Inspection Reports for Chestnut Ridge Retirement Living
2700 CHESTNUT PARKWAY,, CHESTER, PA, 19086
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
60.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
1189% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
80
60
40
20
0
Census
Latest occupancy rate
51% occupied
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 66
Capacity: 130
Deficiencies: 0
Date: Sep 18, 2025
Visit Reason
The inspection was an unannounced partial inspection conducted due to an incident at the facility.
Complaint Details
The inspection was incident-related, triggered by a complaint or allegation, but no deficiencies were found.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
License Capacity: 130
Residents Served: 66
Secured Dementia Care Unit Capacity: 50
Secured Dementia Care Unit Residents Served: 18
Current Hospice Residents: 7
Residents Age 60 or Older: 66
Residents with Mobility Need: 37
Inspection Report
Follow-Up
Census: 49
Capacity: 130
Deficiencies: 11
Date: Aug 21, 2025
Visit Reason
The inspection was an unannounced partial incident review conducted on 08/21/2025 to verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including incomplete resident-home contract signatures, inadequate supervision leading to unauthorized resident exit, improper CPR/First Aid certifications, lack of required annual training hours for direct care staff, lint accumulation in dryer lint traps, medication storage and documentation issues, insufficient positive interventions for resident behaviors, incomplete resident assessments, and inadequate staff training in dementia care. The submitted plan of correction was determined to be fully implemented as of the follow-up review.
Deficiencies (11)
Resident-home contract was not signed by the resident.
Resident exited secured dementia care unit unsupervised, indicating neglect in supervision.
Staff CPR/First Aid certifications obtained from unapproved training sources.
Direct care staff person received 0 hours of required annual training in 2024.
Accumulation of lint in the lint trap of the 5th floor dryer.
Medication narcotic count was not documented prior to administration.
Staff did not use positive interventions to manage resident's exit-seeking behavior.
Resident's support plan lacked assessment of extensive supervision needs and mobility aid use.
Resident's support plan did not document how aggression needs will be met.
Direct care staff person had 0 hours of dementia care training in 2024.
Medication record entries were not permanent, legible, dated, or signed properly; overwriting occurred.
Report Facts
License Capacity: 130
Residents Served: 49
Residents in Secured Dementia Care Unit: 20
Current Hospice Residents: 9
Residents Age 60 or Older: 66
Residents with Mobility Need: 34
Residents with Physical Disability: 2
Total Daily Staff: 83
Waking Staff: 62
Inspection Report
Complaint Investigation
Census: 69
Capacity: 130
Deficiencies: 26
Date: Jul 24, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation with an unannounced partial inspection.
Complaint Details
The inspection was complaint and incident related, with findings including substantiated violations of confidentiality, staff training, medication administration, and resident care documentation.
Findings
The facility was found to have multiple deficiencies including confidentiality breaches, incomplete criminal background checks, inadequate staff training, medication administration errors, improper storage of poisonous materials and medications, and incomplete resident assessments and support plans. The submitted plan of correction was fully implemented by the time of the review.
Deficiencies (26)
Unlocked, unattended 5th floor assignment book containing resident names and room numbers with laundry and showers details.
Contracted painters working unsupervised without completed criminal background checks.
Administrator did not maintain a current list of staff names, addresses, and telephone numbers.
Staff person did not receive orientation on fire safety and emergency preparedness topics on first day.
Staff person did not complete training on emergency medical plan within 40 scheduled work hours.
Direct care staff provided unsupervised ADL services without completing required training and competency test.
Direct care staff received less than required 12 hours of annual training in 2024.
Direct care staff did not receive required annual training in fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, falls prevention, and new population groups.
Plain spray bottles labeled 'Windex' and 'Bleach' stored in unlocked storage room on 7th floor.
Poisonous materials including liquid cleanser, Lysol spray, hand sanitizer, and disinfecting wipes were unlocked and accessible on the 5th floor secured dementia care unit.
Insufficient hot water for showers; water temperature below required levels in some rooms.
Furniture and equipment not in good repair; water heater not heating water above 83 degrees Fahrenheit.
No operable television on the 5th floor secured dementia care unit for approximately 3 weeks.
Beds for two residents lacked pillowcases, sheets, and blankets.
Resident's most recent medical evaluation was not completed within required timeframe.
No menu posted near dining room on 5th floor; incorrect menu posted on 4th floor.
Staff person without medication administration training administered medications including tablets and capsules.
Unlocked, unattended, and accessible prescription medications and syringes in resident rooms.
Discontinued medications remained in medication cart after resident death or medication discontinuation.
Medications stored improperly; syringes stored at room temperature contrary to manufacturer instructions.
Glucometer readings not documented in resident's medication administration record; medication not available in home when prescribed.
Medication administration records did not include initials of staff administering medications or were not documented at time of administration.
Resident not administered prescribed 24-hour patch due to medication unavailability.
Initial resident assessment not completed within 15 days of admission; missing mental health and behavioral cognitive assessments.
Resident participated in support plan development but did not sign the support plan.
Direct care staff in secured dementia care unit had zero hours of required dementia care training during 2024.
Report Facts
License Capacity: 130
Residents Served: 69
Secured Dementia Care Unit Capacity: 50
Secured Dementia Care Unit Residents Served: 19
Deficiency Counts: 28
Staff Training Hours: 0
Annual Training Hours: 5.25
Annual Training Hours: 4
Inspection Report
Complaint Investigation
Census: 71
Capacity: 130
Deficiencies: 7
Date: May 2, 2025
Visit Reason
The inspection was conducted as a complaint and incident investigation following reports of violations at Chestnut Ridge Retirement Living.
Complaint Details
The visit was complaint-related and incident-driven, investigating allegations of neglect, abuse, and failure to comply with reporting and care requirements. The resident involved suffered severe injuries and later died as a result of neglect and inadequate care.
