CHELTENHAM NURSING AND REHAB C

Nursing Home Inspector

600 W CHELTENHAM AVENUE
PHILADELPHIA, PA 19126
Montgomery County
Phone: 215-927-7300
Provider Number: 395330
Last Inspection: 03/08/2017

About the Nursing Home

Number of Beds: 255
Number of Residents: 221
Beds Available: 34
Percent Occupancy: 87%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

42

Facility
18

County
23

PA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

42

2017
31

2016
15

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

3/8/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Pattern : Minimal 4 4/4/2017
 
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Widespread : Potential 4 4/4/2017
 
Failed To: Try to resolve each resident's complaints quickly. Isolated : Minimal 3 4/4/2017
 
Failed To: Provide activities to meet the interests and needs of each resident. Pattern : Minimal 4 4/4/2017
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 4/4/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 4/4/2017
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 4/4/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 4/4/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 4/4/2017
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 4/4/2017
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 4/4/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 4/4/2017
 

2/5/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 3/15/2016
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 3/15/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 3/15/2016
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Actual 4 3/15/2016
 
Failed To: Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. Isolated : Minimal 3 3/15/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 3/15/2016
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 3/15/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 3/15/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 3/15/2016
 

3/13/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 5/12/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 5/12/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 5/12/2015
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 5/12/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

3/8/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 4/4/2017
 

11/16/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 12/13/2016
 

2/5/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents voice a complaint or grievance without being treated differently or badly. Isolated : Minimal 3 3/15/2016
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 3/15/2016
 
Failed To: Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Isolated : Minimal 3 3/15/2016
 

10/19/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 12/1/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 12/1/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg PA State Avg
Number of Residents 221 107.56 110.03
Registered Nurses 0.78 1.11 0.94
Licensed Practical / Vocational Nurses 0.57 0.66 0.85
Certified Nursing Assistants 3.23 2.31 2.26
Total Staff Hours 4.58 4.08 4.05

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% PA State Avg%
of high risk long-stay residents with pressure ulcers 5 5 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 95 93 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98 94 95
of long-stay residents experiencing one or more falls with major injury 0 3 3
of long-stay residents who have depressive symptoms 0 3 2
of long-stay residents who lose too much weight 6 8 7
of long-stay residents who received an antianxiety or hypnotic medication 34 23 22
of long-stay residents who received an antipsychotic medication 26 13 15
of long-stay residents who self-report moderate to severe pain 2 5 6
of long-stay residents who were physically restrained 1 0 0
of long-stay residents whose ability to move independently worsened 26 19 20
of long-stay residents whose need for help with daily activities has increased 20 16 15
of long-stay residents with a catheter inserted and left in their bladder 8 1 1
of long-stay residents with a urinary tract infection 2 2 3
of low risk long-stay residents who lose control of their bowels or bladder 41 56 56
of short-stay residents assessed and appropriately given the pneumococcal vaccine 49 76 83
of short-stay residents who had an outpatient emergency department visit 19 9 10
of short-stay residents who made improvements in function 60 65 64
of short-stay residents who newly received an antipsychotic medication 4 1 1
of short-stay residents who self-report moderate to severe pain 14 13 15
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 71 78 82
of short-stay residents who were rehospitalized after a nursing home admission 34 21 20
of short-stay residents who were successfully discharged to the community 15 54 52
of short-stay residents with pressure ulcers that are new or worsened 0 0 0