Chestelm Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Chestelm Health and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF644Jun 3, 2026

  Based on review of the clinical records, facility documentation, facility policy, and interviews for 3 of 6 residents (Resident #6, Resident #44, and Resident #45 ) reviewed for Preadmission Screening and Resident Review (PASRR), the facility failed to ensure the state agency was updated subsequent to the residents' new psychiatric diagnoses. The findings include: 1.Resident #6 had diagnoses that included stroke, anxiety, and post-traumatic stress disorder. The Notice of Negative PASRR Level I Screen dated 4/20/2020 identified Resident #6 had diagnoses of anxiety and Post Traumatic Stress Disorder (PTSD). The notice indicated that based on the information received, a Level II evaluation was not required at that time, and Level I was approved with a negative outcome. […]

• No harm, potential for more than minimal, patternF684Nov 26, 2024

  50250 Based on observation, review of the clinical record, facility policy and interviews for 15 of 70 residents (Resident #4, Resident #6, Resident #22, Resident #28, Resident #30, Resident #32, Resident #33, Resident #39, Resident #41, Resident #45, Resident #48, Resident #58, Resident #65, Resident #69, Resident #326) reviewed for preventative weekly body audits, the facility failed to perform preventative weekly body audits according facility policy and physician orders. The findings include: 1. […]

• No harm, potential for more than minimal, isolatedF628Jun 3, 2026

  Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #74) reviewed for hospitalization, the facility failed to ensure the Office of the State Long-Term Care Ombudsman was notified when a resident was transferred to the hospital. The findings include:Resident #74 was admitted to the facility on [DATE] with diagnoses that included respiratory failure with hypoxia, pneumonia, and heart failure. The Resident Care Plan (RCP) dated 3/11/26 identified Resident #74 had the potential for alteration in respiratory status related to pneumonia and respiratory failure. […]

• No harm, potential for more than minimal, isolatedF880Jun 3, 2026

  Based on observations, review of clinical record, review of facility policy, review of facility documentation, and interviews for one of three residents (Resident #19) reviewed for pressure ulcer/injury, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with open wounds to ensure the appropriate personal protective equipment (PPE) was utilized when providing wound care. The findings include:Resident #19's diagnoses included vulva cancer status-post surgical interventions with surgical wound, stage 3 pressure ulcer on coccyx, and lymphedema.Physician's orders dated 5/27/26 directed to cleanse the vaginal and suprapubic surgical sites with normal saline, pat dry, and apply witch hazel daily on the evening shift and as needed when soiled, and cleanse the… […]

• No harm, potential for more than minimal, isolatedF580Aug 13, 2025

  Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had a new medication ordered for a change in condition and there was a noted medication interaction identified by the pharmacy, the facility failed inquiry the pharmacy why the medication had not been available and to notify the provider for six (6) days. The findings include: Resident #1's diagnoses included constipation, failure to thrive, and aphasia following cerebral infarction (a stroke resulting in damage to areas of the brain responsible for language). […]