Findings
The inspection found multiple violations including failure to timely report an incident, breaches of resident record confidentiality, inadequate assistance with activities of daily living leading to a resident fall with severe injuries, neglect and abuse of a resident resulting in serious harm and death, failure of staff to provide certified CPR assistance, incomplete resident assessments, and missing support plan signatures.
Deficiencies (7)
Failure to report an incident within 24 hours as required.
Resident records were left unlocked and accessible in common areas.
Resident did not receive required assistance with meals and activities, resulting in a fall with severe injuries.
Resident was neglected and left unattended in unsafe conditions, resulting in serious injury and death.
Staff trained in first aid failed to render assistance to injured resident.
Resident support plan was not updated to reflect service needs.
Resident did not sign the support plan as required.
Report Facts
License Capacity: 130
Residents Served: 71
Secured Dementia Care Unit Capacity: 50
Residents Served in Secure Dementia Care Unit: 21
Hospice Residents: 5
Residents Age 60 or Older: 70
Residents with Mobility Need: 45
Inspection Dates: 2
Staffing Hours: 116
Waking Staff Hours: 87
Inspection Report
Complaint Investigation
Census: 74
Capacity: 130
Deficiencies: 7
Date: Mar 20, 2025
Visit Reason
The inspection was conducted as a complaint investigation following a complaint received by the Pennsylvania Department of Human Services.
Complaint Details
The inspection was complaint-driven, triggered by allegations related to medication administration and incident reporting. The complaint was substantiated as deficiencies were found.
Findings
The inspection found multiple deficiencies related to medication administration, incident reporting, refusal of medication documentation, failure to follow prescriber's orders, and medication error reporting and documentation. The facility failed to discontinue medications as ordered, did not administer medications properly, and did not report or document medication errors and refusals as required.
Deficiencies (7)
Failure to report an incident to the Department within 24 hours as required.
Failure to administer resident's night time medications as prescribed.
Failure to record the date/time of medication administration accurately; staff signed medication record falsely.
Failure to document and report resident's refusal of medication as required.
Failure to follow prescriber's orders regarding medication discontinuation and repeat thyroid function testing.
Failure to immediately report medication error to resident, designated person, and prescriber.
Failure to document medication error and prescriber's response in resident's record.
Report Facts
License Capacity: 130
Residents Served: 74
Secured Dementia Care Unit Capacity: 26
Secured Dementia Care Unit Residents Served: 22
Hospice Current Residents: 5
Residents Age 60 or Older: 73
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 47
Inspection Report
Follow-Up
Census: 71
Capacity: 130
Deficiencies: 16
Date: Feb 20, 2025
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and incident.
Complaint Details
The inspection was conducted due to a complaint and incident as stated in the inspection information section.
Findings
The inspection identified multiple deficiencies including incomplete criminal background checks, insufficient administrator training hours, lack of proper fire safety orientation for new staff, unsecured poisonous materials accessible to residents, improper food labeling, incomplete or late resident medical evaluations and assessments, medication administration by unqualified staff, and missing documentation such as resident signatures on support plans and no objection statements for secured dementia care unit admissions. Plans of correction were accepted and implemented with ongoing audits and training scheduled.
Deficiencies (16)
Staff person A had not completed an FBI criminal background check.
Administrator completed only 21 hours of required annual training instead of 24.
Staff person B did not receive required fire safety orientation on first day.
Staff person B did not complete required rights/abuse training within 40 hours.
Poisonous materials were unlocked, unattended, and accessible to residents not assessed capable of safe use.
Leftover food items were unlabeled, undated, and uncovered in kitchen refrigerators and freezers.
Resident medical evaluations were not completed timely or were missing required documentation.
Staff person B administered medications without completing required DHS-approved medication administration course.
Staff person B administered insulin without completing required training.
Medication administration training records for staff person B lacked documentation of successful course completion.
Resident assessments were incomplete or not completed within required timeframes.
Resident did not sign the support plan despite participation in its development.
Resident's medical evaluation for admission to secured dementia care unit was completed late.
Resident's cognitive preadmission screening for secured dementia care unit was completed late.
No documentation that resident and designated person did not object to admission to secured dementia care unit.
No verification of support plan completion within 72 hours of admission to secured dementia care unit.
Report Facts
License Capacity: 130
Residents Served: 71
Secured Dementia Care Unit Capacity: 30
Secured Dementia Care Unit Residents Served: 21
Current Hospice Residents: 6
Total Daily Staff: 96
Waking Staff: 72
Administrator Annual Training Hours Completed: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in deficiency for incomplete FBI criminal background check and insufficient administrator training. | |
| Staff person B | Named in deficiencies for lack of fire safety orientation, incomplete rights/abuse training, and medication administration without required training. | |
| Executive Director | Executive Director | Responsible for conducting audits, training, and oversight of compliance with DHS regulations. |
| Regional Director of Operations | Provided training and education to facility staff and directors. | |
| Regional Director of Health & Wellness | Provided training, created tickler systems, and reviewed medication technician certifications. | |
| Director of Memory Care | Director of Memory Care | Responsible for conducting audits and ensuring compliance with medical evaluations and care plans. |
| Employee Relations and Administration Coordinator | ERAC | Responsible for oversight of new hires and ensuring required paperwork and training are completed. |
| Director of Dining | Director of Dining | Responsible for educating dining staff on food safety and conducting audits of kitchen refrigerators. |
Inspection Report
Renewal
Census: 55
Capacity: 130
Deficiencies: 14
Date: Jan 22, 2025
Visit Reason
The inspection was conducted as a renewal and complaint investigation to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall, but several deficiencies were identified including missing influenza posters, incomplete criminal background checks, unqualified direct care staff, medication storage issues, incomplete medical evaluations, and lack of required staff training. Plans of correction were implemented and verified.
