Inspection Reports for Chestnut Ridge Nursing and Rehabilitation

The document is a Statement of Deficiencies and Plan of Correction for Chestnut Ridge Nursing & Rehab Center following a survey completed on April 1, 2025.

The report contains initial comments but does not provide specific details on deficiencies or findings.

A health revisit survey was conducted to verify correction of deficiencies cited during the Recertification and Complaint Investigation survey concluded on February 2, 2025.

All deficiencies cited in the prior Recertification and Complaint Investigation survey were found to be corrected during this revisit survey.

The revisit survey was conducted in conjunction with a Complaint Investigation survey concluded on February 2, 2025.

A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.

All previously cited survey tags have been corrected as noted by the surveyor.

The inspection was a State Licensure survey conducted from January 31, 2025 through February 2, 2025, to determine compliance with the State Long Term Care Requirements.

The facility was found deficient in developing and implementing care plans for certain residents, failure to provide adequate ADL care including showers, nail care, and shaving facial hair, environmental sanitation issues including dirty PTAC filters, walls in disrepair, missing chair rails, and ceiling tiles, and food service safety violations including improper food storage, unlabeled foods, improper food temperatures, and unsanitary ice machine. Additionally, the area around the dumpster was found to have garbage and refuse.

A standard survey was conducted from January 31, 2025 through February 2, 2025, including investigations of complaint intake numbers GA00253314, GA00253519, and GA00253634, to assess compliance with Medicare/Medicaid regulations for long term care facilities.

The facility was found not in substantial compliance with multiple deficiencies including environmental maintenance issues, failure to refer a resident for PASARR Level II assessment, incomplete care plans, inadequate ADL care, lack of annual competency evaluations for CNAs, improper food storage and handling, and refuse disposal issues.

Complaint Intake Numbers GA00253314, GA00253519, and GA00253634 were investigated in conjunction with the standard survey.

Routine Life Safety Code Survey and Emergency Preparedness Program review conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA standards.

The facility was found not in substantial compliance with emergency preparedness training and testing requirements, life safety code exit signage, hazardous area enclosures, cooking facility hood system maintenance, fire alarm pull station access, corridor door functionality, and door inspection record keeping.

A health revisit survey was conducted to verify correction of deficiencies cited in a prior COVID-19 Focused Infection Control survey combined with a Complaint Investigation survey concluded on November 7, 2024.

All deficiencies cited in the previous COVID-19 Focused Infection Control and Complaint Investigation surveys were found to be corrected during this revisit survey.

The revisit survey was conducted in conjunction with a Complaint Investigation survey concluded on November 7, 2024.

This document is a Statement of Deficiencies and Plan of Correction for Chestnut Ridge Nursing & Rehab Center following a survey completed on December 30, 2024.

The report contains initial comments and identifies deficiencies requiring correction, but no specific deficiencies or severity levels are detailed in the provided page.

The inspection was conducted as a State Licensure survey at Chestnut Ridge Nursing and Rehab Center from October 30, 2024, through November 7, 2024, to determine compliance with the State Long Term Care Requirements.

The facility failed to ensure that soiled linen hampers located in the hallways were emptied immediately when full, resulting in overflowing hampers on multiple halls. This failure had the potential to impact 71 of 128 residents residing on the A and C Halls. Staff interviews and observations confirmed ongoing issues with timely emptying of soiled linen hampers despite re-education efforts.

A COVID-19 Focused Infection Control Survey was conducted in conjunction with a complaint survey investigating multiple complaint intake numbers, including substantiated and unsubstantiated complaints related to transportation and infection control.

The facility failed to properly assist five of 27 sampled residents with transportation arrangements for medical appointments, resulting in missed important medical procedures. Additionally, the facility failed to ensure soiled linen hampers were emptied immediately when full, potentially impacting 71 of 128 residents.

Complaint Intake Number GA00251022 was substantiated with deficiencies cited. Multiple other complaint intake numbers were investigated and found unsubstantiated or substantiated with no deficiencies.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00249037.

