Chestnut Hill Health and Rehabilitation Center LLC

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Physician's orders included the administration of scheduled and sliding scale insulin with monitoring and recording his/her blood glucose readings, and administration of respiratory medication, the Facility failed to ensure they maintained a complete and accurate medical record, when nursing failed to consistently document administration of his/her respiratory medication and insulin, and blood sugar readings on the Medication Administration Record (MAR), when multiple days during the months of June and July 2026, related to completion of the above, on the MAR, were left blank by nursing.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was newly admitted to the facility, and whose Physician orders included medications to treat both chronic and acute conditions, the facility failed to ensure they obtained and Resident #1 was administered medications as ordered by his/her Provider.

Inspectors wroteBased on observations, and interviews, the facility failed to prepare food in accordance with professional standards for food service safety in the facility's main kitchen. Specifically, the facility failed to: 1. Ensure that [NAME] #1 wore a hair restraint when preparing and cooking food, increasing the risk for food contamination. 2. Monitor the final internal temperature for cooked foods prior to serving the food to residents, increasing the residents' risks for acquiring foodborne illnesses.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to adhere to infection control standards of practice to prevent contamination and the spread of infections for four Residents (#276, #113, #63 and #70) out of a total sample of 24 residents. Specifically, 1) For Resident #276, the facility failed to ensure that Personal Protective Equipment (PPE: items such as gowns and gloves worn to prevent the spread of infection) was worn in the Resident's room when the Resident was on Contact Precautions (measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment) for Clostridium Difficile (C-Diff: a spore forming toxin that can develop in the intestines after antibiotic use and causes watery diarrhea). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a Significant Change in Status Minimum Data Set [MDS] Assessments (SCSA) was completed for one Resident (#34) out of a total sample of 24 residents. Specifically, for Resident #34, the facility failed to ensure that a SCSA was completed

Inspectors wroteBased on record review, and interview, the facility failed to refer one Resident (#37) for a Preadmission Screening and Resident Review (PASRR- a federal and state-required process that is designed to, among other things, identify evidence of serious mental illness [SMI] and/or intellectual or developmental disabilities [ID/DD] in all individuals [regardless of source of payment] seeking admission to Medicaid-or Medicare-certified nursing facilities) Level II Evaluation (an evaluation conducted to determine if an individual with a newly evident or possible SMI, ID, or a related condition for Level II resident review upon a significant change in status assessment) out of a total sample of 24 residents. Specifically, for Resident #37, the facility failed to refer the Resident for a Level II PASRR Evaluation after receiving a new mental health disorder diagnosis.

Inspectors wroteBased on interview, and record review, the facility failed to provide Behavioral Health Care and services to attain or maintain the highest practicable mental and psychosocial wellbeing for one Resident (#109) out of a total sample of 24 residents. Specifically, for Resident #109, the facility failed to obtain Behavioral Health Services timely when the Resident was taking antidepressant medications and had consented for Behavioral Health Services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication pass error rate of less than five percent (%) for two Residents (#82 and #97), for five applicable residents, out of 26 medication pass opportunities. The medication error rate was observed to be 7.6%. Specifically, 1. For Resident #82, the Resident was administered the incorrect Calcium medication when Calcium + Vitamin D 600 mg/10 mcg was administered to the Resident and Calcium 1200 mg was ordered. 2. For Resident #97, the Resident was administered the wrong medication when Senokot 8.6 mg was administered and Senna-S [Senna/Colace] 8.6 mg/50 mg was ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was palatable and served at an appetizing temperature for one unit ([NAME] Unit) of two applicable units, out of three total units. Specifically, the facility failed to ensure: 1. Breakfast items were served at an appetizing temperature. 2. Scrambled eggs were an appropriate texture.