Deficiencies (14)
The home did not display an influenza poster as required by the Influenza Awareness Act.
Criminal background checks were not completed timely for some staff members.
Direct care staff persons B and C lacked required educational qualifications.
Staff person B was not on the staff list.
Staff person B did not receive required fire safety and emergency preparedness orientation.
Direct care staff persons A and B provided unsupervised ADL services without completing required training and competency testing.
Direct care staff persons A, D, and E did not receive required annual training or training on required topics including dementia care and medication administration.
The wall of the dining room was warped and protruding, appearing water damaged.
Resident #1's medical evaluation was completed more than 60 days prior to admission.
Resident #2's medications were not securely stored; medications were found unlocked and loose pills were observed.
Resident #3's glucometer was not calibrated correctly and was later found to be recalled by the manufacturer.
Staff person B administered medications and insulin without completing required Department-approved training.
Resident #7 did not have an initial assessment completed within 15 days of admission.
Direct care staff person A working in the Secure Dementia Care Unit had no dementia care training during the 2024 training year.
Report Facts
License Capacity: 130
Residents Served: 55
Secure Dementia Care Unit Capacity: 30
Secure Dementia Care Unit Residents Served: 23
Hospice Residents: 4
Staffing Hours: 81
Waking Staff Hours: 61
Number of Deficiencies: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff person A | Named in findings related to incomplete criminal background check, unqualified direct care staff, lack of required training, and medication administration violations. | |
| Staff person B | Named in findings related to incomplete criminal background check, unqualified direct care staff, missing from staff list, lack of fire safety orientation, unqualified medication administration, and insulin administration violations. | |
| Staff person C | Named in findings related to unqualified direct care staff. | |
| Staff person D | Named in findings related to lack of required annual training. | |
| Staff person E | Named in findings related to lack of required annual training. |
Inspection Report
Follow-Up
Census: 85
Capacity: 130
Deficiencies: 29
Date: Nov 25, 2024
Visit Reason
The visit was a provisional follow-up inspection conducted on November 25 and 27, 2024, to review the implementation of the plan of correction from a prior inspection on November 25 and 27, 2024.
Findings
The inspection found multiple deficiencies including lack of carbon monoxide detectors, incomplete criminal background checks, insufficient direct care staffing hours, lack of CPR certified staff on duty, incomplete fire safety orientation for new staff, incomplete staff training in various required areas, medication management issues, and incomplete resident assessments and support plans. Many plans of correction were directed but not fully implemented as of the follow-up dates.
Deficiencies (29)
No Carbon Monoxide detector for the kitchen which uses gas appliances.
A criminal background check was not requested for staff person A.
Insufficient direct care staffing hours provided for residents with mobility needs on 11/10/2024 and 11/23/2024.
No staff persons present who were certified in first aid, obstructed airway techniques and CPR on 11/10/2024 and 11/23/2024.
Staff persons B, C, and D did not receive required orientation on fire safety and emergency preparedness topics.
Staff persons B and D did not complete required training within 40 scheduled work hours on resident rights, emergency medical plan, mandatory reporting of abuse and neglect, and reporting of reportable incidents and conditions.
Direct care staff persons A and C provide unsupervised ADL services without documentation of completing Department-approved direct care training and competency test.
Direct care staff persons A and E received 0 hours of required annual training in 2023.
Direct care staff persons A and E did not receive training in required annual training topics including medication self-administration, dementia care, infection control, and safe management techniques during 2023.
Direct care staff persons A and E did not receive training in fire safety, emergency preparedness, resident rights, Older Adult Protective Services Act, falls and accident prevention during 2023.
Alcohol Prep Pads were unlocked and accessible to residents on the 5th floor Memory Care Unit.
Trash was removed from the premises every other Tuesday instead of at least once a week.
Insufficient hot and cold water pressure at the kitchen sink in room 608.
Unlabeled, undated fish and chicken patties found in the main kitchen freezer.
Residents did not evacuate to a designated meeting place during a fire alarm on 11/25/2024.
Resident 1’s medical evaluation was not completed annually as required.
Staff persons B and F transported residents without completing initial new hire direct care staff training.
Resident 2's record did not include a current list of medications; list included discontinued medications.
Milk of Magnesia prescribed for resident 3 was in medication cart but discontinued.
Prescription bubble packs for residents 4, 5, and 6 had tears/punctures with pills still in place.
Pharmacy label for resident 7's medication did not include the resident’s name.
Glucometers for residents 1 and 8 were not calibrated to the correct date and time.
Medications prescribed for residents 3 and 4 were not available in the home.
Resident 8's prescribed medication Polyethylene glycol 3350 powder was not available in the home.
Staff person G administered insulin without completing required Department-approved diabetes patient education program within last 12 months.
Resident 9's initial support plan was not completed within 30 days of admission.
Residents 10 and 11 were not assessed annually for continuing need for the secured dementia care unit in 2023 and 2024.
Resident 12's initial support plan for Secure Dementia Care Unit was not completed within 72 hours of admission.
Direct care staff person E had 0 hours of required dementia care training during 2023.
Report Facts
Residents served: 85
License capacity: 130
Residents with mobility needs: 30
Direct care staffing hours required: 115
Direct care staffing hours provided: 97.5
Total daily staff: 115
Waking staff: 86
Hospice residents: 6
Secured Dementia Care Unit capacity: 50
Secured Dementia Care Unit residents served: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Melissa Thomas | Regional Director of Health and Wellness | Named in medication audit and training findings |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 8, 2024
Visit Reason
The visit was conducted to review the implementation status of the submitted plan of correction for violations identified during the September 9, 2024 inspection.
Findings
The Department determined that the submitted plan of correction for the September 9, 2024 inspection is not fully implemented, and correction of these violations is required to maintain compliance.