The complaint #GA00249037 was substantiated with no deficiency cited.

Complaint #GA00249037 was substantiated with no deficiency cited.

The document is a statement of deficiencies and plan of correction for Chestnut Ridge Nursing & Rehab Center, indicating a regulatory inspection was conducted.

The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.

A revisit survey was conducted to verify correction of deficiencies cited during the August 24, 2023, Standard Survey.

All deficiencies cited in the prior August 24, 2023, Standard Survey were found to be corrected during this revisit survey.

A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.

The Emergency Preparedness Program was reviewed and found to be in substantial compliance with 42 CFR § 483.73. All previously cited survey tags have been corrected.

The inspection was conducted as a State Licensure survey from August 22, 2023 through August 24, 2023 to determine compliance with State Long Term Care Requirements.

The facility was found deficient in infection control practices related to maintaining personal use equipment in a sanitary manner, environmental sanitation issues including unclean PTAC units and a missing wardrobe drawer, and food service sanitation violations including failure to allow dishes to air dry, improper hand hygiene, and failure to wear hairnets and gloves in the kitchen.

A standard survey was conducted at Chestnut Ridge Nursing and Rehabilitation Center from August 22, 2023, through August 24, 2023, to assess compliance with Medicare/Medicaid regulations.

The facility was found not in substantial compliance with multiple deficiencies including failure to maintain sanitary conditions of PTAC units and wardrobes, lack of physician order for urinary catheter, untreated foot wounds, improper respiratory equipment maintenance, absence of a dialysis transfer agreement, poor food handling and hygiene practices in the kitchen, and unlabeled/unbagged personal use equipment in shared bathrooms.

The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and related NFPA standards.

The facility was found not in substantial compliance with emergency preparedness and multiple life safety code requirements including improper use of electrical rooms, fire alarm system deficiencies, sprinkler system issues, improper storage of soiled linen, electrical equipment violations, power strip placement, and unsafe storage of oxygen tanks.

The document is a statement of deficiencies and plan of correction for Chestnut Ridge Nursing & Rehab Center following a state inspection.

No specific deficiencies or findings are detailed in the provided document.

A Revisit Survey was conducted at Chestnut Ridge Health and Rehabilitation from July 25, 2023 through July 27, 2023 to verify correction of deficiencies cited during the May 3, 2023 Complaint Survey.

All deficiencies cited as a result of the May 3, 2023 Complaint Survey were found to be corrected.

The visit was a follow-up to a complaint survey conducted on May 3, 2023; all cited deficiencies were corrected.

An Abbreviated/Partial Extended Survey was conducted from April 24, 2023 to May 3, 2023, investigating multiple complaints and allegations of abuse and other concerns at Chestnut Ridge Nursing & Rehab Center.

The facility was found to be out of compliance with multiple regulatory requirements including failure to prevent, report, and investigate abuse allegations; failure to ensure resident safety during investigations; failure to provide timely and thorough investigations; failure to provide adequate bathing and grooming; failure to conduct weekly skin assessments; failure to ensure medication availability and administration; failure to provide dental services; failure to maintain a clean and odor-free environment; and failure of administration to provide adequate oversight and monitoring of abuse prevention and reporting.

Multiple complaints were investigated including allegations of physical, verbal, and sexual abuse involving residents R#11, R#12, R#18, and R#28. Several complaints were substantiated with deficiencies, while others were unsubstantiated or substantiated without deficiencies. The facility failed to timely report, investigate thoroughly, and protect residents during investigations.

The inspection was conducted as a Licensure Survey from April 24, 2023 through May 3, 2023 to assess compliance with state regulations for the healthcare facility.

The facility failed to adequately assess and monitor the nutritional status of one resident and failed to ensure activities of daily living, including bathing and grooming, were provided to two residents. Documentation and communication deficiencies were noted, resulting in unaddressed weight loss and inadequate hygiene care.

