Chestelm Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who had a new medication ordered for a change in condition and there was a noted medication interaction identified by the pharmacy, the facility failed inquiry the pharmacy why the medication had not been available and to notify the provider for six (6) days. The findings include: Resident #1's diagnoses included constipation, failure to thrive, and aphasia following cerebral infarction (a stroke resulting in damage to areas of the brain responsible for language). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15) indicating slight memory recall deficits, was dependent on staff for toileting and was always incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 6/18/25 identified Resident #1 was at risk for constipation related to a history…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for constipation, the facility failed to ensure an abdominal assessment was conducted and continued monitoring following an incident of rectal bleeding. The findings include: Resident #1's diagnoses included constipation, failure to thrive, aphasia following cerebral infarction (a stroke resulting in damage to areas of the brain responsible for language) and atrial fibrillation (an irregular heart rate). The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of fourteen (14) indicating no memory recall deficits, was dependent on staff for toileting and was always incontinent of bowel and bladder. The Resident Care Plan dated 6/18/25 identified Resident #1 was at risk for constipation related to a history of constipation, impaired mobility, opiate use (narcotic pain medication) and a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy and interviews for 15 of 70 residents (Resident #4, Resident #6, Resident #22, Resident #28, Resident #30, Resident #32, Resident #33, Resident #39, Resident #41, Resident #45, Resident #48, Resident #58, Resident #65, Resident #69, Resident #326) reviewed for preventative weekly body audits, the facility failed to perform preventative weekly body audits according facility policy and physician orders. The findings include: 1. Resident #4 was admitted to the facility in November of 2020 and had diagnoses that included cerebrovascular disease, abnormal posture, and osteoarthritis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3), was at risk for developing pressure injuries and had moisture associated skin damage (MASD) with skin treatments. Resident #4 was dependent for bed mobility and transfers. The Resident Care Plan…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #45) reviewed for activities of daily living (ADL), the facility failed to notify the physician of a change in condition. The findings include: Resident #45 was admitted in February of 2021 and had diagnoses that included chronic obstructive pulmonary disease (COPD), anxiety, and pneumoconiosis (chronic lung disease) due to asbestos and other mineral fibers. A physician's order dated 9/18/24 directed Resident #45 receive a regular diet at dysphagia level 2 (mechanically altered) texture, thin liquids, pureed vegetables, no rice, a 2 handled mug with concave lid and meal items served in individual bowls. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #45 was severely cognitively impaired and required setup or clean-up assistance with eating, was dependent for personal hygiene, and required substantial/maximal assistance with transfers. The Resident Care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, facility documentation and staff interviews, the facility failed to provide medication administration education to a temporary agency staff nurse before starting work to meet professional standards of practice to prevent a significant medication error. The findings include: A Reportable Event Form dated 10/11/24 identified that Resident #1 received Resident #14's medications in error which included the following medications: Amlodipine 5 milligrams (mg) (lowers blood pressure), Aspirin 81mg (NSAID), Depakote 250mg (anticonvulsant), Cymbalta 120 mg (antidepressant), Gabapentin 800mg (anticonvulsant), lacosamide 100mg (antoconvulsant), Keppra 500 mg (anticonvulsant), Metoprolol 25mg (lowers blood pressure), Movantik 25mg (treats opioid induced constipation), Docusate (stool softener), Simethicone (gas relief), Vitamin D (supplement) and Vitamin B12 (supplement). Interview with LPN #1 on 11/25/24 at 1:47 PM identified that she was assigned to administer morning medications to Resident #1 on 10/11/24. LPN #1 identified that she went into the wrong room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, review of facility policy, and interviews for 1 of 3 sampled residents (Resident #58) reviewed for accidents, the facility failed to ensure that side rails were used for positioning and bed mobility resulting in a fall. The findings include: Resident #58's diagnoses included hemiplegia (paralysis) affecting the left side, dementia, anxiety and generalized muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3) and was dependent for toileting hygiene, personal hygiene, bed mobility and transfers. The Resident Care Plan (RCP) dated 10/11/24 identified Resident #58 required assistance with