Inspection Report
Follow-Up
Census: 86
Capacity: 130
Deficiencies: 8
Date: Oct 10, 2024
Visit Reason
The inspection visit on October 10, 2024, was a partial, unannounced follow-up to verify the implementation of the plan of correction from the prior inspection on October 10, 2024, related to a fine.
Findings
The facility was found to have multiple deficiencies related to unsafe storage of poisonous materials, sanitary conditions, use of portable space heaters, medication storage and labeling, glucometer calibration and documentation, and failure to follow prescriber's orders. Several deficiencies were repeat violations and the plan of correction was not fully implemented as of the follow-up date.
Deficiencies (8)
Poisonous materials were unlocked, unattended, and accessible to residents, including in secured dementia care units, without all residents assessed as capable of safely using or avoiding poisons.
Resident's glucometer was used to take another resident's blood glucose readings, violating sanitary conditions.
Portable space heater observed in resident room, which is prohibited.
Prescription and OTC medications and syringes were unlocked, unattended, and accessible in resident rooms.
OTC medications and CAM were not labeled with the resident's name.
Glucometers were not calibrated to the correct date and time.
Glucose log readings did not match glucometer readings, indicating improper documentation.
Facility failed to follow prescriber's orders for glucose checks frequency and documentation.
Report Facts
License Capacity: 130
Residents Served: 86
Residents in Secured Dementia Care Unit: 31
Hospice Residents: 6
Staffing Hours: 128
Waking Staff: 96
Inspection Report
Follow-Up
Census: 87
Capacity: 130
Deficiencies: 7
Date: Aug 20, 2024
Visit Reason
The visit was a follow-up review conducted on October 7, 2024 and November 8, 2024 to assess the implementation of the plan of correction submitted for the August 20, 2024 inspection.
Findings
The facility was found to have multiple repeat violations including record confidentiality breaches, abuse incidents involving a staff member with a weapon, incomplete criminal background checks, maintenance issues, and medication storage problems. The submitted plans of correction were not fully implemented as of the follow-up dates.
Deficiencies (7)
The computer on the 7th floor medication cart housing residents' medication records and personal information was unlocked, unattended, and accessible to residents, staff and visitors.
A loaded handgun, marijuana, and an employee ID card belonging to a staff member were found in a resident's closet; the staff member was arrested and terminated.
The facility failed to follow up on a criminal background check for a staff member until an incident occurred; unclear if the staff member had a criminal record.
The ceiling in the common living room outside the main elevators on the 8th floor was in disrepair from a leak with paint peeling and water spots observed.
The door to the bathroom near the physical therapy room was unable to shut properly or lock.
Medication blister packs were observed with punctured foil exposing medication to contamination or improper sanitation.
Discrepancy in narcotic medication count: 4 tablets physically present but 9 recorded on narcotics record.
Report Facts
License Capacity: 130
Residents Served: 87
Residents in Secured Dementia Care Unit: 33
Current Hospice Residents: 6
Residents Diagnosed with Mental Illness: 26
Residents with Mobility Need: 46
Residents Aged 60 or Older: 87
Staff Training Attendance: 38
Staff Training Attendance: 20
Staff Training Attendance: 7
Staff Training Attendance: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Member A | Alerted to backpack with weapon and drugs found in resident's closet | |
| Staff Member B | Employee found with loaded handgun and marijuana; terminated after arrest |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 130
Deficiencies: 34
Date: Aug 5, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Chestnut Ridge Retirement Living to evaluate compliance with regulations and investigate specific allegations.
Complaint Details
The complaint involved allegations of resident abuse, privacy violations, inadequate staffing, and failure to follow proper procedures for medication administration and resident care.
Findings
Multiple deficiencies were identified including failure to report suspected abuse, inadequate incident policies, confidentiality breaches, non-compliance with health and safety laws, missing or incomplete resident records and assessments, medication administration issues, and insufficient staffing during waking hours.
Deficiencies (34)
Failure to immediately report suspected abuse of a resident in accordance with the Older Adult Protective Services Act.
Failure to follow written policies and procedures on prevention, reporting, notification, investigation and management of reportable incidents and conditions.
Incident of abuse not reported to the Department’s personal care home regional office or complaint hotline within 24 hours.
Medication record computer left unlocked and unattended, exposing resident information.
No smoking sign not posted at the entrance of the building as required by the Clean Indoor Air Act.
Department’s resident rights poster not posted in a conspicuous and public place.
Resident treated without dignity and respect; staff sprayed Lysol on resident's face and was rude.
Telephone numbers of regulatory and protective agencies not posted in a conspicuous and public place.
Staff members without required criminal background checks.
Direct care staff persons lacking required qualifications such as high school diploma, GED or nurse aide registry status.
Direct care staff persons did not receive required fire safety and emergency preparedness orientation on first day.
Direct care staff persons did not complete required orientation training within 40 scheduled working hours.
Ancillary staff persons did not have general orientation to specific job functions prior to working.
Direct care staff persons did not complete and pass Department-approved direct care training course and competency test before providing unsupervised ADL services.
Direct care staff persons did not receive at least 12 hours of annual training relating to job duties.
Direct care staff persons, ancillary staff persons, substitute personnel and volunteers did not receive annual training in required areas including fire safety and emergency preparedness.
Staff training plan for 2024 does not include mandatory reporting, abuse, neglect, or reportable incidents and conditions.
Poisonous materials were unlocked and accessible to residents not assessed as capable of safe use.
Sanitary conditions not maintained; toilet and resident blanket found soiled.
Trash outside the home not kept in covered receptacles preventing insect and rodent penetration.
Bathroom without operable window or ventilation fan.
Resident bed lacked bed sheets for extended period despite resident request.