An abbreviated survey was conducted to investigate complaint #GA00229284.

The complaint #GA00229284 was found to be unsubstantiated and no deficiencies were cited during the survey.

Complaint #GA00229284 was investigated and found to be unsubstantiated with no deficiencies cited.

The document is a statement of deficiencies and plan of correction for Chestnut Ridge Nursing and Rehabilitation Center, indicating a regulatory inspection was conducted.

The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.

A revisit survey was conducted to verify correction of deficiencies cited during the 11/04/2021 standard survey.

All deficiencies cited in the previous standard survey were found to be corrected during this revisit survey.

A Follow-Up Survey desk review was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited survey tags have been corrected.

An unannounced Emergency Preparedness survey was conducted following a State Agency Annual Emergency Preparedness Survey. Additionally, a Life Safety Code Federal Monitoring Survey was conducted by CMS following a state survey.

The facility was found in substantial compliance with emergency preparedness requirements but was not in compliance with Life Safety Code requirements related to building rehabilitation and means of egress daily inspections. Specifically, the facility failed to document daily inspections of areas undergoing construction or alterations affecting 12 resident rooms on two corridors.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found in compliance with the Emergency Preparedness Program requirements under 42 CFR 483.73 and the Life Safety Code requirements under 42 CFR Subpart 483.90(a) and NFPA 101 2012 edition.

The inspection was a licensure survey conducted from November 2, 2021 through November 4, 2021 to assess compliance with state and federal regulations for the facility.

The facility failed to ensure proper pharmacy management including dating of opened medications and twice daily refrigerator temperature logs. Additionally, the facility did not accommodate a quadriplegic resident with an appropriate call light upon readmission and failed to provide actual showers for another resident as scheduled during October 2021.

A standard survey was conducted to assess the facility's compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.

The facility was found not in substantial compliance with regulations, with deficiencies including failure to provide an appropriate call light for a quadriplegic resident, failure to develop a comprehensive care plan addressing this need, failure to provide bathing care as scheduled for one resident, and failure to properly label, store, and discard medications and biologicals including expired medications and incomplete refrigerator temperature monitoring.

A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaints #GA00214282, #GA00214702, and #GA00216726.

The complaints were unsubstantiated with no regulatory violations cited. The facility was found to be in compliance with infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.

Complaints #GA00214282, #GA00214702, and #GA00216726 were investigated and found to be unsubstantiated with no regulatory violations cited.

A revisit survey was conducted to verify correction of deficiencies cited in the January 27, 2021 Complaint and COVID-19 Infection Control Focus Survey.

All deficiencies cited in the prior complaint and infection control survey were found to be corrected during this revisit survey.

The revisit was related to deficiencies cited from a complaint investigation conducted on January 27, 2021.

A revisit survey was conducted to verify correction of deficiencies cited in the January 27, 2021 Complaint and COVID-19 Infection Control Focus Survey.

All deficiencies cited during the January 27, 2021 Complaint and COVID-19 Infection Control Focus Survey were found to be corrected.

A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparedness.

An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints (#GA00211722, #GA00211883, #GA00212178, #GA00212637, and #GA00212675).

Complaints #GA00211722, #GA00211883, and #GA00212637 were unsubstantiated with no deficiencies cited. Complaints #GA00212675 and #GA00212178 were substantiated but with no deficiencies cited.

Complaints #GA00211722, #GA00211883, and #GA00212637 were unsubstantiated. Complaints #GA00212675 and #GA00212178 were substantiated. No deficiencies were cited for any complaints.

A COVID-19 Focused Infection Control Survey was conducted in conjunction with investigations of four complaint intake numbers. Three complaints were unsubstantiated and one was substantiated with no deficiencies. The visit also included a COVID-19 Focused Emergency Preparedness Survey.

