Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aaron Manor Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with intact cognition and multiple behavioral health diagnoses alleged that a nurse aide inserted a finger into their anus while applying hemorrhoidal ointment. The allegation was reported internally and the staff member was removed from the unit, but there was no documentation of the incident in the clinical record, and the event was not reported to the State Agency as required by facility policy. The Administrator was aware of the allegation but could not confirm if it had been reported, and no investigation documentation was found.
A resident with intact cognition and multiple diagnoses alleged that a nurse aide inserted a finger into their anus while applying hemorrhoidal ointment. The accused staff member was not immediately removed from duty as required by facility policy, and staff interviews revealed uncertainty about whether proper procedures were followed after the abuse allegation.
A resident with a history of adjustment disorder, anxiety, and chronic pain alleged that a nurse aide inappropriately applied hemorrhoidal ointment. Although staff reported that such allegations are typically investigated and documented, there was no record of an investigation or related documentation available for review, despite facility policy requiring prompt and thorough investigation of all abuse allegations.
A high-risk resident with a history of falls and dementia fell from a bed left in a high position, resulting in a head laceration and multiple fractures. The resident's care plan required two-person assistance and a low bed position, but these were not followed by the nursing assistant. The facility's policies on positioning and fall risk management were not adhered to, and the resident's fall risk was not adequately addressed.
A resident with severe cognitive impairment and multiple health conditions experienced a significant decline due to the facility's failure to monitor and document fluid intake and bowel movements accurately. Despite abnormal lab results indicating dehydration, the facility did not adjust care plans or make necessary referrals to speech therapy and dietician services. Inaccurate documentation and lack of communication led to severe health complications, including fecal impaction and acute kidney injury, resulting in prolonged hospitalization.
A facility failed to properly store medications for a resident and in the medication storage room. A resident's heparin and sodium chloride flush syringes were found in their room instead of a secure area. Additionally, expired influenza tests and insulin vials past their use date were discovered in the medication storage room. An RN confirmed the improper storage and expired items, acknowledging the facility's policy violations.
The facility failed to properly label and dispose of expired food items and did not maintain the ice machine scoop in a sanitary manner. Unsealed bags of bread and pastries were found without proper labeling, and the ice scoop was stored in unsanitary conditions. The Dietary Director and Administrator acknowledged these lapses, which contravened the facility's policies on food labeling and sanitation.
A facility failed to complete an advance directive form for a resident upon admission, despite the resident being a full code with specific treatment preferences documented. The resident, admitted with conditions like epilepsy and Parkinson's, was cognitively intact. Interviews revealed a lack of clarity in responsibility for completing the form, and the admission policy lacked a formal review process for documents, leading to the oversight.
The facility failed to update the care plans for two residents, one with CHF and another with dialysis access changes. A resident with CHF did not have the condition or necessary interventions included in their care plan, while another resident's care plan was not updated after hospitalization for sepsis and a change in dialysis catheter. The facility's policy requires care plans to be revised as conditions change, which was not adhered to in these cases.
The facility failed to provide adequate oral hygiene and grooming assistance for two residents. One resident, with chronic pain and impaired dentition, did not receive consistent oral care, resulting in swollen gums and plaque accumulation. Another resident, dependent on staff for grooming, was observed with unshaven facial hair. The facility's policy required assistance for residents unable to perform daily living activities independently, which was not followed, leading to deficiencies in care.
A facility failed to provide adequate pressure ulcer care for a resident with a history of pressure injuries. The resident was not repositioned in their wheelchair as per the 24-hour positioning plan, and the right heel was not offloaded as required by provider orders. Observations showed the resident's right foot resting directly on the wheelchair footrest without an offloading boot, contrary to care plan requirements. Staff interviews confirmed a lack of adherence to the care plan and provider orders, contributing to the deficiency.