Inspectors wroteBased on interview, and record review, the facility failed to accurately complete a Comprehensive Minimum Data Set (MDS) Assessment reflective of the status of two Residents (#120 and #67) out of a total sample of 24 residents. Specifically, 1) For Resident #120, the facility failed to accurately code the Resident's discharge destination to home on the MDS Assessment, resulting in an inaccurate assessment of the Resident's discharge location to a short-term general hospital. 2) For Resident #67, the facility failed to accurately code the Resident's status relative to falls on one MDS Assessment, when the Resident was coded as having experienced one fall with major injury and the Resident did not sustain any falls, resulting in an inaccurate assessment of the Resident's health conditions.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents (Resident #1), who was assessed as being at risk for the development of pressure injuries and required assistance from staff with bed mobility and Activities of Daily Living (ADLs), the facility failed to ensure they maintained a complete and accurate medical record when Certified Nurse Aide (CNA) documentation for October 2024 was incomplete.

Inspectors wroteBased on interview, record and document review, the facility failed to provide competent nursing staff to care for one Resident (#16), out of one applicable resident, out of a total sample of 24 residents, who required removal of a urinary stent (a thin flexible tube that holds the ureter open for the flow of urine) in the facility. Specifically, the facility had no evidence that its Licensed Nursing Staff had the competency and skills required to provide care and services for residents with urinary stents when Nurse (#6) was allowed to remove Resident #16's urinary stent without the guidance of any facility policies and procedures.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to provide a dignified environment for three Residents (#107, #335 and #12), out of a total sample of 24 Residents. Specifically, the facility failed to ensure that a wandering Resident (#107) was prevented from intruding into Resident #335's and #12's rooms, removing their personal items and invading their privacy.

Inspectors wroteBased on observations, interviews, record and policy review, the facility failed to provide adequate supervision for one Resident (#107) to eliminate the risk of potential accident, hazards and injury for two Residents (#335 and #12) out of a total sample of 24 residents. Specifically, the facility staff failed to: 1. For Resident #107, implement interventions and provide adequate supervision to prevent intrusion into Resident #335 and #12's rooms when the Resident was identified as having wandering and other physically aggressive behaviors, with the potential for altercations. 2. For Resident #335 and #12, provide monitoring and supervision to eliminate the risk of Resident #107 entering the two Resident's and other residents' rooms and removing and consuming food items that may be hazardous.

Inspectors wroteBased on observation, record and policy review, and interview, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater when two Nurses (#1 and #2) of two Nurses observed, made two errors in 27 opportunities, totaling a medication error rate of 7.41%. These errors impacted two Residents (Resident #4 and #23) out of five residents observed during the medication pass, out of a total sample of 24 residents. Specifically, 1. For Resident #4, the facility staff administered the incorrect dose of Cholecalciferol (Vitamin D3- drug class vitamin used to treat Vitamin D deficiency) medication. 2. For Resident #23, the facility staff prepared the incorrect Insulin medication from another resident's medication vial, requiring the surveyor to intervene and prevent the incorrect dosage from being administered.

Inspectors wroteBased on observation, records reviewed, policy review and interviews, the facility failed to ensure it was free of significant medication errors for one Resident (#23) out of five residents observed during the medication pass, out of a total sample of 24 residents. Specifically for Resident #23, the facility staff prepared the incorrect Insulin medication from a medication vial prescribed to another resident and the surveyor was required to intervene to prevent the medication from being administered the Resident.

Inspectors wroteBased on observation, record and policy review, and interview, the facility failed to provide routine dental services for one Resident (#63), out of a total sample of 24 residents. Specifically, the facility failed to ensure that Resident #63 received routine dental services as requested by the Health Care Proxy (HCP- [a representative, surrogate, or agent] - is a person who can make health care decisions for you if you are unable to communicate these decisions yourself).

Inspectors wroteBased on record review and interview, the facility failed to accurately complete Minimum Data Set (MDS) Assessments for two Residents (#63 and #116) out of a total sample of 24 residents. Specifically, the facility staff failed to: 1) For Resident #63, accurately document a new diagnosis of Anxiety Disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with daily activities) and Psychotic Disorder with delusions (a fixed, or false conviction in something that is not real or shared by other people). 2) For Resident #116, accurately code the location of discharge.