The facility was found noncompliant with nurse staffing information posting requirements, medication storage and security, and proper disposal and sanitary maintenance of garbage and refuse areas. The facility failed to post complete nurse staffing data on two of three days, stored medications in unsecured areas accessible to unauthorized individuals, and maintained an unsanitary outdoor garbage area with grease spills and refuse.

Complaint Intake Numbers GA00210513, GA00210018, GA00210047 were unsubstantiated. Complaint GA00211605 was substantiated with no deficiencies.

A Licensure Survey was conducted from January 25, 2021 through January 27, 2021 to assess compliance with state licensure requirements.

The facility failed to ensure medications were properly secured and stored, with opened medications found in an unlocked dining room area accessible to unauthorized individuals. Additionally, the outdoor garbage and refuse area was not maintained in a sanitary manner, with grease spills, discarded PPE, open trash container doors, and refuse scattered around the dumpster area.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.

The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Infection Control Survey, in conjunction with an Abbreviated/Partial Extended survey, was conducted. Complaint intake numbers GA00209457 and GA00207741 were investigated.

The facility was found to be in compliance with infection control regulations and emergency preparedness requirements. The complaints investigated were unsubstantiated with no regulatory violations cited.

Complaint intake numbers GA00209457 and GA00207741 were investigated and found to be unsubstantiated with no regulatory violations cited.

An offsite desk review was conducted to investigate Covid-19 related infection control allegations included in multiple complaints. An onsite Abbreviated/Partial Extended Survey was conducted to investigate several complaints.

The offsite investigation found no Immediate Jeopardy or Harm. The onsite abbreviated survey concluded that all complaints investigated were unsubstantiated and no regulatory violations were cited.

The investigation involved complaints #GA00205244, GA00205204, GA00205046, GA00205626, GA00203728, GA00203193, GA00201234, and GA00199914. All complaints were found to be unsubstantiated.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations related to emergency preparedness and infection control.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control, including implementation of CMS and CDC recommended practices for COVID-19.

A complaint survey was conducted from 2019-08-20 through 2019-08-22 to investigate complaints #GA00196573, GA00198537, and GA00198597 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

The survey was conducted to investigate complaints #GA00196573, GA00198537, and GA00198597; no deficiencies were found.

A follow-up to the Recertification survey conducted from 1/22/19 through 1/25/19 was performed from 3/25/19 through 3/28/19 to verify correction of deficiencies. Additionally, an Abbreviated/Partial Extended survey was conducted to investigate Complaint #GA00194408 during this revisit.

All previously identified deficiencies had been corrected, and the facility was in substantial compliance as of 3/11/19. No deficient practices were cited during the complaint investigation portion of the survey.

Complaint #GA00194408 was investigated during the revisit survey with no deficient practice cited.

An Abbreviated/Partial Extended survey was conducted to investigate complaint #GA00194408 from 3/25/19 through 3/28/19, along with a revisit survey to the Recertification survey of 1/22/19 through 1/25/19.

No deficient practice was cited for the complaint portion of the survey.

Complaint #GA00194408 was investigated and no deficient practice was found.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The survey noted that all previously cited survey tags have been corrected.

A standard survey was conducted to assess compliance with Medicare/Medicaid regulations and federal requirements for long term care facilities.

The survey identified multiple deficiencies including failure to provide required Medicaid notices, failure to protect a resident from abuse, failure to report alleged abuse timely, failure to follow individualized care plans for psychotropic drug use and behavior monitoring, failure to invite a resident to care plan meetings, failure to provide adequate ADL care related to nail hygiene, unsafe water temperatures in resident rooms, failure to monitor psychotropic medication side effects and behavior, failure to limit PRN psychotropic medication orders to 14 days, failure to follow menu portion sizes, and failure of the Quality Assurance committee to meet all requirements.

The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including review of nursing care, employee health requirements, and physical plant safety standards.

