Inspection Reports for Chestnut Ridge Nursing and Rehabilitation
125 Samaritan Dr, Cumming, GA 30040, United States, GA, 30040
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 1, 2025, found no deficiencies, confirming that previously cited issues were corrected. Earlier inspections showed recurring deficiencies related to resident care planning and activities of daily living, environmental sanitation including dirty PTAC filters and disrepair, and food service safety violations such as improper food storage and unsanitary equipment. Complaint investigations included a substantiated case in November 2024 involving failure to assist residents with transportation and timely emptying of soiled linen hampers, while most other complaints were unsubstantiated or substantiated without deficiencies. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility appears to have made improvements recently, as follow-up surveys consistently found prior deficiencies corrected.
Deficiencies (last 10 years)
Deficiencies (over 10 years)
14.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
204% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
135 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 0
Date: Apr 1, 2025
Visit Reason
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.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Follow-Up
Census: 135
Deficiencies: 0
Date: Apr 1, 2025
Visit Reason
A health revisit survey was conducted to verify correction of deficiencies cited during the Recertification and Complaint Investigation survey concluded on February 2, 2025.
Complaint Details
The revisit survey was conducted in conjunction with a Complaint Investigation survey concluded on February 2, 2025.
Findings
All deficiencies cited in the prior Recertification and Complaint Investigation survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 21, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Annual Inspection
Census: 135
Deficiencies: 4
Date: Feb 2, 2025
Visit Reason
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.
Findings
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.
Deficiencies (4)
Failed to develop and implement care plans for four of 42 sampled residents and failed to ensure ADL care was provided for three residents related to showers, nail care, and shaving of facial hair.
Failed to provide a safe, clean, comfortable, homelike environment related to dirty PTAC filters, walls in disrepair, missing chair rails, and missing/falling ceiling tiles in multiple resident rooms and kitchen.
Failed to store, prepare, distribute and serve food in accordance with professional standards including foods left open to air, unlabeled opened and unopened foods, serving cold fruit at 68°F, and unsanitary ice machine.
Failed to ensure the area around the dumpster was free from garbage and refuse.
Report Facts
Residents sampled: 42
Facility census: 135
Residents affected: 132
Rooms with environmental deficiencies: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HH | Licensed Practical Nurse / Unit Manager | Interviewed regarding medication refusal and ADL care deficiencies |
| JJ | Minimum Data Set Licensed Practical Nurse | Interviewed regarding medication refusal and care planning |
| KK | Minimum Data Set Licensed Practical Nurse | Interviewed regarding medication refusal and care planning |
| DON | Director of Nursing | Interviewed regarding medication refusal, care planning, and ADL care |
| AA | Certified Nursing Assistant | Interviewed regarding bathing and nail care practices |
| CC | Certified Nursing Assistant | Interviewed regarding bathing practices |
| LL | Certified Nursing Assistant | Interviewed regarding ADL care refusal |
| FF | Administrator in Absence | Interviewed regarding environmental sanitation deficiencies |
| Corporate Maintenance Director | Interviewed regarding maintenance and environmental deficiencies | |
| Cook II | Interviewed regarding food safety and kitchen sanitation deficiencies | |
| Regional Dietary Manager | Interviewed regarding food temperature and safety | |
| Registered Dietitian | Observed cleanup of garbage and refuse around dumpster | |
| Regional Nurse Consultant | Observed cleanup of garbage and refuse around dumpster |
Inspection Report
Routine
Census: 135
Deficiencies: 7
Date: Feb 2, 2025
Visit Reason
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.
Complaint Details
Complaint Intake Numbers GA00253314, GA00253519, and GA00253634 were investigated in conjunction with the standard survey.
Findings
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.
Deficiencies (7)
Facility failed to maintain a safe, clean, comfortable environment due to dirty PTAC filters, walls in disrepair, missing chair rails, and falling ceiling tiles in multiple resident rooms and kitchen.
Failure to ensure one resident with serious mental disorder was referred for a Level II PASARR assessment on admission or within 30 days of new diagnosis.
Failure to develop and implement care plans for four sampled residents, risking medical complications and unmet needs.
Failure to provide adequate ADL care including showers, nail care, and facial hair shaving for three residents.
Failure to conduct annual competency evaluations for Certified Nursing Assistants; no evaluations found for sampled CNAs despite years of employment.
Failure to store, prepare, distribute, and serve food in accordance with safety standards including unlabeled/open foods, serving cold fruit at 68°F, and unclean ice machine.
Failure to maintain dumpster area free from garbage and refuse, risking pest attraction.
Report Facts
Facility census: 135
Number of residents sampled: 42
Number of Certified Nursing Assistants on staff: 17
Temperature of cold fruit served: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HH | Licensed Practical Nurse / Unit Manager | Interviewed regarding resident medication refusal and ADL care |
| JJ | Minimum Data Set Licensed Practical Nurse | Interviewed regarding care plan requirements |
| KK | Minimum Data Set Licensed Practical Nurse | Interviewed regarding care plan requirements |
| AA | Certified Nursing Assistant | Interviewed regarding bathing and nail care practices |
| LL | Certified Nursing Assistant | Interviewed regarding resident care and refusal |
| CC | Certified Nursing Assistant | Interviewed regarding bathing policies |
| DON | Director of Nursing | Interviewed regarding PASARR process, care planning, and CNA competency evaluations |
| Regional Nurse Consultant BB | Regional Nurse Consultant | Interviewed regarding DON turnover and competency evaluations |
| Cook II | Interviewed regarding food safety and kitchen observations | |
| Director of Human Resources and Payroll | Interviewed regarding CNA competency evaluations | |
| Regional Dietary Manager | Interviewed regarding food temperature compliance | |
| Registered Dietitian | Observed refuse cleanup and kitchen conditions |
Inspection Report
Routine
Census: 135
Deficiencies: 7
Date: Feb 2, 2025
Visit Reason
Routine inspection to assess compliance with regulatory standards related to resident environment, care planning, activities of daily living, staff competency, food safety, and refuse disposal.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment due to dirty PTAC filters, walls in disrepair, missing ceiling tiles, and missing chair rails. Care planning deficiencies were noted for several residents, including failure to address medication refusals and personal hygiene needs. ADL care was inadequate for some residents, including bathing, nail care, and shaving. The facility failed to conduct annual competency evaluations for CNAs. Food safety violations included unlabeled and improperly stored foods, serving cold fruit at unsafe temperatures, and an unclean ice machine. Garbage and refuse were improperly managed around the dumpster area.
Deficiencies (7)
Dirty filters in PTAC units, walls in disrepair, missing paint, missing chair rails, and missing/falling ceiling tiles in multiple resident rooms and kitchen.
Failure to refer a resident with serious mental disorder for Level II PASARR assessment on admission or within 30 days of diagnosis.
Failure to develop and implement complete care plans for four residents, including addressing medication refusals and personal hygiene deficits.
Failure to provide adequate ADL care including bathing, nail care, and shaving for three residents.
Failure to conduct annual competency evaluations for Certified Nursing Assistants.
