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Deficiency Records for Chestnut Rehab and Nursing
A list of the most recent deficiencies for Chestnut Rehab and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Chestnut Rehab and Nursing. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-23 | 2024-08-19 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2024-07-23 | 2024-07-10 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-02-20 | 2024-03-19 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-04 | 2024-02-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-04 | 2024-02-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-22 | 2023-12-22 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-27 | 2023-12-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-27 | 2023-12-01 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-10-13 | 2023-12-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-10-13 | 2023-12-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-13 | 2023-12-01 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-13 | 2023-11-24 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-10-13 | 2023-11-24 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-10-13 | 2023-11-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-13 | 2023-11-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-10-13 | 2023-11-24 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-10-13 | 2023-11-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-13 | 2023-11-24 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-10-13 | 2023-11-24 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-10-13 | 2023-11-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-10-13 | 2023-11-24 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-10-13 | 2023-11-24 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-13 | 2023-11-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-13 | 2023-11-24 | Y |
| Dispose of garbage and refuse properly. | Health | 2023-10-13 | 2023-11-24 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-13 | 2023-11-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-13 | 2023-11-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-13 | 2023-11-24 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-10-13 | 2023-11-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-10-13 | 2023-11-24 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-10-13 | 2023-11-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-13 | 2023-11-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-13 | 2023-11-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-13 | 2023-11-24 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-10-13 | 2023-11-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-13 | 2023-11-24 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-10 | 2023-08-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-10 | 2023-08-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-10 | 2023-08-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-10 | 2023-08-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-28 | 2022-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-28 | 2022-10-27 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-19 | 2022-10-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-19 | 2022-10-27 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-28 | 2022-10-26 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-19 | 2022-10-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-28 | 2022-10-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-28 | 2022-10-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-28 | 2022-10-21 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-09-28 | 2022-10-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-28 | 2022-10-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-28 | 2022-10-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-28 | 2022-10-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-09 | 2022-10-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-19 | 2022-10-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-19 | 2022-10-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-19 | 2022-10-21 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-05-19 | 2022-10-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-19 | 2022-10-21 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-05-19 | 2022-10-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-19 | 2022-10-21 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-07-07 | 2022-08-04 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-07 | 2022-07-18 | Y |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2022-03-16 | 2022-04-28 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-16 | 2022-04-28 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-09-28 | 2020-12-17 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-09-28 | 2020-12-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-09-28 | 2020-12-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-09-28 | 2020-12-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-09-28 | 2020-12-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-09-28 | 2020-12-17 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-09-28 | 2020-12-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-09-28 | 2020-12-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-09-28 | 2020-12-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-09-28 | 2020-11-06 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2020-09-28 | 2020-11-06 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2020-09-28 | 2020-11-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-09-28 | 2020-11-06 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-09-28 | 2020-11-06 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2020-09-28 | 2020-11-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-09-28 | 2020-11-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-09-28 | 2020-11-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-09-28 | 2020-11-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-09-28 | 2020-11-06 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2020-09-28 | 2020-11-06 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-09-28 | 2020-11-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-09-28 | 2020-11-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-09-28 | 2020-11-06 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-09-28 | 2020-11-06 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2020-09-28 | 2020-11-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-09-28 | 2020-11-06 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2020-09-28 | 2020-11-06 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-09-28 | 2020-11-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-09-28 | 2020-11-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-09-28 | 2020-11-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-09-28 | 2020-11-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-09-28 | 2020-11-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-09-28 | 2020-11-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-09-28 | 2020-11-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-09-28 | 2020-11-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-09-28 | 2020-11-06 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-09-28 | 2020-11-06 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-09-28 | 2020-11-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-09-28 | 2020-11-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-04-03 | 2019-05-02 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-03 | 2019-05-02 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-04-03 | 2019-05-02 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-04-03 | 2019-05-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-04-03 | 2019-05-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-03 | 2019-05-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-03 | 2019-05-02 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-04-03 | 2019-05-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-03 | 2019-05-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-04-03 | 2019-05-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-03 | 2019-05-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-03 | 2019-05-02 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-04-03 | 2019-05-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-03 | 2019-05-02 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-03 | 2019-05-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-03 | 2019-05-02 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-04-03 | 2019-05-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-04-03 | 2019-05-02 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-04-03 | 2019-05-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-04-03 | 2019-05-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-03 | 2019-05-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-03 | 2019-05-02 | N |
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