Bedroom lacked required furniture including chest of drawers, bedside table, and operable lamp.
Food requiring refrigeration not stored at or below required temperatures; thermometers missing or not working.
Outdated or unlabeled food found in kitchen refrigerator and freezer.
Resident medical evaluations missing required information or not completed timely.
Residents not assessed for ability to self-administer medications; medications found unsecured in rooms.
Non-licensed staff administered prescription injections without waiver.
Medications and syringes not kept locked; medications stored improperly or with damaged packaging.
Resident preadmission screening and initial assessments not completed timely or missing.
Resident support plans not developed, implemented, or revised timely; missing required elements and signatures.
Resident records incomplete, missing required demographic, medical, and administrative information.
Resident treated without dignity and respect; staff violated privacy by pulling resident's arm to check blood sugar without consent.
Insufficient direct care staffing hours during waking hours; only 68% of required hours provided.
Report Facts
License Capacity: 130
Residents Served: 86
Secure Dementia Care Unit Capacity: 50
Residents Served in Secure Dementia Care Unit: 33
Total Daily Staff: 126
Waking Staff: 95
Direct Care Hours Required: 126
Direct Care Hours Provided During Waking Hours: 109.5
Direct Care Hours Percentage During Waking Hours: 68
Fines Calculated: 860
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in findings related to abuse, privacy violation, and treatment of residents | |
| Staff member B | Named in findings related to spraying Lysol on resident's face and lack of qualifications | |
| Staff member C | Administrator/Executive Director | Named in findings related to lack of annual training verification |
| Staff member D | Named in findings related to abuse reporting and lack of criminal background check | |
| Staff member E | Named in findings related to lack of criminal background check and direct care training | |
| Staff member F | Named in findings related to lack of direct care training and orientation | |
| Staff member G | Named in findings related to lack of direct care training and orientation | |
| Staff member J | Med Tech | Named in findings related to unauthorized administration of injections |
| Staff member K | Med Tech | Named in findings related to unauthorized administration of injections |
| Staff member L | Med Tech | Named in findings related to unauthorized administration of injections |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 130
Deficiencies: 55
Date: Aug 5, 2024
Visit Reason
The inspection was a complaint and incident investigation conducted at Chestnut Ridge Retirement Living to address allegations of resident abuse and other regulatory compliance issues.
Complaint Details
The complaint involved allegations of resident abuse, privacy violations, and inadequate care and staffing at the facility. Specific incidents included staff spraying Lysol on a resident's face, failure to report abuse, and staff forcing blood sugar checks without consent.
Findings
The inspection found multiple violations including failure to report suspected abuse, inadequate incident policies, breaches of resident privacy and dignity, deficiencies in staff qualifications and training, medication administration errors, unsafe storage of poisonous materials, unsanitary conditions, and incomplete or inaccurate resident records and support plans.
Deficiencies (55)
Failure to immediately report suspected abuse of a resident as required by law.
Incident policies not properly followed regarding reporting, notification, and investigation of abuse incidents.
Incident of staff spraying Lysol on resident's face and being rude.
Medication record computer left unlocked and unattended, exposing resident information.
No smoking signs not posted at building entrance as required.
Resident rights poster not posted in a conspicuous and public place.
Resident treated without dignity and respect; staff sprayed Lysol on resident's face.
Required telephone numbers for complaint and protective services not posted in a public place.
Missing criminal background checks for certain staff members.
Direct care staff lacking required qualifications such as high school diploma or nurse aide registry status.
Direct care staff did not receive required fire safety and emergency preparedness orientation on first day.
Direct care staff did not complete required orientation training within 40 scheduled hours.
Ancillary staff did not receive general orientation to job functions prior to working.
Direct care staff did not complete and pass Department-approved direct care training course and competency test before providing unsupervised ADL services.
Direct care staff did not receive at least 12 hours of annual training related to job duties.
Direct care and ancillary staff did not receive required annual training in fire safety and emergency preparedness.
Staff training plan for 2024 does not include mandatory reporting, abuse, neglect, or reportable incidents.
Poisonous materials were unlocked and accessible to residents not assessed as capable of safe use.
Sanitary conditions not maintained; stained toilet and soiled resident blanket found.
Trash outside home not kept in covered receptacles to prevent insect and rodent penetration.
Bathroom without operable window or ventilation fan.
Resident bed lacked bed sheets for extended period despite resident request.
Bedroom missing required furniture including chest of drawers, bedside table, and operable lamp.
Food stored in kitchen unlabeled, undated, or at improper temperatures.
Lint accumulation in dryer lint trap.
Emergency procedures not posted in a conspicuous and public place.
No documentation of notification to local fire department regarding emergency evacuation needs.
Resident medical evaluations incomplete or not current; missing key information.
Resident annual medical evaluation not completed timely.
Resident self-administration medication assessment not completed.
Non-licensed staff administered medication without waiver.
Medications and syringes not kept locked, including in resident rooms.
Medications stored improperly with damaged packaging.
Procedures for safe storage, access, security, distribution and use of medications not implemented.
Medication administration documentation discrepancies between glucometer readings and EMAR.
Resident education on right to refuse medication not documented; resident denied medication information.
Resident preadmission screening form completed after admission date.
Resident initial assessment not completed within 15 days of admission.
Resident written support plan not developed and implemented within 30 days of admission.
Resident support plan missing documentation of medical, dental, vision, hearing, mental health or behavioral care services.
Resident medical evaluation for secured dementia care unit not completed within 60 days prior to admission.
No documentation that resident and designated person did not object to admission or transfer to secured dementia care unit.
Resident support plan not revised annually or as condition changes.
Resident record entries not permanent, legible, dated and signed; overwritten dates found.
Resident records missing required information including hair color, eye color, religious affiliation, physician contact, dietary restrictions, and insurance information.
