Chesterton Manor

In the surveyor’s words

From the most serious findings on record at Chesterton Manor, in the surveyor’s own words.

• Actual harm, isolatedF686Sep 30, 2022

  Based on record review and interview, the facility failed to ensure a resident admitted with a pressure ulcer received the necessary treatment and services to prevent further breakdown related to providing preventative measures, the lack of documentation of turning, repositioning, and transferring the resident out of bed which resulted in an unstageable necrotic pressure ulcer for 1 of 3 residents reviewed for pressure ulcers. (Resident C) Finding includes: The closed record for Resident C was reviewed on 9/29/22 at 11:00 a.m. The resident was admitted to the facility on [DATE] from the hospital. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) assessment, dated 4/29/22, indicated the resident was rarely understood and rarely understands. […]

• No harm, potential for more than minimal, widespreadF727Feb 12, 2024

  Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) worked 8 consecutive hours in the facility on any given day. This had the potential to affect 67 of 67 residents who resided in the facility. Finding includes: The staffing schedules for 9/1-9/20/23 and 1/1-1/31/24 were reviewed on 2/7/24 at 8:40 a.m. There were currently 2 RN's who worked in the facility as a floor nurse. The other RN's who were employed at the facility, were the Director of Nursing (DON) and the MDS Coordinator. Nursing time cards were reviewed on 2/7/24 at 9:25 a.m., and the following was noted: There was no RN coverage for 7/22/23. There was no RN coverage for 9/2/23. There was no RN coverage for 9/3/23. There was no RN coverage for 9/16/23. […]

• No harm, potential for more than minimal, widespreadF943Nov 15, 2022

  Based on record review and interview, the facility failed to ensure staff at the facility were trained on the facility's abuse policy and procedure, related to 3 of 4 Agency CNA's not educated on the facility's abuse policy and procedures prior to working with residents. This had the potential to affect all 62 residents who resided in the facility. Finding includes: During an interview on 11/15/22 at 9:29 a.m., CNA 2 indicated she worked for an Agency and this was the first day scheduled at the facility. She indicated she had not been educated on the facility's abuse policy and procedures. During an interviews on 11/15/22 at 10:42 a.m., the Administrator indicated it was the responsibility of Human Resources (HR) to ensure all Agency Staff are educated on the abuse policy and procedures. […]

• No harm, potential for more than minimal, patternF684Mar 6, 2025

  Based on observation, record review, and interview, the facility failed to ensure medications were held per blood sugar parameters for 1 of 1 resident reviewed for insulin. The facility also failed to ensure areas of discoloration and dry flaky skin were assessed and monitored for 4 of 4 residents reviewed for skin conditions non-pressure related and signs and symptoms of constipation were monitored and treated for 2 of 2 residents reviewed for constipation. (Residents 53, 3, 69, 58, 176, 13, and 226) Findings include: 1. The record for Resident 53 was reviewed on 3/3/25 at 2:17 p.m. Diagnoses included, but were not limited to, type 2 diabetes and chronic kidney disease stage 3. […]

• No harm, potential for more than minimal, patternF689Mar 6, 2025

  Based on observation, record review, and interview, the facility failed to ensure fall interventions were in place for residents with a history of falls related to floor mats, bed position, and call lights in reach for 2 of 2 residents reviewed for falls. (Residents 46 and 13) The facility also failed to ensure hot water temperatures were below 120 degrees Fahrenheit on 3 of 4 halls throughout the facility. (100, 300 and 400 halls) This had the potential to affect 53 of the 75 residents who resided in the facility. Findings include: 1. During random observations on 3/2/25 at 9:17 a.m., 9:44 a.m. and 3:05 p.m., Resident 46 was observed in bed. At those times, a green wedge cushion was on the floor and a floor mat for between the beds was folded up against the wall. […]