Chestnut Hill Health and Rehabilitation Center LLC

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF638Sep 23, 2022

  Based on record review and interview, the facility failed to ensure that its staff completed quarterly review Minimum Data Set (MDS) assessments for 23 residents (#3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #16, #17, #19, #20, #21, #22, #23, #25, #27, #32, #42, and #43), out of a total of 29 sampled residents. Findings Include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicated the Quarterly MDS Assessment must be completed no later than 14 calendar days after the Assessment Reference Date (ARD-refers to the last day of the observation period that the assessment covers for the resident). 1. […]

• No harm, potential for more than minimal, patternF812May 20, 2025

  Based on observations, and interviews, the facility failed to prepare food in accordance with professional standards for food service safety in the facility's main kitchen. Specifically, the facility failed to: 1. Ensure that [NAME] #1 wore a hair restraint when preparing and cooking food, increasing the risk for food contamination. 2. Monitor the final internal temperature for cooked foods prior to serving the food to residents, increasing the residents' risks for acquiring foodborne illnesses. Findings include: 1. […]

• No harm, potential for more than minimal, patternF880May 20, 2025

  Based on observations, record review, and interviews, the facility failed to adhere to infection control standards of practice to prevent contamination and the spread of infections for four Residents (#276, #113, #63 and #70) out of a total sample of 24 residents. Specifically, 1) For Resident #276, the facility failed to ensure that Personal Protective Equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) was worn in the Resident's room when the Resident was on Contact Precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) for Clostridium Difficile (C-Diff: a spore forming toxin that can develop in the intestines after antibiotic… […]

• No harm, potential for more than minimal, patternF726Mar 14, 2024

  Based on interview, record and document review, the facility failed to provide competent nursing staff to care for one Resident (#16), out of one applicable resident, out of a total sample of 24 residents, who required removal of a urinary stent (a thin flexible tube that holds the ureter open for the flow of urine) in the facility. Specifically, the facility had no evidence that its Licensed Nursing Staff had the competency and skills required to provide care and services for residents with urinary stents when Nurse (#6) was allowed to remove Resident #16's urinary stent without the guidance of any facility policies and procedures. […]

• No harm, potential for more than minimal, patternF636Sep 23, 2022

  Based on record review and interview, the facility failed to ensure staff completed Minimum Data Set (MDS) comprehensive assessments for three Residents (#23, #262, and #162), out of a total of 29 sampled residents. Specifically, the facility failed to complete an annual assessment for one Resident (#23) and admission assessments for two Residents (#262 and #162) as required. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicated both the Annual and the Admission MDS Assessments must be completed no later than 14 calendar days after the Assessment Reference Date (ARD- refers to the last day of the observation period that the assessment covers for the resident). 1. […]