Failure to store, prepare, distribute, and serve food in accordance with professional standards including unlabeled foods, serving cold fruit at 68°F, and unclean ice machine.
Failure to properly dispose of garbage and refuse, resulting in litter around dumpster area.
Report Facts
Facility census: 135
Number of Certified Nurses Aides on staff: 17
Temperature of served fruit: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HH | Licensed Practical Nurse / Unit Manager | Interviewed regarding care plan and ADL care deficiencies |
| JJ | Minimum Data Set Licensed Practical Nurse | Interviewed regarding care plan and medication refusal documentation |
| KK | Minimum Data Set Licensed Practical Nurse | Interviewed regarding care plan and medication refusal documentation |
| AA | Certified Nursing Assistant | Interviewed regarding bathing and nail care practices |
| CC | Certified Nursing Assistant | Interviewed regarding bathing practices and resident self-bathing |
| LL | Certified Nursing Assistant | Interviewed regarding resident refusal of ADL care |
| MM | Certified Nursing Assistant | Training and competency evaluation records reviewed |
| NN | Certified Nursing Assistant | Training and competency evaluation records reviewed |
| BB | Regional Nurse Consultant | Interviewed regarding DON turnover and competency evaluations |
| [NAME] II | Cook II | Interviewed regarding food storage and ice machine cleaning |
| [NAME] II | Regional Dietary Manager | Interviewed regarding food temperature and safety |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan expectations and CNA competency evaluations |
| Director of Human Resources and Payroll | Director of Human Resources and Payroll | Interviewed regarding CNA competency evaluations |
| AIA, FF | Administrator in Absence and Facility Representative | Participated in rounds verifying environmental deficiencies |
| Corporate Maintenance Director | Corporate Maintenance Director | Interviewed regarding maintenance expectations and environmental findings |
Inspection Report
Annual Inspection
Census: 135
Deficiencies: 7
Date: Feb 2, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, facility maintenance, staff competency, food safety, and other operational standards.
Findings
The facility was found deficient in multiple areas including maintenance issues such as dirty PTAC filters, walls in disrepair, missing chair rails, and falling ceiling tiles; failure to ensure proper PASARR Level II assessments; incomplete care plans for residents; inadequate provision of activities of daily living (ADL) care; lack of annual competency evaluations for CNAs; food safety violations including improper food storage, unlabeled foods, and unclean ice machines; and improper garbage disposal around the dumpster area.
Deficiencies (7)
Dirty filters in PTAC units, walls in disrepair, missing chair rails, and missing/falling ceiling tiles in multiple resident rooms and kitchen.
Failure to ensure one resident with serious mental disorder was referred for a Level II PASARR assessment on admission or within 30 days of new diagnosis.
Failure to develop and implement complete care plans for four sampled residents, including documentation of medication refusal and personal hygiene needs.
Failure to provide adequate ADL care including bathing, nail care, and shaving for three residents.
Failure to conduct annual competency evaluations for Certified Nursing Assistants (CNAs).
Failure to store, prepare, distribute, and serve food in accordance with professional standards, including unlabeled foods, food left open to air, serving cold fruit at 68°F, and unclean ice machine.
Failure to ensure the area around the dumpster was free from garbage and refuse, posing a risk for pest attraction.
Report Facts
Facility census: 135
Number of Certified Nurses Aides on staff: 17
Temperature of served fruit: 68
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HH | Licensed Practical Nurse / Unit Manager | Interviewed regarding care plan deficiencies and ADL care |
| JJ | Minimum Data Set Licensed Practical Nurse | Interviewed regarding care plan deficiencies |
| KK | Minimum Data Set Licensed Practical Nurse | Interviewed regarding care plan deficiencies |
| AA | Certified Nursing Assistant | Interviewed regarding bathing and nail care practices |
| CC | Certified Nursing Assistant | Interviewed regarding bathing practices |
| LL | Certified Nursing Assistant | Interviewed regarding facial hair care and CNA competency |
| MM | Certified Nursing Assistant | Mentioned in CNA competency evaluation review |
| NN | Certified Nursing Assistant | Mentioned in CNA competency evaluation review |
| BB | Regional Nurse Consultant | Interviewed regarding CNA competency evaluations and DON turnover |
| Cook II | Interviewed regarding food storage and disposal | |
| [NAME] II | Interviewed regarding food storage, food temperature, and ice machine cleanliness | |
| Director of Human Resources and Payroll | Interviewed regarding CNA competency evaluations | |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan expectations and CNA competency evaluations |
Inspection Report
Routine
Census: 134
Capacity: 150
Deficiencies: 7
Date: Feb 1, 2025
Visit Reason
Routine Life Safety Code Survey and Emergency Preparedness Program review conducted to assess compliance with Medicare/Medicaid participation requirements and NFPA standards.
Findings
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.
Deficiencies (7)
Emergency Preparedness Program lacked documentation of staff training and testing of the emergency plan.
Non-working exit sign on D hall.
Penetrations in the mechanical room ceiling and walls needing fire stopping materials.
Pull station for kitchen hood suppression system blocked by boxes.
Fire alarm pull station access blocked by boxes in the kitchen.
Resident room 36 door will not close completely.
No record of door inspections maintained for the past year.
Report Facts
Certified beds: 150
Census: 134
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to exit sign, hazardous area penetrations, hood system pull station blockage, fire alarm pull station blockage, corridor door, and door inspection records. | |
| Staff N | Confirmed findings related to emergency preparedness program deficiencies. | |
| Staff A | Confirmed findings related to emergency preparedness program deficiencies. |
Inspection Report
Follow-Up
Census: 135
Deficiencies: 0
Date: Dec 30, 2024
Visit Reason
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.
Complaint Details
The revisit survey was conducted in conjunction with a Complaint Investigation survey concluded on November 7, 2024.
Findings
All deficiencies cited in the previous COVID-19 Focused Infection Control and Complaint Investigation surveys were found to be corrected during this revisit survey.
Report Facts
Facility census: 135
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 30, 2024
Visit Reason
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.
Findings
The report contains initial comments and identifies deficiencies requiring correction, but no specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Annual Inspection
Census: 128
Capacity: 128
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
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.
Findings
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.
Deficiencies (1)
The facility failed to ensure the soiled linen hampers located in the hallways were emptied immediately when full, leading to overflowing hampers on A and C Halls.
Report Facts
Residents potentially impacted: 71
Total residents present: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA UU | Certified Nursing Assistant | Interviewed regarding responsibility for emptying soiled linen hampers |
| CNA XX | Certified Nursing Assistant | Interviewed regarding accountability for emptying soiled linen hampers |
| Regional Nurse Consultant | Regional Nurse Consultant | Alerted staff to empty overflowing hampers and provided statements about ongoing issues |
| Housekeeping Director | Housekeeping Director | Interviewed about soiled linen hamper emptying procedures |
| Assistant Director of Nursing and Infection Preventionist | Assistant Director of Nursing and Infection Preventionist | Re-educated staff on expectations for emptying soiled linen hampers |
Inspection Report
Complaint Investigation
Census: 128
Deficiencies: 2
Date: Nov 7, 2024
Visit Reason
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.
