Chestnut Woods Rehabilitation and Healthcare CTR

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF584Sep 10, 2025

  Based on observation and interviews the facility failed to ensure the building and equipment was in good condition and had a homelike environment in 38 out of 40 rooms.Findings include:Review of the facility policy titled Homelike Environment, dated revised February 2021, indicated the following:Residents are provided with a safe, clean, comfortable and homelike environment .Policy Interpretation and Implementation:2. The facility staff and management maximize, to the extent possible, the characteristics of the facility thatreflect a personalized, homelike setting. These characteristics include:a. clean, sanitary and orderly environment On 9/10/2025 at 8:30 A.M. […]

• No harm, potential for more than minimal, patternF656Sep 29, 2022

  Based on observations, record review and interview, the facility failed to develop and/or implement the plan of care for 7 Residents (#126, #133, #31, #46, #15, #19 and #9) of 29 sampled residents. Findings include: The Facility's policy and procedure for Weight Assessment and Interventions (undated), indicated Residents are weighed upon admission and at intervals established by the interdisciplinary team and/or as ordered by the physician. 1. Resident #126 was admitted to the facility in July 2022, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #126's physician order, dated 7/27/22, indicated Weights weekly one time a day every Wed for Monitoring. Resident #126's most recent Minimum Data Set (MDS) assessment, dated 9/12/22, indicated history of significant weight loss. […]

• No harm, potential for more than minimal, patternF677Sep 29, 2022

  Based on observations, record reviews, interviews and policy review, the facility failed to 1) provide assistance with self-feeding tasks for 3 Residents (#16, #28, and #20) and 2) failed to provide assistance with grooming tasks for 1 Resident (#63) out of a total sample of 29 residents. Findings include: Review of the facility policy titled, Activities of Daily Living (ADLs), Supporting, undated indicated the following: *Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). *Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. […]

• No harm, potential for more than minimal, patternF758Sep 29, 2022

  Based on record review, policy review and interview the facility failed to 1) ensure that PRN (as needed) [CONDITION(S)] medication was limited to 14 days, and that the physician evaluated the appropriateness to extend the use and document the rationale and the duration for the PRN medication, for 2 Residents (#4 and #6) and 2) failed to complete the AIMS (Abnormal Involuntary Movement Scale) assessment for 2 Residents (#19 and #57) taking [CONDITION(S)] medications out of a total sample of 29 residents. […]

• No harm, potential for more than minimal, patternF880Sep 29, 2022

  Based on observation, policy review and interview, the facility failed to ensure staff followed proper infection control practices in regard to 1.) disposal of a soiled/contaminated wound care dressing for 1 of 1 Resident (#63) observed, out of a total sample of 29 residents and 2.) hand hygiene during medication administration to prevent the spread of infection for 2 of 2 Residents (#37 and #102) observed, out of a a total sample 29 residents. Findings include: 1. For Resident #63, the facility failed to ensure all soiled dressing materials were promptly removed from the side of his/her overbed table to decrease the risk of spread of infection. […]