A facility failed to provide necessary social services follow-up for a resident after a hospitalization and change in condition. The resident, with severe cognitive impairment, was eligible for hospice and had a change in code status to DNR. Despite these changes, the social worker did not follow up with the resident's representatives regarding goals of care after readmission. The social worker was not present at the care conference and last discussed goals of care in July, despite the resident's readmission in October.
A resident with pressure ulcers did not receive proper wound care due to an LPN's failure to follow infection control practices. The LPN did not maintain a clean field, failed to change gloves, and used unclean scissors during the dressing change, contrary to the facility's wound care policy.
The facility did not ensure residents were informed about the location of state inspection results, as revealed during a resident council meeting where several residents and the Ombudsman stated their unawareness. The survey binder was located in the lobby, but the administrator was unaware of the residents' lack of knowledge about its location.
The facility failed to document and address grievances for two residents, one with cognitive impairment and another cognitively intact, leading to a deficiency in honoring residents' rights. Concerns about personal belongings, cleanliness, and room intrusions were communicated to staff, but no grievance forms were completed, contrary to facility policy.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation to the State Agency for one resident. The resident, who had diagnoses including adjustment disorder, anxiety disorder, and chronic pain disorder, alleged that a nurse aide applied hemorrhoidal ointment and, during the process, inserted a finger into the resident's anus. The allegation was made to a registered nurse, who stated that he immediately informed the Administrator and Director of Nursing Services (DNS) and removed the accused staff member from the unit, but did not document the incident until directed by administration. Review of clinical records and nurse's notes did not reveal any documentation of the incident or the need for hemorrhoidal ointment during the relevant period. Further review of the State Agency Reportable Events website showed that the abuse allegation was not reported to the State Agency as required. The Administrator confirmed awareness of the allegation and acknowledged that it should have been reported, but was unsure if it had been. An investigation was initiated and statements were obtained, but the Administrator could not recall the reason for the unsubstantiated outcome. The DNS, who was not employed at the time, stated that such allegations should be reported immediately and the staff member removed pending investigation. No investigation documentation was found for the incident, and the facility's abuse prevention policy required immediate reporting of abuse allegations to the Department of Public Health within two hours.
Failure to Immediately Remove Accused Staff Following Abuse Allegation
Penalty
Summary
The facility failed to immediately remove a staff member accused of abuse following an allegation made by a resident. The resident, who had diagnoses including adjustment disorder, anxiety disorder, and chronic pain disorder, alleged that a nurse aide applied hemorrhoidal ointment and, during the process, inserted a finger into the resident's anus. The resident was cognitively intact and required moderate assistance with personal hygiene, transfers, and ambulation. Documentation review showed no incident or allegation recorded in the nurse's notes for the relevant period, and the accused staff member's timecard indicated they completed their full shift on the day of the alleged incident. Interviews with facility staff, including the RN, Administrator, and DNS, revealed uncertainty and lack of recall regarding whether the accused staff member was removed from duty immediately after the allegation was reported. The facility's abuse prevention policy requires immediate reporting and removal of accused staff during investigations, but there was no evidence that this protocol was followed in this case. Attempts to interview the accused staff member and the interim DNS were unsuccessful.
Failure to Document Abuse Investigation Following Resident Allegation
Penalty
Summary
The facility failed to maintain documentation that an investigation was completed following an allegation of abuse made by a resident. The resident, who had diagnoses including adjustment disorder, anxiety disorder, and chronic pain disorder, alleged that a nurse aide applied hemorrhoidal ointment and, during the process, inserted a finger into the resident's anus. The resident was cognitively intact and required moderate assistance with personal hygiene, transfers, and ambulation. The care plan and physician's orders included interventions for constipation and hemorrhoidal care, but there was no documentation in the nurse's notes regarding the incident or the need for ointment during the relevant period. Interviews with staff revealed uncertainty about the notification and documentation process for the abuse allegation. The RN interviewed could not recall being notified of the specific allegation but stated that all such allegations are reported to administration and the accused staff member is removed from duty. The administrator confirmed awareness of the allegation and stated that an investigation was initiated and unsubstantiated, but could not provide documentation of the investigation or recall the rationale for the outcome. Review of the facility's abuse prevention policy indicated that all reports of abuse should be promptly and thoroughly investigated, with documentation maintained, but the required investigation records could not be located.