Complaint Details
Complaint Intake Number GA00251022 was substantiated with deficiencies cited. Multiple other complaint intake numbers were investigated and found unsubstantiated or substantiated with no deficiencies.
Findings
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.
Deficiencies (2)
Failure to properly assist five of 27 sampled residents with transportation arrangements for medical appointments, resulting in missed appointments.
Failure to ensure soiled linen hampers located in hallways were emptied immediately when full, potentially impacting 71 of 128 residents.
Report Facts
Residents sampled: 27
Residents impacted: 5
Facility census: 128
Residents potentially impacted: 71
Missed appointments per week: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LL | Social Worker | Documented grievances related to missed appointments due to transportation |
| JJ | Unit Clerk | Responsible for scheduling and arranging transportation; reported multiple missed appointments |
| II | Social Services Director | Documented grievances and apologized for missed appointments due to transportation issues |
| CC | Licensed Practical Nurse | Reported residents missed several appointments due to lack of alternative transportation |
| KK | Activities Director | Reported transportation was a major problem with no backup plan |
| UU | Certified Nursing Assistant | Responsible for emptying soiled linen hampers |
| XX | Certified Nursing Assistant | Stated accountability is needed for emptying soiled linen hampers |
| ADON/IP | Assistant Director of Nursing and Infection Preventionist | Re-educated staff on expectations for emptying soiled linen hampers |
| Housekeeping Director | Reported soiled linen hampers emptied by CNAs at least every two hours | |
| RNC | Regional Nurse Consultant | Performed in-service and alerted staff to empty overflowing linen hampers |
Inspection Report
Routine
Census: 128
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on the management of soiled linen hampers in the hallways.
Findings
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 issue potentially impacted 71 of 128 residents on the A and C halls. Staff interviews and observations confirmed inconsistent emptying of hampers despite policies and re-education efforts.
Deficiencies (1)
Failure to ensure soiled linen hampers were emptied immediately when full, leading to overflowing hampers in hallways.
Report Facts
Residents potentially impacted: 71
Current census: 128
Number of halls: 4
Number of soiled linen hampers per hall: 2
In-service sessions conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA UU | Certified Nursing Assistant | Revealed CNAs were responsible for emptying soiled linen hampers and taking them outside during mealtime |
| Regional Nurse Consultant | Alerted staff to empty overflowing soiled linen hamper and stated the issue had been a pain point | |
| Housekeeping Director | Revealed soiled linen hampers were emptied by CNAs at least every two hours and moved outside during mealtimes | |
| Assistant Director of Nursing and Infection Preventionist | ADON/IP | Re-educated staff on expectations for emptying soiled linen hampers consistently |
| CNA XX | Certified Nursing Assistant | Stated that everyone must be accountable for emptying soiled linen hampers |
Inspection Report
Routine
Census: 128
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically focusing on the management of soiled linen hampers in the hallways.
Findings
The facility failed to ensure that soiled linen hampers were emptied immediately when full, resulting in overflowing hampers in multiple hallways. This issue potentially impacted 71 of 128 residents on the A and C halls. Staff interviews and observations confirmed inconsistent emptying of hampers despite policies and re-education efforts.
Deficiencies (1)
Failure to ensure soiled linen hampers located in the hallways were emptied immediately when full, leading to overflowing hampers.
Report Facts
Residents potentially impacted: 71
Current census: 128
Number of halls: 4
Number of soiled linen hampers per hall: 2
In-service sessions: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA UU | Certified Nursing Assistant | Revealed CNAs were responsible for emptying soiled linen hampers and taking them outside during mealtime |
| Regional Nurse Consultant | Regional Nurse Consultant (RNC) | Alerted staff to empty overflowing hampers and conducted in-service training |
| Housekeeping Director | Housekeeping Director | Revealed soiled linen hampers were emptied by CNAs at least every two hours and moved outside during mealtimes |
| Assistant Director of Nursing and Infection Preventionist | Assistant Director of Nursing and Infection Preventionist (ADON/IP) | Re-educated staff on expectations for emptying soiled linen hampers |
| CNA XX | Certified Nursing Assistant | Stated accountability concerns regarding emptying soiled linen hampers |
Inspection Report
Complaint Investigation
Census: 137
Deficiencies: 0
Date: Jul 29, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00249037.
Complaint Details
Complaint #GA00249037 was substantiated with no deficiency cited.
Findings
The complaint #GA00249037 was substantiated with no deficiency cited.
Report Facts
Census: 137
Inspection Report
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Chestnut Ridge Nursing & Rehab Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 135
Deficiencies: 0
Date: Oct 10, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the August 24, 2023, Standard Survey.
Findings
All deficiencies cited in the prior August 24, 2023, Standard Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 6, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
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.
Inspection Report
Annual Inspection
Capacity: 133
Deficiencies: 3
Date: Aug 24, 2023
Visit Reason
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.
Findings
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.
Deficiencies (3)
Failure to maintain personal use equipment in a sanitary manner in two shared bathrooms with unlabeled/unbagged wash basins.
Failure to maintain packaged terminal air conditioners in a sanitary condition in two resident rooms and failure to maintain a wardrobe in functional condition.
Failure to allow dishes to air dry, ensure kitchen staff perform hand hygiene and wear gloves when preparing food, and ensure staff entering the kitchen wear hair nets and perform hand hygiene.
Report Facts
Residents receiving oral diet: 128
Total licensed capacity: 133
Number of unlabeled/unbagged wash basins in bathroom for room 32: 2
Number of unlabeled/unbagged wash basins in bathroom for room 33: 4
Number of urinals in bathroom for room 33: 1
Number of resident rooms sampled for environmental sanitation: 20
Number of resident wardrobes on B Hall: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Observed preparing food without proper hand hygiene and glove use; confirmed deficiencies in dish drying and sanitation practices. |
| Cook BB | Observed drying dishes with a towel and preparing food without proper hand hygiene. | |
| Maintenance Assistant | Maintenance Assistant | Confirmed black substance on PTAC units and repaired missing wardrobe drawer. |
| Administrator | Administrator | Entered kitchen without hairnet or hand hygiene; confirmed expectations for sanitation compliance. |
| Unit Manager | Unit Manager | Confirmed unlabeled/unbagged wash basins in shared bathrooms and stated staff should label and bag personal use equipment. |
Inspection Report
Routine
Census: 133
Deficiencies: 7
Date: Aug 24, 2023
Visit Reason
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.
Findings
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.
Deficiencies (7)
Failed to maintain sanitary PTAC units in rooms 16 and 20 and a functional wardrobe in room 23.
Failed to obtain a physician's order for an indwelling urinary catheter for Resident #69.
Failed to identify and treat four of five wounds on the toes of Resident #32.
Failed to change disposable respiratory supplies and maintain cleanliness for eight residents on oxygen or BiPAP therapy.
Failed to secure a contract agreement with the dialysis center for residents receiving dialysis.
Failed to allow dishes to air dry, ensure kitchen staff perform hand hygiene and wear gloves, and require hair nets for kitchen entrants.