Inspectors wroteBased on record review and interview, the facility failed to ensure that its staff completed quarterly review Minimum Data Set (MDS) assessments for 23 residents (#3, #4, #5, #6, #8, #9, #10, #11, #12, #13, #14, #16, #17, #19, #20, #21, #22, #23, #25, #27, #32, #42, and #43), out of a total of 29 sampled residents. Findings Include: Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual indicated the Quarterly MDS Assessment must be completed no later than 14 calendar days after the Assessment Reference Date (ARD-refers to the last day of the observation period that the assessment covers for the resident). 1. Resident #3 was admitted to the facility in July 2019. Review of the Quarterly MDS assessment with an Assessment Reference Date (ARD) of 7/20/22 indicated it had not been completed within 14 days of the ARD. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure staff completed Minimum Data Set (MDS) comprehensive assessments for three Residents (#23, #262, and #162), out of a total of 29 sampled residents. Specifically, the facility failed to complete an annual assessment for one Resident (#23) and admission assessments for two Residents (#262 and #162) as required.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure staff followed infection prevention and control standards specifically, related to 1. proper hand hygiene practices, 2. the practice of donning (putting on) and doffing (taking off) personal protective equipment (PPE), on one of three units observed; and 3. caring for one Resident's (#93) urinary catheter (a sterile tube inserted into the bladder that drains urine into a bag outside of the body), out of a total of 23 residents sampled.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff completed a Significant Change Minimum Data Set (MDS) assessment for one Resident (#28), out of a total of 29 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to provide medically-related social services for one Resident (#92), out of 23 total sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to create a policy for an independent smoker and for the safety of others in the facility, for one Resident (#17), out of a total of 23 sampled residents. Findings Include: Resident #17 was admitted to the facility in January 2022. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/3/22, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 meaning the Resident was cognitively intact. During an interview on 9/20/22 at 11:32 A.M., the Resident said he/she smoked outside the building under the tree at the end of the sidewalk and said there was an ash tray there. The Resident said he/she retrieved his/her smoking supplies from the nurse prior to going outside and gave them back to the nurse upon return to the building. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided a Notice of Transfer and Discharge to the Resident and/or the Resident's Representative in writing upon transfer from the facility for five Residents (#31, #84, #28, #80, and #46), out of a total of 23 sampled residents. Findings Include: 1. Resident #31 was admitted to the facility in September 2017. Review of the Clinical Nurse's note, dated 6/28/22, indicated Resident #31 was sent to the hospital on 6/28/22. Further review of the Resident's medical record indicated no documentation that a written Notice of Transfer and Discharge had been provided to the Resident and/or Resident's Representative at the time of discharge. 2. Resident #84 was admitted to the facility in March 2022. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure its staff provided the Resident and/or the Resident's Representative a written notice regarding the facility's Bed Hold Policy for four Residents (#31, #84, #28, and #80), out of a total of 23 sampled residents. Findings Include: Review of the facility's policy titled Bed Hold Policy, revised 12/6/21, indicated the following: -When emergency transfers are necessary, the facility will provide the resident or representative (sponsor) with information concerning our bed-hold within 24 hours of such transfer. 1. Resident #31 was admitted to the facility in September 2017. Review of the Clinical Nurse's Note, dated 6/28/22, indicated Resident #31 was sent to the hospital on 6/28/22. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that staff transmitted Minimum Data Set (MDS) assessments within the required 14 days of completion for three Residents (#2, #15, and #46), out of a total of 29 residents sampled. Findings Include: 1. Resident #2 was admitted to the facility in March 2022. Review of the Resident's MDS assessments indicated a required MDS assessment was completed 5/23/22 but was not accepted in the electronic medical record (had not been sent to the Centers for Medicare and Medicaid Services (CMS)). 2. Resident #15 was admitted to the facility in May 2022. Review of the Resident's MDS assessments indicated a required MDS assessment was completed by the facility on 5/18/22 but was not accepted in the electronic medical record. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff issued a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN) to two Residents (#7 and #262), out of a total of three sampled Residents. SNFABN: A notice issued to inform a resident of his/her financial liability to the facility when he/she transitioned off Medicare benefits. Findings Include: 1. Resident #7 was admitted to the facility in March 2022. Review of the Beneficiary Notice-Residents discharged Within the Last Six Months (a form the facility completes that indicates when a resident comes off their Medicare benefit and whether they remained in the facility or discharged to the community) indicated Resident #7's Medicare benefit ended 6/4/22 and he/she remained in the facility. [...]