Chestnut Hill Lodge Health and Rehab CTR

In the surveyor’s words

From the most serious findings on record at Chestnut Hill Lodge Health and Rehab CTR, in the surveyor’s own words.

• Actual harm, isolatedF684Apr 30, 2026

  Based on review of clinical records, Insulin Glargine's manufacturer's guidelines, and interview with staff, it was determined the facility failed to monitor the blood sugar of resident on Insulin Glargine which resulted in harm to one resident that was transferred to the hospital with Hypoglycemia for one of ten residents on insulin reviewed (Resident R1). This was identified as Past Non-Compliance.Findings Include: Review of the Insulin Glargine's (Lantus) manufacture's guideline revealed under section titled Dosage and Administration: individualized dosage based and metabolic needs, blood glucose monitoring, glycemic control type of diabetes and prior insulin use. […]

• Actual harm, isolatedF580Mar 10, 2026

  Based on review of facility policy, clinical records, facility documentation and interview with staff, it was determined the facility failed to ensure timely notification to the physician of fall incident sustained by Resident R1. This failure resulted in actual harm to Resident R1 who experienced a delay of treatment after a fall in the shower room with injuries, requiring transfer to the hospital and diagnoses of subdural hematoma, left zygomatic fracture, and acute right 3rd - 4th rib fractures for one of four residents reviewed. This deficiency is being cited as past non- compliance. […]

• Actual harm, isolatedF600Mar 10, 2026

  Based on review of facility policy, clinical records, facility documentation and interview with staff, it was determined the facility failed to ensure that Resident R1 was free of neglect. This failure resulted in actual harm to Resident R1 who sustained a fall in the shower room with resulting physical injuries; delay in timely assessment and medical treatment for one of four residents reviewed. This deficiency was cited as past non compliance,(Resident R1)Findings include: Review of facility policy 'Falls Prevention and Management,' revised January 12, 2023, indicated that the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. […]

• Actual harm, isolatedF600Apr 17, 2023

  Based on observation, review of clinical record, review of facility documentation, review of facility policies and procedures, review of the PA Nurse Aide handbook and interviews with resident and staff, it was determined that the facility failed to ensure that residents were free from neglect during provision of care for one of 37 residents reviewed. (Resident R13). This failure resulted in actual harm to Resident R13 who fell out of bed, was emergently transfered to the hospital and sustained a fracture of the right femur. Findings include: Review of facility policy, Abuse Prevention, dated October 2017, revealed: The facility prohibits the mistreatment, neglect, and abuse of residents and misappropriation of resident property by anyone including staff, family, and friends. […]

• Actual harm, isolatedF689Apr 17, 2023

  Based on observation, review of clinical record, review of facility documentation, review of facility policies and procedures, review of the PA Nurse Aide handbook and interviews with resident and staff, it was determined that the facility failed to ensure that a resident was assessed for smoking safety and that safety devices were in place to prevent accidents during the provision of care for two of 37 residents reviewed. (Resident R331 and Resident R13). This failure resulted in actual harm to Resident R13, who fell out of bed, required emergency transfer to the hospital and sustained a fracture of the right femur. […]