Failed to maintain personal use equipment in a sanitary manner; unlabeled/unbagged wash basins observed in shared bathrooms for rooms 32 and 33.
Report Facts
Resident census: 133
Residents affected by respiratory equipment deficiency: 8
Residents affected by foot care deficiency: 1
Residents affected by urinary catheter order deficiency: 1
Residents affected by personal use equipment deficiency: 2
Residents affected by food handling deficiency: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse EE | Licensed Practical Nurse | Confirmed Resident #69 had urinary catheter without physician order |
| Director of Nursing | Director of Nursing | Confirmed no physician order for Resident #69's urinary catheter and verified respiratory equipment deficiencies |
| Cook BB | Observed drying dishes with towel and plating food without gloves | |
| Dietary Manager | Dietary Manager | Observed drying dishes with towel, not performing hand hygiene, and not wearing gloves during food preparation |
| Unit Manager LPN JJ | Unit Manager | Confirmed unlabeled/unbagged wash basins in shared bathrooms |
| Administrator | Administrator | Entered kitchen without hairnet or hand hygiene; confirmed expectations for sanitation |
| Maintenance Assistant | Confirmed black substance on PTAC units and repaired wardrobe drawer |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 24, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, facility environment, infection control, respiratory care, dialysis services, and dietary practices at Chestnut Ridge Nursing & Rehab Center.
Findings
The facility was found deficient in maintaining a sanitary environment, obtaining physician orders for urinary catheters, providing appropriate foot and respiratory care, securing dialysis service contracts, ensuring proper dietary hygiene and food handling, and maintaining infection prevention protocols for shared equipment.
Deficiencies (7)
Failed to maintain packaged terminal air conditioners (PTAC) in a sanitary condition and failed to maintain a resident wardrobe in functional condition.
Failed to obtain a physician's order for a urinary catheter for one resident.
Failed to identify and treat four wounds on toes of one resident's left foot.
Failed to change disposable respiratory supplies and maintain cleanliness of respiratory equipment for eight residents on oxygen or BiPAP therapy.
Failed to secure a contract with the dialysis center for residents receiving dialysis services.
Failed to allow dishes to air dry, ensure kitchen staff perform hand hygiene and wear gloves, and ensure staff wear hair nets and perform hand hygiene upon entering the kitchen.
Failed to maintain personal use equipment in a sanitary manner in shared bathrooms; unlabeled and unbagged wash basins observed.
Report Facts
Residents affected: 20
Residents affected: 5
Residents affected: 7
Residents affected: 22
Facility census: 133
Residents affected: 128
Shared bathrooms: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse EE | Licensed Practical Nurse | Verified urinary catheter presence without physician order and unaware of bruised toes on resident |
| Licensed Practical Nurse JJ | Unit Manager | Confirmed bruised toes on resident and unbagged wash basins in shared bathrooms |
| Maintenance Assistant | Confirmed PTAC black substance and repaired wardrobe drawer | |
| Dietary Manager | Dietary Manager | Observed drying dishes with towels, failure to perform hand hygiene, and failure to wear gloves during food preparation |
| Administrator | Administrator | Entered kitchen without hairnet or hand hygiene, confirmed contract issues with dialysis center, and stated expectations for dietary sanitation |
| Director of Nursing | Director of Nursing | Confirmed respiratory care deficiencies and explained staff responsibilities for oxygen supply changes |
Inspection Report
Life Safety
Census: 128
Capacity: 150
Deficiencies: 11
Date: Aug 23, 2023
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and related NFPA standards.
Findings
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.
Deficiencies (11)
Emergency Preparedness Plan was not in substantial compliance with 42 CFR § 483.73; Administrator unfamiliar with emergency plan documentation accessibility.
Electrical room was being used as an office (mixed use).
Smoke detector installed too close (3 feet) to HVAC vent in storage room.
Fire alarm sensitivity test documents were not available upon request.
Central supply storage stacked without required 18 inch clearance from fire sprinklers.
Sight glass in Post Indicator valve was damaged and darkened, preventing visibility of valve position.
Three fire sprinklers in main kitchen covered with grease/debris.
Soiled utilities room used as storage and not using correct containers for soiled linen.
Mechanical room storage blocking electrical panels; electrical panel loose from wall in D hall.
Power strips were kept on the floor in main kitchen office, business office, nurses' station, and MDS room.
Oxygen tanks stored with combustibles inside enclosed container and empty tanks outside without proper signage.
Report Facts
Census: 128
Total Capacity: 150
Deficiencies cited: 11
Inspection date: Aug 23, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour | |
| Staff A | Confirmed emergency preparedness plan findings |
Inspection Report
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Chestnut Ridge Nursing & Rehab Center following a state inspection.
Findings
No specific deficiencies or findings are detailed in the provided document.
Inspection Report
Re-Inspection
Census: 139
Deficiencies: 0
Date: Jul 27, 2023
Visit Reason
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.
Complaint Details
The visit was a follow-up to a complaint survey conducted on May 3, 2023; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the May 3, 2023 Complaint Survey were found to be corrected.
Report Facts
Resident Census: 139
Inspection Report
Abbreviated Survey
Census: 126
Deficiencies: 8
Date: May 3, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (8)
Failure to prevent, report, and investigate allegations of verbal, sexual, and physical abuse for multiple residents, including failure to suspend alleged perpetrators during investigations and failure to thoroughly investigate allegations.
Failure to provide adequate bathing and grooming assistance to residents, including failure to provide showers as scheduled and failure to provide facial grooming.
Failure to conduct weekly skin assessments for multiple residents at risk for pressure ulcers.
Failure to ensure medication availability and administration for multiple residents, including failure to reorder medications timely and lack of medication in the facility.
Failure to ensure medication carts were securely locked and accessible only to authorized staff, with one medication cart found unlocked with keys hanging.
Failure to provide dental services for a resident with documented dental needs.
Failure to maintain a clean, safe, and sanitary environment, with persistent foul odors on two hallways related to a resident who frequently refused care and was incontinent.
Failure of administration to provide adequate oversight and monitoring related to abuse prevention, reporting, and investigation.
Report Facts
Resident census: 126
Weight loss percentage: 4.67
Medication administration missing dates: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA BB | Certified Nursing Assistant | Named in abuse allegation involving resident R#11 |
| CNA CC | Certified Nursing Assistant | Named in abuse allegation involving resident R#11 |
| CNA DD | Certified Nursing Assistant | Named in abuse allegation involving resident R#28 |
| RN AA | Registered Nurse | Named in medication cart security finding |
| LPN MM | Licensed Practical Nurse | Named in resident transportation delay for resident R#20 |
| LPN LL | Licensed Practical Nurse | Named in resident transportation delay for resident R#20 |
| Administrator | Named as Abuse Coordinator and involved in abuse investigation oversight | |
| DON | Director of Nursing | Named as involved in abuse investigation oversight and medication administration oversight |
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 11
Date: May 3, 2023
Visit Reason
The inspection was conducted due to multiple allegations of abuse, neglect, and failure to provide adequate care and services to residents, including verbal, physical, and sexual abuse, failure to report and investigate abuse allegations, and concerns about resident care and safety.
