Chestnut GRN HLTH CTR Blakehur

In the surveyor’s words

From the most serious findings on record at Chestnut GRN HLTH CTR Blakehur, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF641Dec 18, 2025

  Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 7 (#12, #3, #7, #28, #22, #2, #4) of 23 residents reviewed during the recertification/complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. […]

• No harm, potential for more than minimal, patternF756Dec 18, 2025

  Based on medical record review, interview, and review of facility policies and procedures, it was determined the facility failed to 1) timely respond to concerns noted on pharmacy reviews and, 2) have policies and procedures in place for monthly drug regimen review to include time frames for the different steps in the process. This was evident for 5 (#4, #6, #26, #28, #7) of 6 residents reviewed for monthly drug regimen review during a recertification/complaint survey.The findings include: 1) Review of Resident #4's medical record on 12/16/25 revealed the Resident was admitted to the facility on [DATE]. Further review of Resident #4's medical record the Pharmacist conducted a MRR (Monthly Regimen Review) on 11/13/25 and documented Irregularities (see consultant pharmacist report). […]

• No harm, potential for more than minimal, patternF883Dec 18, 2025

  Based on medical record review and interview, it was determined that the facility failed to document residents were offered and provided education regarding the benefits, risks, and potential side effects of receiving the influenza and pneumococcal vaccines to residents; and failed to maintain documentation related to influenza and pneumococcal vaccination in residents' medical records. This was evident for 2 of 5 residents (Resident #4, #5) reviewed for influenza vaccination and 4 of 5 residents (Resident #1, #4, #5, #36) reviewed for pneumococcal vaccinations during a recertification/complaint survey. […]

• No harm, potential for more than minimal, patternF812Jul 24, 2024

  Based on observation and interview with facility staff, it was determined that the facility failed to: 1) keep complete kitchen records and, 2) store food in accordance with professional standards for food service and safety. This was evident of 2 out of 3 observations of food storage during the annual survey. The finding include: 1) On 7/15/24 at 8:58 AM, the surveyor took a tour of the first-floor kitchen with the Dietary Manager Staff #7. During the tour the surveyor reviewed the area where the three compartment sink and dishwasher were located. On further review of the area the temperature and chemical log was missing documentation on July 12 through July 15th. […]

• No harm, potential for more than minimal, isolatedF550Dec 18, 2025

  Based on observation, interview, and record review, it was determined that facility staff failed to treat residents with dignity. This was evident for 1 (Resident #12) of 6 residents observed during the recertification/complaint survey. The findings include:On 12/17/25 at 12:48 PM observation was made of Geriatric Nursing Assistant (GNA) #5 sitting in a chair next to Resident #12 on the left side of the bed. Prior to the surveyor knocking on the door to Resident #12's room, the surveyor observed, by the reflection in the glass of a picture on the right side of the wall (entrance), of GNA #5 sitting next to the resident. At the time of the observation, GNA #5 was looking down and not feeding Resident #12. […]