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Inspection visit

Inspection

SACHEM CENTER FOR HEALTH AND REHABILITATIONCMS #22532228 citations on this visit
28 citations recorded

Citations

28 citations recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0565GeneralS&S Epotential for harm

    F565 - The resident has a right to organize and participate in resident groups in the

    Honor the resident's right to organize and participate in resident/family groups in the facility.

  • 0580GeneralS&S Dpotential for harm

    F580 - Notification of Changes

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  • 0585GeneralS&S Epotential for harm

    F585 - Grievances

    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

  • 0600SeriousS&S Gactual harm

    F600 - Freedom from Abuse, Neglect, and Exploitation

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  • 0607GeneralS&S Dpotential for harm

    F607 - The facility must develop and implement written policies and procedures that:

    Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  • 0609GeneralS&S Dpotential for harm

    F609 - The facility must develop and implement written policies and procedures that:

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • 0610GeneralS&S Dpotential for harm

    F610 - In response to allegations of abuse, neglect, exploitation, or mistreatment, the

    Respond appropriately to all alleged violations.

  • 0641GeneralS&S Bno actual harm

    F641 - Accuracy of Assessments

    Ensure each resident receives an accurate assessment.

  • 0655GeneralS&S Dpotential for harm

    F655 - Comprehensive Person-Centered Care Planning

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  • 0656GeneralS&S Epotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  • 0658GeneralS&S Dpotential for harm

    F658 - Comprehensive Care Plans

    Ensure services provided by the nursing facility meet professional standards of quality.

  • 0679GeneralS&S Dpotential for harm

    F679 - Activities

    Provide activities to meet all resident's needs.

  • 0686GeneralS&S Epotential for harm

    F686 - Skin Integrity

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  • 0688GeneralS&S Dpotential for harm

    F688 - Mobility

    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

  • 0692GeneralS&S Dpotential for harm

    F692 - Assisted nutrition and hydration

    Provide enough food/fluids to maintain a resident's health.

  • 0693GeneralS&S Dpotential for harm

    F693 - Assisted nutrition and hydration

    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.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0697SeriousS&S Gactual harm

    F697 - Pain Management

    Provide safe, appropriate pain management for a resident who requires such services.

  • 0761GeneralS&S Epotential for harm

    F761 - Labeling of Drugs and Biologicals

    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.

  • 0843GeneralS&S Cno actual harm

    F843 - Transfer agreement

    Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

  • 0844GeneralS&S Cno actual harm

    F844 - Disclosure of ownership

    Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.

  • 0880GeneralS&S Epotential for harm

    F880 - Infection Control

    Provide and implement an infection prevention and control program.

  • 0940GeneralS&S Epotential for harm

    F940 - Training Requirements

    Develop, implement, and/or maintain an effective training program for all new and existing staff members.

  • 0941GeneralS&S Epotential for harm

    F941 - Training Requirements

    Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

  • 0944GeneralS&S Epotential for harm

    F944 - Quality assurance and performance improvement

    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

  • 0945GeneralS&S Epotential for harm

    F945 - Infection control

    Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

  • 0946GeneralS&S Fpotential for harm

    F946 - Compliance and ethics

    Provide training in compliance and ethics.

  • 0949GeneralS&S Epotential for harm

    F949 - Training Requirements

    Provide behavior health training consistent with the requirements and as determined by a facility assessment.

FAQ · About this visit

Common questions about this visit

What happened during the February 6, 2024 survey of SACHEM CENTER FOR HEALTH AND REHABILITATION?

This was a inspection survey of SACHEM CENTER FOR HEALTH AND REHABILITATION on February 6, 2024. The surveyor cited 28 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SACHEM CENTER FOR HEALTH AND REHABILITATION on February 6, 2024?

Yes, 28 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to organize and participate in resident/family groups in the facility."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.