Complaint Details
The complaint investigation was triggered by multiple allegations of abuse including verbal, physical, and sexual abuse of residents R#11, R#12, R#18, and R#28. The facility failed to timely report, investigate, and protect residents from abuse. Immediate Jeopardy was identified on 4/28/2023 and removed on 5/1/2023 after the facility implemented a removal plan.
Findings
The facility failed to maintain an environment free from abuse for multiple residents, failed to timely report and thoroughly investigate abuse allegations, failed to protect residents from potential abuse, failed to provide adequate care including bathing, grooming, skin assessments, nutrition monitoring, medication administration, dental care, and failed to maintain a clean and odor-free environment. Immediate Jeopardy was identified and removed after the facility implemented a removal plan including staff training and management oversight.
Deficiencies (11)
Failed to protect residents from verbal, sexual, and physical abuse and failed to suspend alleged perpetrators during investigations.
Failed to timely report allegations of abuse to the Abuse Coordinator and State Survey Agency.
Failed to thoroughly investigate allegations of abuse, including failure to interview residents and staff and identify perpetrators.
Failed to provide adequate assistance with activities of daily living including bathing, grooming, and toileting for residents.
Failed to perform weekly skin assessments consistently for residents at risk for pressure ulcers.
Failed to ensure timely return transportation for a resident from a medical appointment.
Failed to ensure medication availability and administration for residents, resulting in missed doses due to lack of medication in the facility.
Failed to ensure medication carts were securely locked when unattended, leaving medications accessible.
Failed to provide dental services for a resident with dental pain and chewing difficulties.
Failed to provide adequate administrative oversight and monitoring related to prevention, reporting, and investigation of abuse allegations.
Failed to maintain a clean, safe, and sanitary environment, resulting in persistent foul odors related to a resident's incontinence and hygiene issues.
Report Facts
Residents affected: 126
Weight loss: 4.67
Medication missed: 15
Medication missed: 20
Medication missed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA BB | Certified Nursing Assistant | Named in abuse allegation involving resident R#11; not suspended during investigation |
| CNA CC | Certified Nursing Assistant | Named in abuse allegation involving resident R#11; not suspended during investigation |
| CNA DD | Certified Nursing Assistant | Named in abuse allegation involving resident R#28; not suspended during investigation |
| RN AA | Registered Nurse | Left medication cart unlocked during inspection |
| Administrator | Facility Administrator/Abuse Coordinator | Responsible for abuse investigations and oversight; acknowledged failures in abuse investigations and suspensions |
| DON | Director of Nursing | Confirmed failures in abuse investigations and oversight |
| Clinical Nurse Consultant | Interim Director of Nursing | Provided expectations for abuse reporting and medication ordering |
| LPN OO | Licensed Practical Nurse | Reported medication availability issues |
| RN PP | Registered Nurse | Reported medication availability issues |
| LPN QQ | Licensed Practical Nurse | Reported medication availability issues |
| LPN RR | Licensed Practical Nurse | Reported medication availability issues |
| Consulting Pharmacist | Noted concerns with medication administration documentation and availability | |
| Wound Care Nurse | Performed skin assessments and reported issues with weekly skin assessments | |
| Social Services Director | Reported transportation and abuse reporting issues | |
| Housekeeping Director | Reported ongoing odor problems related to resident R#28 | |
| Ombudsman | Reported odor issues and resident care concerns |
Inspection Report
Complaint Investigation
Census: 126
Deficiencies: 11
Date: May 3, 2023
Visit Reason
The inspection was conducted due to multiple allegations of abuse, neglect, and failure to provide adequate care and services at the facility, including verbal, physical, and sexual abuse investigations, failure to report and investigate abuse allegations timely, and concerns about resident care and safety.
Complaint Details
The complaint investigation revealed multiple allegations of abuse (physical, verbal, sexual) involving residents R#11, R#12, R#18, and R#28. The facility failed to timely report and investigate these allegations, failed to protect residents from alleged perpetrators, and failed to suspend staff during investigations. The investigation also identified failures in care provision, medication management, and environmental cleanliness.
Findings
The facility failed to maintain an environment free from abuse for multiple residents, failed to timely report and thoroughly investigate abuse allegations, failed to protect residents from potential abuse, failed to provide adequate care including bathing, grooming, skin assessments, nutrition monitoring, medication availability, dental care, and failed to maintain a clean and odor-free environment. Immediate Jeopardy was identified and removed after the facility implemented a removal plan including staff training and management oversight.
Deficiencies (11)
Failed to protect residents from verbal, sexual, and physical abuse and failed to suspend alleged perpetrators during investigations.
Failed to timely report allegations of abuse to the Abuse Coordinator and State Survey Agency.
Failed to thoroughly investigate allegations of abuse including failure to interview residents and staff and identify perpetrators.
Failed to provide activities of daily living including bathing, grooming, and toileting assistance for residents.
Failed to perform weekly skin assessments for residents at risk for pressure ulcers.
Failed to provide timely return transportation for a resident from a medical appointment.
Failed to ensure medication availability and administration for residents due to lack of medication in the facility.
Failed to ensure medication carts were securely locked and accessible only to authorized staff.
Failed to provide routine and emergency dental care for a resident with dental pain.
Failed to provide adequate administrative oversight and monitoring related to prevention, reporting, and investigation of abuse.
Failed to maintain a clean, safe, and sanitary environment related to foul odors from a resident with incontinence and hygiene issues.
Report Facts
Residents affected: 126
Residents sampled: 31
Weight loss: 6.4
Weight loss percentage: 4.67
Medication unavailable dates: 20
Shower frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN AA | Registered Nurse | Left medication cart unlocked with keys accessible |
| CNA BB | Certified Nursing Assistant | Alleged perpetrator of verbal and physical abuse to resident R#11, not suspended during investigation |
| CNA CC | Certified Nursing Assistant | Alleged perpetrator of verbal and physical abuse to resident R#11, not suspended during investigation |
| CNA DD | Certified Nursing Assistant | Alleged perpetrator of physical and verbal abuse to resident R#28, not suspended during investigation |
| LPN OO | Licensed Practical Nurse | Reported medication sometimes unavailable, responsible for ordering medications |
| RN PP | Registered Nurse | Agency nurse unable to administer some medications due to unavailability |
| LPN QQ | Licensed Practical Nurse | Reported medication unavailability and reordering issues |
| LPN RR | Licensed Practical Nurse | Reported delays in receiving controlled pain medications |
| LPN MM | Licensed Practical Nurse | Documented resident R#20 returned late from medical appointment |
| DON | Director of Nursing | Confirmed failures in abuse investigations, medication management, and skin assessments |
| Administrator | Facility Administrator/Abuse Coordinator | Failed to ensure abuse investigations and suspensions were conducted properly |
| Wound Care Nurse | Wound Care Nurse | Confirmed lack of weekly skin assessments |
| Social Services Director | Social Services Director | Reported transportation issues for resident R#20 |
| Housekeeping Director | Housekeeping Director | Reported ongoing odor problems related to resident R#28 |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 3, 2023
Visit Reason
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.
Findings
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.
