A list of the most recent deficiencies for Chestnut Ridge Post Acute LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-02 | 2024-02-23 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-05 | 2023-11-07 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-10-05 | 2023-11-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-05 | 2023-11-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-05 | 2023-11-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-10-05 | 2023-11-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-05 | 2023-11-07 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-10-05 | 2023-11-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-05 | 2023-11-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-10-05 | 2023-11-05 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-10-05 | 2023-11-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-10-05 | 2023-11-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-05 | 2023-11-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-05 | 2023-11-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-05 | 2023-08-31 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-05 | 2023-08-31 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-28 | 2023-05-26 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-05-11 | 2023-05-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-06 | 2023-03-03 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-10-21 | 2022-11-14 | N |
| Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Health | 2022-10-21 | 2022-11-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-10-21 | 2022-11-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-21 | 2022-11-14 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-10-21 | 2022-11-14 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-10-21 | 2022-11-14 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-10-21 | 2022-11-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-10-21 | 2022-11-14 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-10-21 | 2022-11-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-10-21 | 2022-11-14 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-10-21 | 2022-11-14 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-10-21 | 2022-11-14 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-10-21 | 2022-11-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-21 | 2022-11-14 | Y |
| Provide immediate access to any resident. | Health | 2022-10-21 | 2022-11-14 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-10-21 | 2022-11-14 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-10-21 | 2022-11-14 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-10-21 | 2022-11-14 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-10-21 | 2022-11-14 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-10-21 | 2022-11-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-21 | 2022-11-14 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-10-21 | 2022-11-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-21 | 2022-11-14 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-10-21 | 2022-11-14 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-10-20 | 2022-10-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-10-20 | 2022-10-30 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-10-20 | 2022-10-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-10-20 | 2022-10-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-10-20 | 2022-10-30 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2022-10-20 | 2022-10-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-20 | 2022-10-30 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2022-10-20 | 2022-10-30 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-25 | 2022-09-09 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-08-24 | 2022-08-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-07-18 | 2022-08-26 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-18 | 2022-08-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-08-01 | 2022-08-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-13 | 2022-07-29 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-07-13 | 2022-07-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-06 | 2022-04-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-21 | 2022-04-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-22 | 2022-03-30 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-13 | 2022-03-29 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-03-01 | 2022-03-14 | Y |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-01 | 2022-03-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-15 | 2022-02-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-02 | 2022-02-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-30 | 2022-02-07 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-30 | 2022-02-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-08 | 2021-11-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-08 | 2021-11-18 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-08 | 2021-11-18 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-01 | 2021-10-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-25 | 2021-07-23 | Y |
