Complete Care at Chestnut Hill LLC

In the surveyor’s words

From the most serious findings on record at Complete Care at Chestnut Hill LLC, in the surveyor’s own words.

• Immediate jeopardy, patternF578Dec 5, 2024

  Based on interview, record review, and review of facility policy, it was determined that the facility failed to ensure residents had the correct code status, which matched their physician's orders in the medical record, that identified their wishes in the event of a medical emergency. This deficient practice was identified for 3 of 31 residents reviewed for code status (Resident #4, R #36, and R #40). 1. Resident #40 had a Practitioner Orders for Life-Sustaining Treatment (POLST; a form that enables residents to indicate their preferences regarding life-sustaining treatment) dated [DATE], for a full-code status (all resuscitation procedures will be provided when a person stops breathing or their heart stops beating). […]

• Immediate jeopardy, patternF835Dec 5, 2024

  Based on interviews and review of pertinent facility documents, it was determined that the facility failed to ensure the Licensed Nursing Home Administrator (LNHA) ensured staff implemented the facility's code status policy for residents during a medical emergency to ensure residents' wishes regarding life-sustaining treatments were honored. This deficient practice was identified for 3 of 31 residents reviewed for code status (Resident #4, R #36. and R #40). Refer F 578 1. Resident #40 had a Practitioner Orders for Life-Sustaining Treatment (POLST; a form that enables residents to indicate their preferences regarding life-sustaining treatment) dated [DATE], for a full-code status (all resuscitation procedures will be provided when a person stops breathing or their heart stops beating). […]

• Actual harm, isolatedF692Jun 12, 2026

  Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to identify, assess, and implement timely and appropriate interventions for a resident (Resident #59) with an unplanned significant weight loss of 27.9 pounds (lbs.) or 17.23% significant weight loss in six months and a 31.6 lbs. or 19.13% significant weight loss in one month. This deficient practice was identified for 1 of 5 residents (Resident #59) reviewed for nutrition, and was evidenced by the following:The surveyor reviewed the medical record for Resident #59. […]

• Actual harm, isolatedF692Aug 18, 2022

  Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure identified Care Plan interventions were implemented timely, and the resident's physician was notified of significant weight loss for one resident, (Resident (R)69), of one reviewed for a significant weight loss. Specifically, R69's physician was not notified when R69's weight decreased and to potentially obtain orders to treat the weight loss and R69's supplements were not given as ordered in a timely manner. In total, R69's weight went from 155 pounds (lbs) to 113 lbs. Findings include: 1. […]

• No harm, potential for more than minimal, widespreadF865Dec 5, 2024

  Based on record review, interviews, and policy review, the facility failed to maintain documentation of the facility's ongoing Quality Assessment and Performance Improvement (QAPI) program. This failure had the potential to negatively affect 103 of 103 residents who resided at the facility. Findings Include: Review of the facility's policy titled, QAPI Plan Quality Assessment and Performance Improvement, updated 05/24 indicated, . Complete Care's mission is to continue its long history of providing the highest quality person-centered post-acute short-term subacute rehabilitation and long-term care residency in an environment that couples warmth of care with clinical The administrator, or designee, is responsible for assuring that all QAPI activities and required documentation is completed… […]