Chestnut Park Rehabilitation And Nursing Center

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

unsuccessful. The thermometer was unable to read the temperature of the resident. Staff attempted to obtain a blood pressure with the machine as well as manually but was unable to obtain due to the resident shaking. Summary of Investigation Report dated 09/29/2025 documented on 09/28/2025 at 11:30 PM, Resident #1 was found in their room after an unwitnessed fall from their bed to the floor. There was a small skin tear on their left elbow and a bump on the left back of their head. Resident #1's temperature was unreadable. Was unable to determine the blood pressure. Heart rate was 115. Oxygen saturation level was 73 percent ‘but may be inaccurate due to how cold the resident was.' The summary further documented that Resident #1 was sent to the Emergency Department and admitted to the hospital with changes in mental status. The Summary of Investigation Report did not include an investigation of the amount of time Resident #1 was on the floor or factors that contributed to why Resident #1 was cold and their body temperature was unreadable. Physician progress note dated 09/28/2025 at 11:47 PM documented nursing staff noted Resident #1 had an unwitnessed fall. They were found sitting on the floor next to their bed. It appeared the resident slid out of the bed and on to the floor. Body check was performed. No visible injuries.

No open wounds or abrasions. Resident was unreliable to tell whether they had a head strike. Nursing staff noted the resident was holding their head. No mental status changes. The resident was not on any systemic anticoagulation (medical treatment that prevents blood clots from forming or growing). Vital signs were stable.There was no documented evidence in the Investigation Report that addressed the discrepancies between the Physician progress note dated 09/28/2025 at 11:47 PM, including but not limited to vital signs and mental status.Hospital Emergency Department Provider Notes, Medical Decision Making dated 09/29/2029 at 12:37 AM, documented Resident #1 presented to the Emergency Department after an unwitnessed fall where they were on the ground for an unknown amount of time. Initial vital signs reviewed were ‘concerning for hypothermia with a core temperature of 85.6 Fahrenheit taken rectally,' tachycardia (increased heart rate) with heart rate in the 160's, tachypnea (abnormally rapid breathing) with respiratory rate of 30, and hypoxia (low levels of oxygen in body tissues) in the mid 80's. During an interview on 10/23/2025 at 11:30 AM, Registered Nurse #101 stated they were the Registered Nurse who received Resident #1 into the Emergency Department on 09/29/2025 at around or just after 12:00 AM. They stated

the rectal temperature was 85.8 degrees Fahrenheit, the resident was in respiratory distress requiring nebulizer treatments, intravenous antibiotics, and lots of warmed intravenous fluids, and stated there was ‘no plausible explanation' provided for the hypothermia.During an interview on 10/14/2025 at 3:15 PM, Director of Nursing #1 stated they were the Registered Nurse on-call on 09/28/2025. They stated they were called by Licensed Practical Nurse #4 and was told the resident fell, had an acute change in condition and

they were unable to obtain vital signs. It was not reported to them that the resident was found naked, cold and shivering, or that their body temperature was unreadable because it was so low. Director of Nursing #1 stated they did not have that information upon initial investigation and did not ask any further questions about the resident.During an interview on 10/08/2025 at 1:40 PM, Director of Nursing #1 stated a statement from Resident #1's roommate regarding the unwitnessed fall on 09/28/2025 was not obtained. They further stated that Resident #1's roommate should have been interviewed as the roommate was alert and oriented and may have been able to provide information pertaining to the fall. During an interview on 10/08/2025 at 12:52 PM, Administrator #1 stated they had not identified a timeline for when the resident might have fallen

on 09/28/2025. New York Codes, Rules and Regulations 483.12(c)(2)

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestnut Park Rehabilitation and Nursing Center

330 Chestnut Street Oneonta, NY 13820

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656

2:24 PM, Medical Director #1 stated residents who were at a high risk for falls should be monitored closely.? 10 New York Code of Rules and Regulations 415.11(c)(1)

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestnut Park Rehabilitation and Nursing Center

330 Chestnut Street Oneonta, NY 13820

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Observations on [DATE REDACTED] noted 24 ‘falling star' resident nameplates (23 residents plus one (1) resident who expired), however, the facility supplied a list of 16 residents at risk for falls. During an interview on [DATE REDACTED] at approximately 11:05 AM, Assistant Director of Nursing #1 stated they believed there were only 12 residents who fit for ‘falling stars,' and that falling stars included residents who were acutely ill.The Immediate Jeopardy was removed on [DATE REDACTED] at 3:30 PM. The facility's immediacy removal actions included the following: On [DATE REDACTED], the census was 72. Of the 72 residents, 23 residents were identified with having a high risk for falls. The fall care plans for the 23 residents identified as having a high risk for falls were reviewed. All of the 23 care plans documented ‘Hourly rounding. Refer to binder' as an intervention. The care Kardex for the 23 residents identified as having a high risk for falls were reviewed. All 23 Kardex's documented ‘Hourly rounding. Refer to binder.' Attestation by Administrator dated [DATE REDACTED] documented 100 percent of staff working on [DATE REDACTED] were educated on the systematic changes and policy review (accidents and incidents prevention, investigation, hourly checks, communicating to the emergency management system and hospital system). 95 percent or greater of all active employees were educated on these systemic changes and policy reviews. No staff reported to active duty without having this education.

Interview with Medical Director on [DATE REDACTED] at 2:30 PM. Medical Director was aware of Immediate Jeopardy issued for F-F689. They attended morning meeting on [DATE REDACTED] where interventions to abate the Immediate Jeopardy were reviewed. Medical Director agreed with interventions and increased monitoring for residents with high risks for falls. Medical Director was briefed on Resident #1's discharge to the hospital on [DATE REDACTED] and condition at time of discharge. On [DATE REDACTED], an ad hoc Quality Assurance Performance Improvement meeting was held. Interviews with Certified Nurse Aides, Licensed Practical Nurses, and Registered Nurses

on [DATE REDACTED] indicated staff were educated regarding the new policy involving hourly checks for residents identified as increased risk for falling. Certified Nursing Assistants documented completion of hourly checks for the identified residents in a binder at the nursing station and nursing staff would verify completion of this task at shift completion. All staff interviewed verbalized understanding of the new policy and procedures involving hourly rounding on residents identified as having a high risk for falls. 10 New York Code of Rules and Regulations 415.12(h)(2)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Chestnut Park Rehabilitation and Nursing Center

330 Chestnut Street Oneonta, NY 13820

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

at 11:50 PM. Cause of death was septic shock, pneumonia, acute hypoxic respiratory failure and encephalopathy. During an interview on [DATE REDACTED] at 1:30 PM, Certified Nurse Aide #1 stated they were familiar with Resident #1 and was the assigned Certified Nurse Aide at the time of the [DATE REDACTED] incident.

They stated Resident #1 did not use the call bell. Certified Nurse Aide #1 stated that on [DATE REDACTED], they were told at the start of their shift that Resident #1 had pneumonia and had a COVID-19 test. They stated that

they were not instructed to monitor the resident, that Resident #1 had been asleep all day, slept through dinner, and had not voided much. During an interview on [DATE REDACTED] at 10:30 AM, Registered Nurse #2 stated

the order was to stabilize in the facility, that a Licensed Practical Nurse would administer nebulizer, ideally a nurse should stay and monitor the effectiveness during treatment, and the oncoming nurse would ensure treatments were given as ordered. During an interview on [DATE REDACTED] at 12:52 PM, Administrator #1 stated they knew Nursing staff were ‘in and out' of the room with nebulizer treatments on [DATE REDACTED]. 10 New York Code of Rules and Regulations 415.12(k)(6)

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If continuation sheet