Deficiencies (2)
Failure to assess and monitor the nutritional status of one resident (R#14), including lack of weight monitoring and documentation of food/fluid intake.
Failure to provide activities of daily living (ADL) such as showers and facial grooming/assistance with toileting for two residents (R#17 and R#19).
Report Facts
Weight loss percentage: 4.67
Sample size: 5
Sample size: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| TT | Unit Manager | Confirmed weight monitoring procedures and lack of weight documentation for resident R#14. |
| FF | Certified Nursing Assistant (CNA) | Agency employee familiar with facility; stated residents sometimes missed showers and facial hair was to be shaved on shower days. |
| GG | Certified Nursing Assistant (CNA) | Worked three days per week; stated showers were given twice weekly and facial grooming was to be done on shower days. |
| HH | Certified Nursing Assistant (CNA) | Frequently worked in facility; stated showers were given based on room number and refusals were to be documented. |
| Interim Director of Nursing | Clinical Nurse Consultant (CNC) | Stated baths/showers were scheduled twice weekly and refusals were to be documented. |
| HRN II | Hospital Registered Nurse | Reported resident R#17's raw and excoriated skin and family concerns about care. |
| DON | Director of Nursing | Stated Unit Managers checked CNA documentation and emphasized if care was not documented, it was considered not done. |
| Registered Dietitian | Described facility policy for weight and nutrition monitoring and stated unawareness of resident R#14's weight loss. | |
| Director of Rehabilitation | Reported nursing staff awareness of resident R#14's feeding difficulties. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 3, 2022
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00229284.
Complaint Details
Complaint #GA00229284 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint #GA00229284 was found to be unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Deficiencies: 0
Date: Jan 10, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Chestnut Ridge Nursing and Rehabilitation Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies, but no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 91
Deficiencies: 0
Date: Jan 10, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 11/04/2021 standard survey.
Findings
All deficiencies cited in the previous standard survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 5, 2022
Visit Reason
A Follow-Up Survey desk review was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Life Safety
Census: 103
Capacity: 150
Deficiencies: 1
Date: Dec 10, 2021
Visit Reason
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.
Findings
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.
Deficiencies (1)
Failed to document means of egress daily inspection of areas that have undergone construction, repair, alterations or additions to ensure instant usability in case of emergency.
Report Facts
Resident rooms affected: 12
Census: 103
Certified beds: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed and present when deficiency was identified regarding failure to document daily inspections |
Inspection Report
Life Safety
Census: 102
Capacity: 150
Deficiencies: 0
Date: Nov 8, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
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.
Inspection Report
Original Licensing
Deficiencies: 3
Date: Nov 4, 2021
Visit Reason
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.
Findings
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.
Deficiencies (3)
Medications were not dated appropriately when opened to determine discard date in medication room and carts; refrigerator temperatures were not logged twice daily; expired biologicals and medical supplies were not discarded prior to expiration.
Failure to accommodate a quadriplegic resident (R#95) with an appropriate call light upon readmission on 10/13/2021.
Failure to provide actual showers for resident (R#31) for the remainder of October 2021, providing only bed and sponge baths instead.
Report Facts
Medication carts with expired medications: 3
Sample size of residents reviewed: 30
Date of resident readmission: Oct 13, 2021
Resident shower schedule days: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Verified lack of open dates on medications and confirmed expired medications. |
| LPN NN | Licensed Practical Nurse | Verified lack of open dates on medications, confirmed refrigerator temperature log issues, and explained medication expiration procedures. |
| LPN CC | Charge Nurse | Confirmed expired medications found in medication cart A. |
| LPN DD | Charge Nurse | Confirmed expired medications found in medication cart C. |
| LPN KK | Licensed Practical Nurse | Full-time staff nurse familiar with resident R#95 and call light needs. |
| LPN LL | Licensed Practical Nurse | Reported need for appropriate call light for resident R#95 to Unit Manager. |
| Director of Nursing | Director of Nursing (DON) | Provided information on medication administration trainings, refrigerator temperature monitoring, and call light installation timing. |
| Unit Manager | Unit Manager | Reported on call light installation for resident R#95 and lack of prior awareness. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Recalled need for special call light for resident R#95 but was unaware it had not been installed. |
Inspection Report
Routine
Census: 105
Deficiencies: 4
Date: Nov 4, 2021
Visit Reason
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.
Findings
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.
Deficiencies (4)
Failed to accommodate the need of one resident with quadriplegia by not providing an appropriate call light upon readmission.
Failed to develop and implement a comprehensive person-centered care plan for two residents related to providing an appropriate call light for a resident with quadriplegia.
Failed to provide bathing care (actual showers) for one resident for the remainder of October 2021, providing only bed and sponge baths instead.
Failed to ensure medications were dated appropriately when opened, failed to discard expired medications, and failed to log refrigerator temperatures twice daily as required.
Report Facts
Resident census: 105
Sample size: 30
Expiration dates of medications: 5
Expired medications: 1
Expired medications: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN KK | Licensed Practical Nurse | Provided information about resident #95's call light and care needs |
| LPN LL | Licensed Practical Nurse | Reported to Unit Manager about resident #95 needing an appropriate call light |
| Unit Manager | Responded to call light issue for resident #95 and initiated maintenance work order | |
| Assistant Director of Nursing | ADON | Interviewed regarding awareness of call light issue for resident #95 |
| Director of Nursing | DON | Interviewed regarding care plan and call light issues for resident #95 and medication administration and storage policies |
| LPN BB | Licensed Practical Nurse | Identified undated opened vials and verified lack of open dates on medications in cart A and B |
| LPN NN | Licensed Practical Nurse | Confirmed refrigerator temperature monitoring and medication labeling issues |
| LPN CC | Charge Nurse | Confirmed expired medications found in medication cart A |
| LPN DD | Charge Nurse | Confirmed expired medications found in medication cart C |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Nov 4, 2021
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to accommodate the needs of a resident with quadriplegia by providing an appropriate call light, failure to develop a comprehensive care plan, failure to provide bathing care, and failure to properly label and store medications and biologicals.
Complaint Details
The investigation was complaint-driven, focusing on issues raised about the facility's failure to meet the needs of residents, including inadequate call light accommodations for a quadriplegic resident, incomplete care planning, insufficient bathing care, and medication storage and labeling deficiencies.
Findings
The facility failed to provide an appropriate call light for a quadriplegic resident upon readmission, failed to develop a comprehensive care plan addressing this need, failed to provide actual showers for a resident as scheduled, and failed to ensure medications were properly labeled with open dates and expired medications were removed. Refrigerator temperatures were not logged twice daily as required.
Deficiencies (4)
Failed to accommodate the needs of a quadriplegic resident by providing an appropriate call light upon readmission.
Failed to develop a person-centered, comprehensive care plan for a resident with quadriplegia to communicate needs appropriately.
Failed to provide actual showers for a resident for the remainder of October 2021, providing only bed and sponge baths instead.
Failed to ensure medications were dated appropriately when opened, failed to log refrigerator temperatures twice daily, and failed to discard expired medications and biologicals prior to expiration.