Failure to Prevent Fall in High-Risk Resident
Penalty
Summary
The facility failed to ensure the safety of a resident identified as a high fall risk, resulting in a fall with a major injury. The resident, who had a history of falls, dementia, and a recent hip fracture, was admitted to the facility with a care plan that required the bed to be kept in a low position and assistance from two staff members for bed mobility and transfers. However, on the day of the incident, the resident's bed was left in a high position after care was provided by a nursing assistant who did not follow the care plan's requirements for assistance and bed positioning. The resident fell from the bed, sustaining a head laceration and multiple fractures, including cervical and sacral fractures. The nursing assistant who provided care was unaware of the resident's need for two-person assistance and did not check the resident care card for guidance. Additionally, the facility's Director of Nursing Services was not aware of the resident's high fall risk status, and the facility did not evaluate the use of an air mattress from an interdisciplinary approach, which was initially thought to be a contributing factor to the fall. Interviews with staff and another resident in the room revealed that the resident was restless before the fall and that the bed was in a high position, which contributed to the incident. The facility's policies on positioning and fall risk management were not adhered to, as the bed was not lowered after care, and the resident's fall risk was not adequately addressed in practice, despite being documented in the care plan.
Failure to Monitor and Document Resident's Nutrition and Hydration
Penalty
Summary
The facility failed to adequately monitor and document the fluid intake and bowel movements of Resident #3, leading to a severe health decline and prolonged hospitalization. Resident #3, who was admitted with conditions including spinal stenosis, dementia, and protein-calorie malnutrition, was identified as severely cognitively impaired and dependent on assistance for daily activities. Despite being at risk for weight loss and dehydration, the facility did not accurately track the resident's intake and output, nor did they adjust the care plan to address the risk of constipation, which was exacerbated by the resident's pain management regimen and lack of mobility. Laboratory reports indicated elevated levels of blood urea nitrogen, creatinine, and sodium, suggesting dehydration and impaired kidney function. Orders to encourage additional fluid intake and adjust diuretic medication were not effectively implemented, as evidenced by continued abnormal lab results and the resident's deteriorating condition. The facility's documentation of fluid intake was inaccurate, with nursing assistant #8 admitting to not properly recording the resident's actual intake. Additionally, bowel movement records were misleading, as loose stools were not reported accurately, leading to a lack of appropriate medical intervention. The facility also failed to make timely referrals to speech therapy and dietician services despite Resident #3's documented weight loss and poor meal intake. Observations revealed that the resident was not consuming adequate food and often coughed while drinking fluids, yet no adjustments were made to the diet or feeding approach. The speech and language pathologist was not informed of the resident's declining intake, and the diet was not downgraded until after surveyor inquiry. This lack of communication and failure to reassess the resident's needs contributed to the resident's severe fecal impaction, acute kidney injury, and other complications that necessitated hospitalization.
Improper Medication Storage and Expired Medications Found
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for a resident and within the medication storage room. A resident admitted with osteomyelitis and other conditions had heparin and sodium chloride flush syringes improperly stored in their room on top of a refrigerator, contrary to facility policy which requires such medications to be stored in a medication room or on medication carts. This was confirmed by an RN who was unable to explain why the medications were stored in the resident's room. Additionally, during an inspection of the medication storage room, expired influenza tests and insulin vials past their beyond use date were found. The insulin vials were dated beyond the 28-day usage period recommended by the manufacturer. An RN acknowledged the presence of these expired items and indicated that expired medications should be placed in a designated bin for pharmacy pick-up, as per facility policy. The facility's failure to adhere to its medication storage policies resulted in these deficiencies.
