed. During an interview conducted on 5/24/23 at 9:47 AM the Certified Dietary Manager stated that her expectation for food stored in the freezer be labeled, dated and fully closed and that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to submit the Minimum Data Set (MDS 3.0) discharge summary in a timely manner for 1 (Resident #21) of 4 residents reviewed for discharge. Findings include: Review of Resident #21's MDS 3.0 summary assessment titled Discharge-return not anticipated was completed on 1/12/2023 and was accepted on 5/23/2023. Section A Identification Information read F. Entry/discharge reporting 10. Discharge-return not anticipated. A200. discharge date [DATE]. Review of Resident #21's admission record documented Resident #21 was discharged on 12/16/2022. During an interview on 5/24/2023 at 8:40 AM Staff D, MDS Coordinator, stated, It was completed [MDS 3.0 Discharge-return not anticipated] on 12/16/2022 and locked as of yesterday [5/23/2023]. This happened due to the way it had been set up, the report was not setup to be send to CMS and the correction was made yesterday. The assessment had been done in a timely manner just not submitted. Upon request of a policy and procedure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to implement comprehensive resident centered care plan interventions for 2 (Resident #9, #338) of 12 residents review for accidents and pressure ulcers. Photographic evidence obtained. Findings include: 1) During an observation on 5/22/2023 at 10:03 AM Resident #9 was lying in bed, one fall mat was placed on the floor on the right side of the bed while the left side of the bed there was no fall mat on the floor. During an observation on 5/23/2023 at 9:00 AM Resident #9 was lying in bed, one fall mat was placed on the floor on the right side of the bed while the left side of the bed there was no fall mat on the floor. During an observation on 5/24/2023 at 8:30 AM Resident #9 was lying in bed, one fall mat was placed on the floor on the right side of the bed while the left side of the bed there was no fall mat on the floor. During an observation on 5/24/2023 at 12:30 PM AM Resident #9 was lying in bed, one fall mat was placed on the floor on the right side of the bed while the left side of the bed there was no fall…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.