Resident incident report missing from record; resident face sheet incomplete.
Resident-home contract not signed by resident.
Resident statement acknowledging receipt of rights and complaint procedures not in record.
Resident treated without dignity and respect; staff forced blood sugar check without consent.
Resident privacy violated by staff pulling resident from shower to check blood sugar without consent.
Less than 75% of required personal care service hours provided during waking hours.
Resident bedroom missing chair.
Resident bedroom missing pillows, bed linens, and blankets.
Resident bedroom missing bedside table or shelf.
Resident and staff did not sign support plans as required.
Report Facts
License Capacity: 130
Residents Served: 86
Memory Care Unit Capacity: 50
Memory Care Residents Served: 33
Current Hospice Residents: 5
Residents 60 Years or Older: 86
Residents Diagnosed with Mental Illness: 19
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 40
Residents with Physical Disability: 1
Total Daily Staff: 126
Waking Staff: 95
Direct Care Hours Required: 126
Direct Care Hours Provided During Waking Hours: 109.5
Calculated Fine: 430
Calculated Fine: 430
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in resident abuse and privacy violation findings; received write-up and education. | |
| Staff member B | Named in resident abuse incident involving spraying Lysol on resident's face. | |
| Staff member C | Director of Nursing | Reported abuse allegation to higher management. |
| Staff member D | Director of Health and Wellness | Responsible for reporting abuse and investigation follow-up; named in medication administration training. |
| Executive Director | Administrator | Named in multiple findings including abuse reporting, staff training, and compliance monitoring. |
| Memory Care Director | Responsible for audits and staff education related to memory care unit compliance. | |
| Health and Wellness Coordinator | Responsible for audits and staff education related to medication administration and resident privacy. | |
| Dining Director | Named in food storage and sanitation findings. | |
| Maintenance Director | Named in findings related to facility maintenance and safety. | |
| Staff member J | Med Tech | Administered medication without proper waiver. |
| Staff member K | Med Tech | Administered medication without proper waiver. |
| Staff member L | Med Tech | Administered medication without proper waiver. |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 130
Deficiencies: 39
Date: Aug 5, 2024
Visit Reason
The inspection was conducted as a complaint and incident investigation at Chestnut Ridge Retirement Living to assess compliance with regulations and investigate specified allegations.
Complaint Details
The complaint investigation included allegations of resident abuse, privacy violations, inadequate staffing, and failure to comply with regulatory requirements related to resident care, medication administration, and facility operations.
Findings
Multiple deficiencies were found including failure to report suspected abuse, inadequate incident policies, confidentiality breaches, non-compliance with health and safety laws, missing or incomplete resident records and assessments, medication administration issues, and inadequate staffing during waking hours.
Deficiencies (39)
Failure to immediately report suspected abuse of a resident in accordance with the Older Adult Protective Services Act.
Failure to follow written policies and procedures on prevention, reporting, notification, investigation and management of reportable incidents.
Incident of abuse not reported to the Department’s personal care home regional office or complaint hotline within 24 hours.
Medication record computer left unlocked and unattended, exposing resident information.
No sign posted at entrance indicating smoking policy as required by the Clean Indoor Air Act.
Department’s resident rights poster not posted in a conspicuous and public place.
Resident treated without dignity and respect; staff sprayed Lysol on resident's face and was rude.
Required telephone numbers not posted in a conspicuous and public place in the home.
Staff members lacked required criminal background checks.
Direct care staff lacked required qualifications including high school diploma, GED or active registry status.
Direct care staff did not receive required fire safety and emergency preparedness orientation on first day.
Direct care staff did not complete required orientation training within 40 scheduled work hours.
Ancillary staff did not have general orientation to specific job functions prior to working.
Direct care staff did not complete and pass Department-approved direct care training and competency test before providing unsupervised ADL services.
Direct care staff did not receive at least 12 hours of annual training relating to job duties.
Direct care and ancillary staff did not receive annual training in fire safety by a fire safety expert or trained staff.
Poisonous materials were unlocked and accessible to residents not assessed as capable of safe use.
Sanitary conditions not maintained; stained toilet and soiled resident blanket found.
Trash outside the home not kept in covered receptacles preventing insect and rodent penetration.
Bathroom lacked operable ventilation fan or window.
Resident bed lacked bed sheets for extended period despite resident request.
Resident bedroom lacked required furniture including chest of drawers, bedside table, chair, and operable lamp.
Food in kitchen refrigerator and freezer unlabeled and undated; refrigerator/freezer temperatures not properly maintained.
Lint accumulated in dryer lint trap, posing fire hazard.
Emergency preparedness plan incomplete and not posted in a conspicuous place.
Lack of documentation of notification to local fire department regarding emergency evacuation.
Resident medical evaluations incomplete or not current; missing required information.
Resident assessments and support plans not completed timely or missing required elements.
Resident self-administration medication assessments not completed as required.
Non-licensed staff administered prescription medication without waiver.
Medications and syringes not kept locked; medications found unlocked and accessible in resident rooms.
Medications not stored properly; blister packs damaged and loose pills found in medication carts.
Discrepancies between glucometer readings and medication administration records.
Resident education on right to refuse medication not documented; resident denied medication information.
Resident records incomplete; missing required demographic, medical, and administrative information.
Resident incident reports missing from records; resident-home contract and signed statements missing or incomplete.
Resident treated without dignity and respect; staff violated privacy and dignity during care.
Insufficient direct care staffing hours during waking hours; only 68% of required hours provided.
Resident support plans missing required signatures from residents and staff.
