Chestnut Park Rehabilitation and Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Oct 27, 2025

  Based on record review and interviews conducted during an abbreviated survey (Case #2635234), the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for two (2) of four (4) residents (Resident #1 and 3) reviewed for falls. Specifically, [a.] Resident #1 had severe cognitive impairment and had five (5) unwitnessed falls from [DATE] to [DATE]. The facility failed to develop appropriate interventions to mitigate falls when it was known that the resident was self-transferring. On [DATE] at 11:30 PM, Resident #1 was found on the floor unresponsive, unclothed and cold to the touch by Certified Nurse Aide #1. […]

• Actual harm, isolatedF695Oct 27, 2025

  Based on record review and interview conducted during an abbreviated survey (Case #2635234), the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for one (1) of four (4) residents (Resident #1) reviewed. Specifically, on [DATE] at 11:30 PM, Resident #1 was found unresponsive with an oxygen saturation of 73 percent (normal 95 to100 percent) and signs of respiratory distress. Emergency Medical Services documented 'extreme' wheezing in all lung fields and a clinical impression of pneumonia (an infection in one or both lungs). […]

• Actual harm, isolatedF600May 22, 2023

  Based on record review and interview during the recertification survey and an abbreviated survey (Case #NY00316948) dated 05/15/23 through 05/22/23, the facility failed to protect the resident's right to be free from neglect for 1 (Resident #23) of 4 residents reviewed for abuse/neglect. Specifically, on 04/16/2023 Certified Nurse Aide (CNA) #2 did not use two staff for bed mobility as documented in Resident #23's Comprehensive Care Plan (CCP) . Subsequently, on 4/16/2023 Resident #23 rolled out of bed onto the floor sustaining a fracture of their left elbow and a gash requiring stitches on their left elbow. This resulted in actual harm that is not immediate jeopardy for Resident #23. […]

• Actual harm, isolatedF684Apr 1, 2021

  Based on record review and interviews conducted during an abbreviated survey on 4/1/21 (Case #NY 307), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #7) of 4 residents reviewed. Specifically, the facility did not ensure Resident #7 received blood [CONDITION(S)] as ordered by the physician and nurse practitioner on 8/31/20, 9/3/20 and 9/4/20. Subsequently, Resident #7 had critically low blood values and was transferred to the hospital with a rapid heart rate and low blood pressure. This resulted in actual harm that is not immediate jeopardy. […]

• No harm, potential for more than minimal, widespreadF755Dec 12, 2025

  Based on observations, record reviews and interviews during a recertification survey, the facility did not ensure it established a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and that it determined that drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled. Specifically, the facility did not document nursing unit narcotics were counted by two (2) licensed staff members and signed as appropriately done on the facility provided narcotic record sheets.This is evidenced by:The Policy and Procedure titled, Medications - Controlled Substance/Narcotic Management Protocol, effective 2/2021 and last revised 1/2025, documented it was the facility's policy to It… […]