Chatham Hills Subacute Care Center
Inspection Findings
F-Tag F0584
Federal health inspectors cited CHATHAM HILLS SUBACUTE CARE CENTER in CHATHAM, NJ for a deficiency under regulatory tag F-F0584 during a standard health inspection conducted on 2025-11-18.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of CHATHAM HILLS SUBACUTE CARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-28.
F-Tag F0605
Federal health inspectors cited CHATHAM HILLS SUBACUTE CARE CENTER in CHATHAM, NJ for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2025-11-18.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of CHATHAM HILLS SUBACUTE CARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-28.
F-Tag F0628
F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint #403805Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that written notice of a resident's transfer to a hospital was provided to a family member or guardian for 1 of 4 residents (Resident #102) reviewed for hospitalization.This deficient practice was evidenced by the following: A review of Resident #102's admission Record reflected the resident was admitted to the facility on [DATE REDACTED] with diagnoses that included but were not limited to; 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 (a rupture of a weakened area of
a blood vessel) in the brain. The admission Record further reflected the resident's mother was listed as his/her emergency contact and court appointed guardian. A review of Resident #102's admission Minimum Data Set (MDS), an assessment tool, dated 3/14/2025 reflected the resident had a severely impaired cognition and was dependent on staff for all activities of daily living (ADLs) care. A review of Resident #102's medical record reflected the resident was transferred to the hospital on 3/18/2025 at 10:00AM, for further evaluation of low blood pressure, rapid heart rate and elevated body temperature. On 09/15/2025 at 10:10 AM, the surveyor interviewed the Unit Manager (UM), for the North Unit. The UM confirmed she did not provide written notice that Resident #102 was transferred to a hospital to the resident's guardian. On 09/15/2025 at 12:30 PM, the surveyor interviewed the facility's Licensed Social Worker (LSW). The LSW confirmed she had not provided written notice of Resident #102's was transfer to the resident's guardian.
On 09/12/2025 at 10:12 PM, the surveyor discussed the concern with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The LNHA confirmed the facility had not provided written notice that Resident #102 was transferred to a hospital to the resident's guardian. A review of the facility policy, Emergency Transfer or Discharge, dated 3/12/2025, revealed.Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement
the following procedures . Notify the representative (sponsor) or other family member. N.J.A.C. 8.39 27.1(a)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Chatham Hills Subacute Care Center
415 Southern Blvd Chatham, NJ 07928
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0656
Federal health inspectors cited CHATHAM HILLS SUBACUTE CARE CENTER in CHATHAM, NJ for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-11-18.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of CHATHAM HILLS SUBACUTE CARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-28.
F-Tag F0677
F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
review of Resident #64's Quarterly MDS, dated [DATE REDACTED], revealed that Resident #64 had a BIMS score of 15 out of 15, indicating that the resident's cognition was intact. The MDS further revealed that the resident was dependent on staff for toileting hygiene, and he/she was frequently incontinent of bladder and always incontinent of bowel. A review of Resident #64's CP initiated on 5/3/24 had a focus area that included [Resident] requires assistance with ADLs, with interventions that included but were not limited to; dependent on staff for toileting hygiene. 4.) On 9/16/25 at 7:57 AM, the surveyor, accompanied by CNA #1, observed Resident #4 in bed. CNA #1 exposed Resident 4's incontinence brief, and the surveyor observed that it was saturated with urine and feces. CNA #1 confirmed that the brief was saturated with urine and feces. A review of Resident #4's admission Record reflected that the resident was admitted to the facility with diagnoses which included but were not limited to: acute kidney failure with tubular necrosis (damage to
the renal tubule cells which impairs the kidney's ability to filter blood) and diabetes mellitus.A review of Resident #4's most recent MDS, dated [DATE REDACTED], revealed that Resident #4's cognitive skills for daily decision making were severely impaired. The MDS further revealed that the resident was dependent on staff for personal and toileting hygiene, and he/she was frequently incontinent of bowel and bladder. A review of Resident #4's CP initiated on 6/12/25 had a focus area that included [Resident] requires assistance with ADLs, with interventions that included but were not limited to; dependent on staff for toileting hygiene. At that same time, during an interview with the surveyor, CNA #1 stated that incontinence care should be provided every 2 hours on all shifts and that it did not appear to have been done.On 9/16/25 at 9:30 AM,
during an interview with the surveyor, the Registered Nurse/Unit Manager stated that incontinence rounds should be conducted 3-4 times on all shifts.On 9/16/25 at 10:15 AM, during an interview with the surveyor,
the staffing coordinator called the CNA (CNA #2), who was assigned to Residents #10 and #4 on the 11-7 AM shift. The CNA stated that she had 17 residents on her assignment and that she had provided incontinence care for them. On 9/16/25 at 10:20 AM, the staffing coordinator called the CNA (CNA #3) who was assigned to care for Residents #43 and #64 on the 11-7 AM shift. CNA #4, who had 17 residents assigned to their care during the 11-7 AM shift, did not return the call.On 9/16/25 at 1:22 PM, the survey team discussed the above observations and concerns with the Director of Nursing and Licensed Nursing Home Administrator.A review of the facility's Activities for Daily Living policy dated 2/3/25 reflected .the facility will provide activities of daily living for those needed for self-care: bathing, dressing, toileting . NJAC 8:39-27.1 (a), 27.2 (h)
Event ID:
Facility ID:
If continuation sheet
F-Tag F0698
Federal health inspectors cited CHATHAM HILLS SUBACUTE CARE CENTER in CHATHAM, NJ for a deficiency under regulatory tag F-F0698 during a standard health inspection conducted on 2025-11-18.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of CHATHAM HILLS SUBACUTE CARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-28.
F-Tag F0755
Federal health inspectors cited CHATHAM HILLS SUBACUTE CARE CENTER in CHATHAM, NJ for a deficiency under regulatory tag F-F0755 during a standard health inspection conducted on 2025-11-18.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of CHATHAM HILLS SUBACUTE CARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-28.
F-Tag F0756
Federal health inspectors cited CHATHAM HILLS SUBACUTE CARE CENTER in CHATHAM, NJ for a deficiency under regulatory tag F-F0756 during a standard health inspection conducted on 2025-11-18.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of CHATHAM HILLS SUBACUTE CARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-28.
F-Tag F0812
Federal health inspectors cited CHATHAM HILLS SUBACUTE CARE CENTER in CHATHAM, NJ for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-11-18.
Category: Nutrition and Dietary Deficiencies
The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 9 deficiencies cited during this inspection of CHATHAM HILLS SUBACUTE CARE CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-28.
CHATHAM HILLS SUBACUTE CARE CENTER in CHATHAM, NJ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in CHATHAM, NJ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from CHATHAM HILLS SUBACUTE CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.