The facility was found deficient in providing adequate nursing care as evidenced by unclean resident fingernails and lack of behavioral monitoring for residents on psychotropic medications. Employee health records were incomplete, lacking timely physical exams and PPD skin tests. Additionally, unsafe hot water temperatures exceeding state limits were observed in multiple resident rooms.

The inspection was conducted as a Life Safety Code Survey to assess compliance with fire safety and emergency preparedness regulations.

The facility was found not in substantial compliance with emergency preparedness requirements and Life Safety Code standards, including outdated emergency plans, blocked fire alarm pull stations, missing fire alarm strobes, improperly spaced sprinklers, unsealed smoke barrier penetrations, malfunctioning smoke barrier doors, and lack of documentation for fire door maintenance.

A revisit survey was conducted on 11/29/18 to investigate multiple complaint intake numbers and verify correction of deficiencies cited in the 9/25/18 complaint survey.

All deficiencies cited as a result of the 9/25/18 complaint survey were found to be corrected. The complaint investigation found one complaint partially substantiated related to deficient practice in the physical environment, but no deficiencies were cited.

Complaint GA00192319 was partially substantiated with an allegation of deficient practice related to the physical environment, but no deficiencies were found.

A complaint survey was conducted on 2018-05-03 to investigate multiple complaints identified by numbers GA 00193065, GA00192319, GA 00192105, GA00192297, and GA 00192864.

The survey determined compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, and no deficiencies were cited.

The complaint investigation was conducted and no deficiencies were found, indicating the complaints were not substantiated.

A complaint survey was conducted on 3/29/18 to investigate complaint #GA00186473 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facility.

No deficiencies were cited during the complaint survey.

Complaint #GA00186473 was investigated and found to have no deficiencies.

A revisit survey was conducted to verify correction of deficiencies cited during the 1/22/18 recertification survey.

All deficiencies cited as a result of the 1/22/18 recertification survey were found to be corrected.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.

A complaint survey was conducted to investigate complaint GA 00184676 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.

The complaint was substantiated, but no deficiencies were cited.

Complaint GA 00184676 was investigated and substantiated, with no deficiencies cited.

The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code standards.

The facility was found not in substantial compliance with emergency preparedness and life safety code requirements, including an incomplete emergency preparedness plan, cooking equipment not properly installed under vent hoods, and lack of a remote annunciator for the emergency power generator.

The inspection was conducted as a complaint survey from 11/27/2017 through 11/30/2017 to investigate complaint GA00182339.

No health deficiencies were cited during the complaint investigation.

Complaint GA00182339 was investigated and found to have no health deficiencies.

An Abbreviated Survey was conducted on 7/10/17 through 7/11/17 at Chestnut Ridge Nursing and Rehab to investigate complaint GA00176667.

The complaint was not substantiated and the facility was found to be in compliance with Federal and State Long Term Care Requirements 42 CFR, Part 483, Subpart B, Requirements for Long Term Care Facilities.

Complaint GA00176667 was investigated and found to be not substantiated.

An unannounced abbreviated survey was conducted to investigate complaint GA00173574 at Chestnut Ridge Nursing and Rehabilitation.

The facility was found to be in substantial compliance with 42 CFR, Part 483, Subpart B, Requirements for long term care facilities.

Investigation of complaint GA00173574; facility found in substantial compliance.

The visit was a Health Revisit conducted to determine if previous deficiencies cited during the Standard and Abbreviated survey of December 22, 2017 had been corrected.

It was determined that all previous deficiencies cited during the prior surveys had been corrected.

A follow-up survey was conducted to verify that all previously cited survey deficiencies had been corrected.

All previously cited violations were corrected as noted by the follow-up survey conducted on 02/13/2017.

Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and NFPA 101 Life Safety Code 2012 edition.

The facility was found not in substantial compliance with life safety requirements, including obstructed means of egress, lack of emergency lighting in required areas, damaged corridor doors allowing smoke passage, inadequate fire drill documentation, improper use of power strips and extension cords, and improper storage and marking of oxygen cylinders.