Report Facts
Sample size: 30
Medication expiration dates: 5
Temperature log frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN KK | Licensed Practical Nurse | Reported familiarity with resident R#95 and confirmed use of soft touch call light |
| LPN LL | Licensed Practical Nurse | Reported to Unit Manager about the need for an appropriate call light for resident R#95 |
| Unit Manager | Placed work order for call light after being informed of resident R#95's needs | |
| Assistant Director of Nursing | ADON | Interviewed regarding awareness of call light needs for resident R#95 |
| Director of Nursing | DON | Interviewed regarding call light issue, care plan deficiencies, and medication storage policies |
| LPN BB | Licensed Practical Nurse | Identified undated opened medications and confirmed expired medications |
| LPN NN | Licensed Practical Nurse | Identified undated opened medications and confirmed expired medications; explained medication labeling and storage procedures |
| LPN CC | Charge Nurse | Confirmed expired medications found in medication cart A |
| LPN DD | Charge Nurse | Confirmed expired medications found in medication cart C |
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Date: Sep 8, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaints #GA00214282, #GA00214702, and #GA00216726.
Complaint Details
Complaints #GA00214282, #GA00214702, and #GA00216726 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
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.
Inspection Report
Re-Inspection
Census: 104
Deficiencies: 0
Date: Mar 18, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the January 27, 2021 Complaint and COVID-19 Infection Control Focus Survey.
Complaint Details
The revisit was related to deficiencies cited from a complaint investigation conducted on January 27, 2021.
Findings
All deficiencies cited in the prior complaint and infection control survey were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 104
Deficiencies: 0
Date: Mar 18, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the January 27, 2021 Complaint and COVID-19 Infection Control Focus Survey.
Findings
All deficiencies cited during the January 27, 2021 Complaint and COVID-19 Infection Control Focus Survey were found to be corrected.
Inspection Report
Routine
Census: 110
Deficiencies: 0
Date: Mar 15, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with infection control regulations and preparedness for COVID-19.
Findings
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.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 11, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints (#GA00211722, #GA00211883, #GA00212178, #GA00212637, and #GA00212675).
Complaint Details
Complaints #GA00211722, #GA00211883, and #GA00212637 were unsubstantiated. Complaints #GA00212675 and #GA00212178 were substantiated. No deficiencies were cited for any complaints.
Findings
Complaints #GA00211722, #GA00211883, and #GA00212637 were unsubstantiated with no deficiencies cited. Complaints #GA00212675 and #GA00212178 were substantiated but with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 3
Date: Jan 27, 2021
Visit Reason
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.
Complaint Details
Complaint Intake Numbers GA00210513, GA00210018, GA00210047 were unsubstantiated. Complaint GA00211605 was substantiated with no deficiencies.
Findings
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.
Deficiencies (3)
Failed to post daily nurse staffing information on two of three days; posted data was incomplete.
Failed to ensure all medications were secured and stored properly; medications were stored in unlocked dining room area accessible to unauthorized individuals.
Failed to ensure outdoor garbage and refuse area was maintained in a sanitary manner; grease spills, discarded PPE, open trash container doors, and refuse present.
Report Facts
Census: 111
Number of days nurse staffing information not posted: 2
Number of opened medication bottles observed unsecured: 33
Length of grease spill: 20
Length of grease spill around grease trap: 5
Number of Dietary Manager employees: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding nurse staffing posting and medication storage deficiencies |
| Scheduler | Interviewed regarding responsibility and education on posting daily nurse staffing | |
| Dietary Manager | Dietary Manager | Interviewed regarding garbage disposal and outdoor refuse area maintenance |
Inspection Report
Renewal
Census: 111
Deficiencies: 2
Date: Jan 27, 2021
Visit Reason
A Licensure Survey was conducted from January 25, 2021 through January 27, 2021 to assess compliance with state licensure requirements.
Findings
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.
Deficiencies (2)
Medications were not secured and stored properly; opened cases of Tylenol, Miralax, and Mylanta were found in an unlocked dining room area accessible to unauthorized individuals.
Outdoor garbage and refuse area was not maintained in a sanitary manner, including large grease spills, discarded PPE, open trash container doors, used tire, Styrofoam containers, and refuse scattered around the dumpster area.
Report Facts
Facility census: 111
Number of employees: 12
Length of grease spill: 20
Length of grease spill: 5
Number of opened Tylenol bottles: 15
Number of opened Miralax bottles: 10
Number of Mylanta bottles: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication storage and Central Supply vacancy | |
| Dietary Manager | Interviewed regarding garbage disposal and dumpster area maintenance |
Inspection Report
Routine
Census: 119
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
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.
Findings
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.
Report Facts
Total census: 119
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 18, 2020
Visit Reason
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.
Complaint Details
Complaint intake numbers GA00209457 and GA00207741 were investigated and found to be unsubstantiated with no regulatory violations cited.
Findings
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.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 11, 2020
Visit Reason
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.
Complaint Details
The investigation involved complaints #GA00205244, GA00205204, GA00205046, GA00205626, GA00203728, GA00203193, GA00201234, and GA00199914. All complaints were found to be unsubstantiated.
Findings
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.
Inspection Report
Routine
Census: 119
Deficiencies: 0
Date: Jul 21, 2020
Visit Reason
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.
Findings
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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 22, 2019
Visit Reason
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.
Complaint Details
The survey was conducted to investigate complaints #GA00196573, GA00198537, and GA00198597; no deficiencies were found.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 28, 2019
Visit Reason
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.
Complaint Details
Complaint #GA00194408 was investigated during the revisit survey with no deficient practice cited.
Findings
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.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Mar 28, 2019
Visit Reason
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.
Complaint Details
Complaint #GA00194408 was investigated and no deficient practice was found.
Findings
No deficient practice was cited for the complaint portion of the survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 12, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited survey tags have been corrected.
Inspection Report
Routine
Census: 132
Deficiencies: 11
Date: Jan 25, 2019
Visit Reason
A standard survey was conducted to assess compliance with Medicare/Medicaid regulations and federal requirements for long term care facilities.
Findings
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.
Deficiencies (11)
Failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to a resident discharged from Medicare Part A services.
Failed to protect a resident from physical abuse by two CNAs causing a bruise.
Failed to report an allegation of physical abuse to the State Agency within required timeframes.
Failed to follow individualized care plans for behavior monitoring for psychotropic drug use for three residents.
Failed to invite a resident to participate in care plan meetings for over one year.
Failed to provide adequate ADL care related to nail hygiene for a dependent resident.
Failed to maintain safe water temperatures below 120 degrees Fahrenheit in 12 resident rooms.
Failed to document behavior monitoring and medication side effects for a resident receiving psychotropic medications.
Failed to ensure PRN psychotropic medication orders were limited to 14 days unless clinically indicated.
Failed to follow established menu and portion sizes for meat served to residents.
Quality Assurance and Performance Improvement committee failed to meet quarterly with required members and failed to review quality of care related to behavior monitoring.