Report Facts
Residents served: 86
Total licensed capacity: 130
Residents served in secured dementia care unit: 33
Current residents in hospice: 5
Staffing hours required: 126
Staffing hours provided during waking hours: 109.5
Percentage of staffing hours during waking hours: 68
Fines calculated: 430
Fine per resident per day: 5
Census at inspection: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Named in findings related to resident abuse, privacy violation, and treatment without dignity | |
| Staff member B | Named in findings related to spraying Lysol on resident's face and lack of required qualifications | |
| Staff member C | Administrator/Executive Director | Named in findings related to lack of annual training verification |
| Staff member D | Named in findings related to failure to report abuse and lack of criminal background check | |
| Staff member E | Named in findings related to lack of criminal background check and direct care training | |
| Staff member F | Named in findings related to lack of direct care training and orientation | |
| Staff member G | Named in findings related to lack of direct care training and orientation | |
| Staff member J | med tech | Named in findings related to unauthorized administration of Ozempic injections |
| Staff member K | med tech | Named in findings related to unauthorized administration of Ozempic injections |
| Staff member L | med tech | Named in findings related to unauthorized administration of Ozempic injections |
Inspection Report
Plan of Correction
Census: 85
Capacity: 130
Deficiencies: 5
Date: Feb 21, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 02/21/2024 to review the submitted plan of correction for the facility.
Findings
The facility was found to have implemented the submitted plan of correction fully. Deficiencies related to locking poisonous materials, first aid kit contents, preadmission screening forms, and staff training in the Secure Dementia Care Unit were addressed and corrected by the proposed dates.
Deficiencies (5)
Poisonous materials such as Purell hand sanitizer dispensers and Lysol cleaner were accessible to residents in the Secure Dementia Care Unit.
The first aid kit in the fourth floor nursing station was missing antiseptic, breathing shield, eye coverings, and scissors.
The home did not provide a preadmission screening form for a resident.
A written cognitive preadmission screening was not provided for a resident admitted to the Secure Dementia Care Unit within 72 hours prior to admission.
Direct care staff in the Secure Dementia Care Unit had insufficient dementia care training hours; one staff had only one hour and another had three hours instead of the required six hours annually.
Report Facts
License Capacity: 130
Residents Served: 85
Memory Care Capacity: 22
Memory Care Residents Served: 16
Hospice Residents: 9
Total Daily Staff: 104
Waking Staff: 78
Inspection Report
Complaint Investigation
Census: 83
Capacity: 130
Deficiencies: 15
Date: Dec 14, 2023
Visit Reason
The inspection was an unannounced partial complaint investigation and incident review conducted on 12/14/2023 at Chestnut Ridge Retirement Living.
Complaint Details
The inspection was complaint and incident driven, with allegations of abuse and neglect investigated. The home submitted incident reports and plans of correction were reviewed and accepted. Some violations were repeat violations from prior years.
Findings
The inspection found multiple deficiencies including failure to provide complete resident and staff records upon request, improper handling of abuse allegations, failure to report incidents timely, incomplete resident contracts, abuse and neglect incidents involving restraints, medication storage and administration issues, and failure to follow prescriber's orders. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (15)
Failure to provide complete resident and staff records upon request.
Failure to immediately suspend staff involved in alleged abuse and improper supervision.
Failure to timely report an incident of resident restraint and abuse to the Department.
Resident did not have a resident-home contract completed timely.
Resident was found restrained improperly, constituting abuse.
Failure to maintain privacy of resident during restraint incident.
Discontinued medications for former residents found stored improperly in the wellness office closet.
Medications stored in a disorganized manner and some discontinued medications present.
Discontinued medications not destroyed properly according to regulations.
Over-the-counter medications and CAM not labeled with resident's name.
Unlocked and unattended treatment cart and medications found in wellness center closet.
Failure to follow prescriber's orders; medication not administered due to unavailability.
Failure to implement positive interventions to modify or eliminate resident behavior; improper use of restraints.
Use of prohibited restraints on resident's arms and ankles.
Failure to complete preadmission screening form within required timeframe.
Report Facts
License Capacity: 130
Residents Served: 83
Secured Dementia Care Unit Capacity: 22
Residents Served in Dementia Care Unit: 19
Hospice Residents: 9
Total Daily Staff: 104
Waking Staff: 78
Deficiencies Cited: 15
Inspection Report
Complaint Investigation
Census: 130
Capacity: 130
Deficiencies: 8
Date: Feb 9, 2023
Visit Reason
The inspection was conducted as a complaint investigation with unannounced partial visits on 02/09/2023, 02/22/2023, and 02/24/2023 to review compliance and the submitted plan of correction.
Complaint Details
The inspection was complaint-driven, with the reason explicitly stated as 'Complaint' and conducted as a partial, unannounced visit on 02/09/2023 with follow-up off-site reviews on 02/22/2023 and 02/24/2023.
Findings
The facility was found to have multiple deficiencies including failure to report incidents timely, unsanitary conditions, unclean linens, uncalibrated glucometers, medication record errors, lack of positive interventions for hoarding behavior, and missing support plan signatures. The submitted plan of correction was determined to be fully implemented.
Deficiencies (8)
Failure to report incidents of resident hospitalizations to the Department within 24 hours as required.
Room had a strong odor of urine indicating unsanitary conditions.
Bed linens for a resident were stained and unclean; pillow lacked a pillowcase.
Carpet in a resident's bedroom was not vacuumed and unclean.
Glucometers were not calibrated to the correct date and time.
Medication record errors: medications present on cart but not included on resident's medication administration record.
Lack of positive interventions to address resident's hoarding tendencies, creating a tripping hazard.
Resident participated in support plan development but did not sign the support plan; signature page missing.
Report Facts
License Capacity: 130
Residents Served: 130
Memory Care Capacity: 22
Memory Care Residents Served: 20
Residents 60 Years or Older: 82
Residents Diagnosed with Mental Illness: 12
Residents with Mobility Need: 32
Residents with Physical Disability: 4
Total Daily Staff: 162
Waking Staff: 122
Inspection Report
Complaint Investigation
Census: 79
Capacity: 130
Deficiencies: 0
Date: May 16, 2022
Visit Reason
The inspection was conducted as a complaint investigation at the Chestnut Ridge Retirement Living facility on 05/16/2022.
