The missing documents, called POLST forms, tell emergency responders and medical staff whether residents want CPR, breathing tubes, or other life-sustaining treatments if they become unresponsive or critically ill.
Federal inspectors found the social worker, identified only as SW 1, had no idea where most of the forms were located during interviews on January 2nd. For some residents, she speculated the documents might be "in the resident's old records." For others, she simply didn't know if the forms existed at all.
The director of nursing told inspectors that staff rely on POLST forms to identify whether residents are "full code" during emergencies, especially when someone is found unresponsive. Without access to these documents, medical staff would be forced to guess about a resident's end-of-life preferences in critical moments.
SW 1 acknowledged during interviews that POLST forms should be stored in residents' current medical charts, not in her office. Yet she admitted keeping at least some of these vital documents in her personal workspace, making them inaccessible to nursing staff who might need them during overnight shifts or weekend emergencies.
The facility's own policy, dated September 2022, requires social workers to inquire about advance directives within 48 to 72 hours of a resident's admission. The policy also mandates that these documents be placed prominently in medical records where "any facility staff" can retrieve them.
For Resident 3, SW 1 found a POLST buried in previous medical records rather than the current chart. She told inspectors she wasn't sure if Resident 6 even had a POLST. For Resident 8, described as "new to the facility," SW 1 acknowledged it was her responsibility to obtain the POLST but hadn't done so.
Resident 9, also new to the facility, had no POLST in the current medical chart. SW 1 said she was "unsure if Resident 9 was offered a POLST" despite facility policy requiring this conversation within three days of admission.
The social worker's job description specifically states that she "works with residents to complete advance directive documentation." Yet during the inspection, she repeatedly told investigators she didn't know the location or existence of these critical forms.
For Resident 11, both the POLST and advance directive were missing from the current medical chart. SW 1 confirmed these documents should be in the resident's chart rather than stored in her office.
The facility policy emphasizes that advance directive information must be "displayed prominently in the medical record in a section that is retrievable by any staff." It also requires that copies of these documents be "readily retrievable by any facility staff."
The director of nursing reinforced this requirement during her interview, stating that SW 1 must obtain residents' advance directives and POLST forms within 48 hours of admission. She explained that nursing staff need immediate access to determine appropriate emergency interventions.
POLST forms are particularly crucial in nursing homes, where residents often have complex medical conditions and may experience sudden health crises. These documents prevent unwanted aggressive treatments for residents who prefer comfort care, while ensuring that others receive full resuscitation efforts if that matches their wishes.
The inspection found that multiple residents admitted to Chestnut Ridge Post Acute were left in a documentation limbo. Some had been at the facility long enough that their POLST forms should have been located and properly filed. Others were recent admissions who should have been offered the opportunity to complete these forms.
SW 1's repeated statements that she "didn't know" whether residents had POLST forms or where they might be located revealed a systematic breakdown in the facility's advance directive process. Her acknowledgment that some documents were improperly stored in her office rather than medical charts compounded the problem.
The facility's policy requires that if residents haven't established advance directives, staff must offer assistance in creating them. Yet SW 1's uncertainty about whether newly admitted residents had even been offered POLST forms suggests this requirement wasn't being met.
Federal inspectors classified this as a violation affecting "many" residents, indicating the problem extended beyond the nine specific cases documented during the survey. The breakdown left an unknown number of residents without proper advance directive documentation in their medical records.
For families who carefully completed POLST forms with their loved ones, the social worker's failure to maintain proper records meant those end-of-life wishes could be ignored during medical emergencies simply because staff couldn't locate the paperwork.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Chestnut Ridge Post Acute LLC from 2026-01-02 including all violations, facility responses, and corrective action plans.
Additional Resources
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