Chestnut Ridge Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Chestnut Ridge Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF656Aug 7, 2023

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents' comprehensive person-centered care plans were developed and implemented that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs for nine (9) of sixty-one (61) sampled residents, Residents #6, #15, #11, #51, #72, #84, #242, #243, and #244. 1. The facility failed to thoroughly develop and implement a comprehensive care plan for dialysis for Residents #242, #243, #244 and #11. (a) The facility failed to ensure Resident #242 received his/her dialysis treatment on 04/23/2022 and on 04/26/2022, as per the resident's care plan. […]

• Immediate jeopardy, patternF689Aug 7, 2023

  Based on observation, interview, record review and review of facility policy, it was determined the facility failed to have an effective system in place to ensure adequate supervision and monitoring to prevent falls and accident hazards for four (4) of sixty-one (61) sampled residents, Residents #6, #15, #51, and #72. Observation on 07/23/2023, revealed Resident #6 being transferred by a mechanical lift with the assistance of one (1) staff member. The facility assessed Resident #6 to require extensive assistance of two (2) staff to move between surfaces on 06/21/2023. Record review revealed Resident #15 had a fall on 06/28/2023 and was diagnosed with a right hip fracture on 07/07/2023. Review revealed Resident #15 was noted to be rolling to the edge of the bed on 07/28/2023. […]

• Immediate jeopardy, isolatedF656Dec 13, 2025

  Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive, individualized care plan that accurately reflected the nutritional and dietary needs for 1 of 7 residents sampled for dietary needs out of the total sample of 21 residents, (Resident (R)86). The facility failed to develop and ensure R86's care plans accurately reflected the resident's risk for choking, the Speech Therapy (ST) recommendations, dietary consistency requirements, and safe snack provisions consistent with the resident's physician's orders and with interventions necessary to address the risk. […]

• Immediate jeopardy, isolatedF803Dec 13, 2025

  Based on interview, record review and review of the facility's policy, the facility failed to ensure residents received a therapeutic diet per the physician's order for 1 of 7 residents sampled for diets out of the total sample of 21 residents, (Resident (R)86). The physician ordered a pureed diet for R86; however, on 04/25/2025, a Certified Nurse Assistant (CNA) gave the resident a peanut butter sandwich. R86 choked on the sandwich and subsequently lost his pulse. The Emergency Medical Services (EMS) transferred R86 to a hospital where R86 expired. Review of the official Kentucky Certificate of Death listed the immediate cause of death as, choking on a food bolus. […]

• Immediate jeopardy, isolatedF698Aug 7, 2023

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents, who required dialysis/hemodialysis received such services, consistent with professional standards of practice for four (4) of nineteen (19) sampled residents who received dialysis (Residents #242, #243, #244, and #11). In addition, the facility failed to ensure communication sheets, used to communicate information on the resident, were completed for each dialysis treatment. 1. The facility failded to secure and set-up Resident #243's dialysis treatments prior to admission to the facility on [DATE]. The facility failed to ensure Resident #243 received his/her dialysis treatment on 07/12/2023. […]