Complaint Details
The inspection was complaint-related, but no deficiencies were found and the complaint was not substantiated.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
License Capacity: 130
Residents Served: 79
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 18
Total Daily Staff: 97
Waking Staff: 73
Residents 60 Years or Older: 78
Residents with Mobility Need: 18
Inspection Report
Follow-Up
Census: 85
Capacity: 130
Deficiencies: 4
Date: Mar 4, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 03/04/2022 due to an incident at the facility.
Findings
The facility was found to have fully implemented the submitted plan of correction related to previous deficiencies including abuse, labeling/return of clothes, admission support plan, and staff training. Continued compliance must be maintained.
Deficiencies (4)
Resident #1 was physically abused by staff member C who grabbed and twisted the resident's arms, resulting in bruises.
The facility lacked a system to safeguard resident laundry from loss; a basket of unlabeled clothes was found in the laundry room.
Resident #1's initial support plan was not completed within 72 hours of admission to the secured dementia care unit.
Direct care staff person C had zero hours of dementia care training during the training year, contrary to requirements.
Report Facts
License Capacity: 130
Residents Served: 85
Memory Care Capacity: 22
Memory Care Residents Served: 18
Staff Training Hours Required: 6
Inspection Report
Renewal
Census: 75
Capacity: 130
Deficiencies: 14
Date: Nov 3, 2021
Visit Reason
The inspection was conducted as a renewal visit to review compliance with licensing regulations at Chestnut Ridge Retirement Living.
Findings
The inspection identified multiple deficiencies including failure to post current license documents, incomplete direct care staff training, unsanitary conditions, improper medication management, maintenance issues, and failure to follow prescriber's orders. Plans of correction were accepted and implemented with ongoing monitoring and audits planned.
Deficiencies (14)
Failure to post the current violation report and licensing chapter in a conspicuous place.
Direct care staff provided unsupervised ADL services before completing required training and competency test.
Trash compactor room floor wet with standing water and blackish/brown liquid; carpet heavily stained in resident's room.
Large dumpster outside uncovered and overflowing with garbage and debris.
Sliding doors to balcony/patio in disrepair and do not lock properly; damaged laminate countertop; falling ceiling tile in kitchen.
Residents #2, #4, and #5 lacked access to operable bedside lamps.
Triangular hole in wall near resident #6's bathroom door.
Blocked egress due to rock salt buildup on emergency stairwell threshold.
Staff smoking outside designated smoking area at loading dock/dumpster area.
Expired medication belonging to resident #7 present on medication cart and not properly removed.
Medication bottles for resident #8 had labeling inconsistent with current orders.
Glucometers for residents #8 and #9 not calibrated to correct time; multiple discrepancies between glucose logs and meter readings.
Resident #11 did not receive prescribed supplement on multiple dates; glucometer checks not completed as ordered for several residents.
Resident #10 participated in support plan development but did not sign the support plan.
Report Facts
License Capacity: 130
Residents Served: 75
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 19
Hospice Residents: 8
Total Daily Staff: 112
Waking Staff: 84
Residents with Mobility Need: 37
Residents 60 Years or Older: 73
Residents Diagnosed with Mental Illness: 5
Residents with Physical Disability: 1
Notice
Capacity: 130
Deficiencies: 0
Date: Sep 24, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Chestnut Ridge Retirement Living, a Personal Care Home, following receipt of the renewal application dated September 21, 2021.
Findings
The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation. No findings of noncompliance are reported in this document.
Report Facts
Maximum capacity: 130
Secure Dementia Care Unit capacity: 22
Inspection Report
Complaint Investigation
Census: 78
Capacity: 130
Deficiencies: 4
Date: Sep 15, 2021
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations at Chestnut Ridge Retirement Living.
Complaint Details
The visit was complaint-related as indicated by the inspection reason. The complaint involved sanitary and infestation concerns which were substantiated by observations during the inspection.
Findings
The inspection found multiple sanitary and infestation issues including unsanitary conditions under the soda machine, flies and dead bugs in the kitchen, mold on vents and ceiling tiles, uncovered food in the refrigerator, and open drains. Plans of correction were accepted and implemented with ongoing monitoring.
Deficiencies (4)
Unsanitary conditions under the soda machine and unclean prep-station cutting board.
Evidence of infestation including flies in the kitchen and dead bugs in light fixtures.
Mold on vents and ceiling tiles and open uncovered drains on the floor.
Prepared Jello stored uncovered in the refrigerator.
Report Facts
License Capacity: 130
Residents Served: 78
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 17
Hospice Current Residents: 10
Total Daily Staff: 117
Waking Staff: 88
Residents with Mobility Need: 39
Residents Diagnosed with Intellectual Disability: 5
Inspection Report
Complaint Investigation
Census: 72
Capacity: 130
Deficiencies: 0
Date: May 4, 2021
Visit Reason
The inspection was conducted as a complaint investigation with multiple unannounced visits between 05/04/2021 and 06/11/2021 to the Chestnut Ridge Retirement Living facility.
Complaint Details
The inspection was complaint-related as explicitly stated under Inspection section with reason 'Complaint'. No deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of the inspection visits conducted during the complaint investigation.
Report Facts
Total Daily Staff: 105
Waking Staff: 79
License Capacity: 130
Residents Served: 72
Secured Dementia Care Unit Capacity: 22
Secured Dementia Care Unit Residents Served: 15
Hospice Current Residents: 4
Residents Age 60 or Older: 72
Residents with Mobility Need: 33
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