ADL's due to left hemiplegia, mobility deficit and self-care deficit. Interventions included using 2 quarter siderails to assist with positioning and bed mobility, assistance with personal hygiene and maintaining proper body alignment and positioning. A facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1. Based on observations, review of the clinical record, facility documentation, facility policy and interviews for 2 of 4 residents (Resident #22 and Resident #34) reviewed for nutrition, the facility failed to obtain a reweight as directed by provider order and failed to notify a provider of a weight change and failed to obtain daily weights as directed by a provder order. The findings include: Resident #22 was admitted to the facility in October of 2024 and had diagnoses that included periprosthetic fracture around other internal prosthetic joint, constipation, heart failure and acute prosthetic anemia. A Nutrition evaluation dated 10/16/24 at 11:57 AM identified a regular puree consistency diet with thin liquids and identified no swallowing difficulties. The evaluation identified Resident #22 had dentures but did not wear them, had 2 remaining teeth on the bottom, and had a left hip surgical site. A provider order dated 10/16/24 directed to obtain weekly weights for 4 weeks then obtain monthly weights.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 2 of 2 residents (Resident #44 and 422) reviewed for indwelling urinary catheters, the facility failed to ensure the residents dignity when the urinary drainage bags were left uncovered and visible. The findings include: 1. Resident #44 was admitted to the facility with diagnoses that included benign prostate hyperplasia and obstructive and reflux uropathy. The quarterly MDS dated [DATE] identified Resident #44 had intact cognition, required extensive assistance with transfers, bed mobility, dressing, toileting, and personal hygiene and had an indwelling catheter. The care plan dated 12/22/22 identified Resident #44 had an indwelling urinary catheter with interventions that included to use a drainage bag cover at all times. Observation on 2/7/23 at 10:45 AM identified Resident #44 was sitting in a wheelchair on the left side of the bed next to the door. The indwelling urinary catheter drainage bag was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility policy and interview for 1 of 2 residents (Resident #36) reviewed for positioning, the facility failed to ensure a physician's order was in place and nurse monitoring was regularly performed and documented, for a resident utilizing a positioning device, and for 1 resident (Resident #52) reviewed for accidents, the facility failed to ensure a RN assessment was completed when the resident had a change in condition. The findings include: 1. Resident #36's diagnoses included Alzheimer's disease, hypertension, and osteoarthritis. Review of the physician's order history identified a lap buddy (a positioning device) for positioning was ordered on 10/16/21 with instructions to document the resident's ability to remove the device every shift. Further review identified the lap buddy was discontinued 5 months later, on 3/24/22. The quarterly MDS dated [DATE] identified the resident had severely impaired cognition with behaviors of continuous disorganized…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #44) reviewed for respiratory care, the facility failed to ensure respiratory equipment was dated per facility policy. The findings include: Resident #44 was admitted to the facility with diagnoses that included acute and chronic respiratory failure with hypoxia and chronic congestive heart failure. A physician's order dated 10/27/22 directed to apply oxygen at 2 liters per minute via nasal cannula and to change the oxygen tubing weekly on Tuesday during the night shift. The quarterly MDS dated [DATE] identified Resident #44 had intact cognition, had shortness of breath with exertion, while sitting at rest, and while lying flat and did not require oxygen prior to being at the facility. The care plan dated 12/22/22 identified the resident had alteration in respiratory status with interventions that included to provide oxygen as ordered and as needed per nursing measure and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 1 residents (Resident #7) reviewed for hemodialysis, the facility failed to monitor a hemodialysis Arterio-Venous (AV) fistula. The findings include: Resident #7 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included end-stage renal disease, hypertension, and atherosclerotic heart disease. A Resident Care Plan dated 5/18/18 through 1/29/20 identified a problem with needing hemodialysis related to end stage renal disease. Interventions included to notify physician for change in fistula, dialysis on Mondays, Wednesdays, and Fridays, and do not draw blood or take blood pressures in the arm with the graft. The quarterly Minimum Data Set (MDS) assessment dated [DATE] and the 5 day (re-admission) MDS assessment dated [DATE] identified Resident #7 was cognitively intact and required extensive assistance of one for bed mobility, transfers, walking in the room, dressing, toilet…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.