Touchpoints at Chestnut: Skin Assessment Gaps - CT
That is what inspectors found when they visited Touchpoints at Chestnut on August 18, 2025, following a complaint. The facility disputed the citation.
The resident, identified in inspection records only as Resident #1, had been assessed using the Braden scale, the standard clinical tool for predicting pressure sore risk, and scored at the very high end of that risk spectrum. She had a stroke with left-sided weakness, epilepsy, difficulty swallowing, and zero score on a cognitive assessment, meaning her cognition was severely impaired. She was always incontinent of both bowel and bladder and required two staff members to assist her with every basic activity of daily living. She wore splints. Her care plan directed staff to turn and reposition her every two hours, provide incontinence care every two hours, and complete a weekly skin check.
The last documented skin assessment before the gap was dated February 11, 2025. The next one on record was dated June 27, 2025. In between, a span of more than nineteen weeks, inspectors found nothing.
A second resident, Resident #2, had her own gap. She had been admitted with a chronic wound on her left foot and bone infection, diagnoses that put skin integrity at the center of her care. Her care plan, dated May 15, 2025, flagged her as at risk for skin breakdown due to fragile skin. Her Braden score also placed her at risk for pressure sores. The last skin observation tool entry before her gap was April 27, 2025. The next was July 12, 2025. Nearly eleven weeks with no documented assessment.
Unlike Resident #1, this second resident had intact cognition, scoring a perfect fifteen on the same mental status interview. She required only supervision, not hands-on assistance, for daily activities. She was continent. None of that changed what her record was missing.
When inspectors sat down with the Director of Nursing Services at 1:39 in the afternoon on the day of the inspection, she confirmed what the records showed. She could not produce skin assessment documentation for Resident #1 covering the February-to-June period, or for Resident #2 covering the late April-to-July period. She acknowledged that the expectation at the facility was for skin assessments to be completed and documented every week.
The facility's own pressure ulcer prevention policy stated the same thing: upon admission and weekly after that, a nurse is to complete a head-to-toe skin check to identify any new or pre-existing skin issues.
Inspectors noted that neither resident had documented pressure ulcers at the time of the inspection. The citation was rated at the level of minimal harm or potential for actual harm.
But the concern with undocumented skin checks is not only what was found. It is what might have developed undetected. Residents like Resident #1, who cannot reposition themselves, cannot report pain, and are constantly exposed to moisture from incontinence, are precisely the people for whom weekly skin surveillance exists. A pressure sore can begin as a small area of redness and progress to a wound reaching bone within days if unaddressed. The assessment is how staff catch it early.
Touchpoints at Chestnut is disputing the citation. What the inspection record does not dispute is that for the better part of two seasons, a woman who could not speak for herself and could not move without help had no documented evidence that anyone was looking closely at her skin.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Touchpoints At Chestnut from 2025-08-18 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
TOUCHPOINTS AT CHESTNUT in EAST WINDSOR, CT was cited for violations during a health inspection on August 18, 2025.
That is what inspectors found when they visited Touchpoints at Chestnut on August 18, 2025, following a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.