Chestnut Hill Rehabilitation and Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF600Jun 24, 2026

  Based on a review of the facility's abuse policy, clinical records, facility-provided investigative documentation, and staff interviews, it was determined the facility failed to protect one of five residents reviewed (Resident 1) from non-consensual sexual contact by another resident (Resident 2) despite Resident 2's known history of documented inappropriate sexual behaviors. As a result, Resident 1 experienced actual harm when Resident 2 placed his hand underneath her clothing, touched her bare breast, and twisted her nipple, constituting non-consensual sexual contact.Findings included: A review of the facility policy titled Abuse Policy, last reviewed by the facility on January 21, 2026, revealed that its purpose is to establish policy and procedures to prevent, identify, investigate,… […]

• No harm, potential for more than minimal, widespreadF880Apr 25, 2025

  Based on observations, a review of select facility policies, the facility's infection control log, and staff interviews, it was determined the facility failed to maintain and implement a comprehensive infection prevention and control program and failed to implement transmission-based precautions to mitigate the spread of infectious disease for one out of the 27 residents sampled (Resident 56). Findings included: A review of a facility policy titled Respiratory Syncytial Virus (RSV) Prevention, last reviewed by the facility on January 22, 2025, revealed it is the facility policy to ensure that residents diagnosed with RSV are placed on contact precautions for the duration of the illness. […]

• No harm, potential for more than minimal, widespreadF880Jun 14, 2024

  Based on a review of clinical records, CDC (centers for disease control) infection control guidance, facility's infection control policy and COVID-19 testing logs, and staff interview it was determined he facility failed to promptly implement infection control practices for cohorting like respiratory infections and testing for COVID-19 to prevent the spread of COVID-19 infections in the facility placing at least 12 residents (Residents 4, 6, 8, 10, 14, 16, 2, 20, 22, 24, 26 and 28) at increased risk for contracting COVID-19 and failed to implement effective interventions to prevent the spread of COVID-19 virus. […]

• No harm, potential for more than minimal, widespreadF880Jun 14, 2024

  Based on a review of clinical records, CDC (centers for disease control) infection control guidance, facility's infection control policy and COVID-19 testing logs, and staff interview it was determined he facility failed to promptly implement infection control practices for cohorting like respiratory infections and testing for COVID-19 to prevent the spread of COVID-19 infections in the facility placing at least 12 residents (Residents 4, 6, 8, 10, 14, 16, 2, 20, 22, 24, 26 and 28) at increased risk for contracting COVID-19 and failed to implement effective interventions to prevent the spread of COVID-19 virus. […]

• No harm, potential for more than minimal, patternF810Sep 23, 2025

  Based on clinical record review, observation, and staff interviews, it was determined the facility failed to provide adaptive dining equipment as required and prescribed for three residents out of 12 sampled (Residents 1, 2, and 3).Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnosis to include dysphagia (difficulty swallowing food or liquid), mild protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of protein and nutrients needed for health), and lack of coordination. A review of the physician's orders, dated January 16, 2025, revealed the resident was to utilize a Kennedy cup (lightweight, spill-proof drinking cup designed to be easy to hold and grip) with meals. […]