Report Facts
Resident census: 132
Water temperature: 127.4
Water temperature: 113.8
Psychotropic medication dose: 10
Psychotropic medication dose: 75
Psychotropic medication dose: 1
Protein portion size: 4
Protein portion size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| TT | Unit Manager | Confirmed PRN medication order for lorazepam lacked stop date |
| GG | Licensed Practical Nurse Unit Manager | Stated behavior monitoring should be done for residents on psychotropic medications |
| LL | Licensed Practical Nurse | Observed and documented resident behavior on behavior monitoring sheets |
| DD | Minimum Data Set Registered Nurse | Sends care plan invite letters and verbal invites to residents |
| HH | Cook | Served roast beef slices of varying thickness and portion sizes |
| DM | Dietary Manager | Eyeballs protein portions and does not weigh servings |
| Administrator | Notified of hot water temperature issues and Medical Director attendance issues | |
| Director of Nursing | Acknowledged issues with behavior monitoring and abuse reporting | |
| Maintenance Supervisor | Confirmed unsafe water temperatures and adjustments made | |
| Maintenance Aide | Checks water temperatures weekly and reports to supervisor |
Inspection Report
Routine
Census: 132
Deficiencies: 4
Date: Jan 25, 2019
Visit Reason
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.
Findings
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.
Deficiencies (4)
Resident fingernails were found dirty with dark brown substance underneath, indicating inadequate nursing care.
Behavioral monitoring sheets for residents on psychotropic medications were not consistently completed as required.
Two of seven employee files lacked physical examinations prior to hire date; five of seven lacked PPD skin tests prior to hire date.
Unsafe hot water temperatures above 110 degrees Fahrenheit were found in 12 resident rooms across two halls.
Report Facts
Resident rooms with unsafe hot water temperatures: 12
Facility census: 132
Employee files reviewed: 7
Employee files lacking physical exam prior to hire: 2
Employee files lacking PPD skin test prior to hire: 5
Inspection Report
Life Safety
Census: 129
Capacity: 150
Deficiencies: 11
Date: Jan 24, 2019
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with fire safety and emergency preparedness regulations.
Findings
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.
Deficiencies (11)
Emergency preparedness plan not updated since 2017 and not in substantial compliance with Appendix Z requirements.
Emergency preparedness communication plan not updated since 2017 and incomplete.
Emergency preparedness training and testing program not updated since 2017.
Facility did not have documentation of emergency preparedness exercises and drills.
Emergency preparedness plan documentation not available at time of survey.
Fire alarm pull stations blocked at main entrance and dining area; visitor's restroom lacked fire alarm strobe.
Two fire sprinklers in administration offices spaced too close (4 ft apart, minimum 6 ft required).
Fire sprinkler riser had a yellow tag indicating an intermediate problem.
Smoke barrier penetrations not properly sealed with fire caulk.
Two magnetic smoke barrier doors (in A Hall and C Hall) did not seal properly to prevent smoke.
No documentation of annual fire/smoke rated door maintenance and testing.
Report Facts
Residents at risk due to emergency preparedness deficiencies: 129
Residents at risk due to blocked fire alarm pull stations and missing strobes: 10
Residents/staff at risk due to sprinkler spacing: 5
Residents at risk due to sprinkler system intermediate problem: 20
Residents at risk due to unsealed smoke barrier penetrations: 25
Residents at risk due to malfunctioning smoke barrier doors: 25
Residents at risk due to lack of fire door maintenance documentation: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to emergency preparedness plan, fire alarm pull stations, sprinkler issues, smoke barrier penetrations, and door maintenance. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Nov 29, 2018
Visit Reason
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.
Complaint Details
Complaint GA00192319 was partially substantiated with an allegation of deficient practice related to the physical environment, but no deficiencies were found.
Findings
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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 29, 2018
Visit Reason
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.
Complaint Details
The complaint investigation was conducted and no deficiencies were found, indicating the complaints were not substantiated.
Findings
The survey determined compliance with Federal and State Long Term Care Requirements, 42 CFR, Part 483, Subpart B, and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 29, 2018
Visit Reason
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.
Complaint Details
Complaint #GA00186473 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Mar 16, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 1/22/18 recertification survey.
Findings
All deficiencies cited as a result of the 1/22/18 recertification survey were found to be corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 5, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 31, 2018
Visit Reason
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.
Complaint Details
Complaint GA 00184676 was investigated and substantiated, with no deficiencies cited.
Findings
The complaint was substantiated, but no deficiencies were cited.
Inspection Report
Life Safety
Census: 122
Capacity: 150
Deficiencies: 3
Date: Jan 10, 2018
Visit Reason
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.
Findings
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.
Deficiencies (3)
Emergency Preparedness Plan was not complete and did not meet the requirements of Appendix Z.
Cooking equipment (Convection Oven) not covered by hood, posing fire risk.
Emergency power generator lacked a remote annunciator to indicate alarm conditions.
Report Facts
Census: 122
Total Capacity: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and interviews |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 30, 2017
Visit Reason
The inspection was conducted as a complaint survey from 11/27/2017 through 11/30/2017 to investigate complaint GA00182339.
Complaint Details
Complaint GA00182339 was investigated and found to have no health deficiencies.
Findings
No health deficiencies were cited during the complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 11, 2017
Visit Reason
An Abbreviated Survey was conducted on 7/10/17 through 7/11/17 at Chestnut Ridge Nursing and Rehab to investigate complaint GA00176667.
Complaint Details
Complaint GA00176667 was investigated and found to be not substantiated.
Findings
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.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 8, 2017
Visit Reason
An unannounced abbreviated survey was conducted to investigate complaint GA00173574 at Chestnut Ridge Nursing and Rehabilitation.
Complaint Details
Investigation of complaint GA00173574; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with 42 CFR, Part 483, Subpart B, Requirements for long term care facilities.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 27, 2017
Visit Reason
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.
Findings
It was determined that all previous deficiencies cited during the prior surveys had been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 13, 2017
Visit Reason
A follow-up survey was conducted to verify that all previously cited survey deficiencies had been corrected.
Findings
All previously cited violations were corrected as noted by the follow-up survey conducted on 02/13/2017.
Inspection Report
Life Safety
Census: 122
Capacity: 150
Deficiencies: 6
Date: Dec 20, 2016
Visit Reason
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.
Findings
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.
Deficiencies (6)
Obstructions in exit corridors including linen carts, wheelchairs, and waste containers blocking means of egress.
Emergency lighting missing in the Medication Room and lack of required annual testing documentation.
Corridor doors damaged allowing passage of smoke; door to clean linen closet damaged and does not set properly in frame.
Fire drill documentation incomplete with missing reports for multiple shifts and quarters.
Improper use and placement of power strips and extension cords, including use as permanent wiring and unsecured cords on floors.
Oxygen cylinders improperly stored without signs indicating full or empty and combustibles stored within 5 feet of cylinders.
Report Facts
Residents at risk due to obstructed egress: 75
Residents at risk due to improper power strip and extension cord use: 90
Residents at risk due to improper oxygen cylinder storage: 18
Census: 122
Total licensed capacity: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings related to obstructions, emergency lighting, door damage, fire drill documentation, power strip and extension cord use, and oxygen cylinder storage |
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