Deficiencies in Food Storage and Ice Machine Sanitation
Penalty
Summary
The facility failed to adhere to proper food storage and labeling protocols, as observed during a tour of the dietary department. Unsealed bags containing cake and cornbread were found with expired dates, and other bags containing hotdog and hamburger rolls lacked any expiration or open dates. Additionally, the ice machine scoop was improperly stored in a holder with water and covered in white residue, indicating a lack of cleanliness. The facility's policy requires all food items to be labeled and dated, and for potentially hazardous foods to be discarded within three days of preparation. Further inspection revealed a box of Danishes and a container of thickened cranberry cocktail in the nursing unit nourishment room refrigerator, both of which were not properly labeled with open dates. The Dietary Director acknowledged that expired foods should have been discarded and that open bags should have been labeled. The Administrator confirmed the need to dispose of the improperly stored items. The facility's policy mandates that ice machines and storage containers be maintained in a clean and sanitary manner, which was not observed in this instance.
Failure to Complete Advance Directive Form Upon Admission
Penalty
Summary
The facility failed to complete an advance directive form for Resident #28 upon admission. Resident #28, who was admitted with diagnoses including epilepsy, Parkinson's disease, and dysphagia, was identified as cognitively intact with a BIMS score of 14. Despite being a full code, as documented in the Resident Care Plan and physician's orders, the advance directive form in the resident's paper chart remained blank and unsigned. Interviews with the Advanced Practice Registered Nurse (APRN) and Medical Director (MD) revealed a lack of clarity and responsibility regarding the completion of the advance directive form, with MD #2 acknowledging that he would have filled out the form if it was missing during his review. The Registered Nurse Supervisor (RN) was unaware of the blank advance directive form and had not completed the admission process for Resident #28. The facility's process for completing advance directives involves the resident or their representative filling out and signing the form, followed by verification and signatures from two staff members, and notification to the provider for an order in the EMR. However, the admission policy lacked a formal process for reviewing all admission documents, contributing to the oversight. The advance directive form was eventually completed after surveyor inquiry, but the initial failure to document the resident's treatment preferences upon admission constituted a deficiency.
Failure to Update Resident Care Plans for CHF and Dialysis Access
Penalty
Summary
The facility failed to revise the comprehensive Resident Care Plan (RCP) for two residents, leading to deficiencies in care planning. Resident #20, admitted with diagnoses including diabetes, chronic kidney disease, and hypertension, was identified by a medical doctor as having congestive heart failure (CHF) and was prescribed Furosemide to manage fluid overload. However, the RCP did not include CHF as an active diagnosis or interventions to monitor for fluid overload, such as monitoring neck vein distention or abnormal lung sounds. The oversight was discovered during an interview and clinical record review with a registered nurse, who was unaware of the CHF diagnosis and stated that the RCP would have been updated if she had known. Resident #33, admitted with end-stage renal disease and other conditions, was hospitalized for sepsis related to an infected hemodialysis catheter. Upon readmission, the resident had a new catheter placed, and the previous catheter was removed due to a positive MRSA culture. The RCP failed to document these changes, including the discontinuation of monitoring for an AV fistula that was no longer in use. The registered nurse acknowledged that the RCP should have been updated to reflect the resident's current status and hospitalization details, but believed the existing interventions were still relevant. The facility's policy on Comprehensive Person-Centered Care Plans requires that care plans be revised as residents' conditions change, particularly after hospital readmissions. The failure to update the RCPs for both residents indicates a lapse in adhering to this policy, resulting in care plans that did not accurately reflect the residents' current medical conditions and necessary interventions.
Deficiencies in Oral Hygiene and Grooming Assistance
Penalty
Summary
The facility failed to provide adequate oral hygiene and grooming assistance for two residents, leading to deficiencies in their care. Resident #10, who was admitted with chronic pain, fibromyalgia, rheumatoid arthritis, depression, and anxiety disorder, required moderate assistance with oral care due to mouth pain and impaired dentition. Despite having a care plan that included daily mouth care and oral brushing, observations revealed that Resident #10 had swollen and inflamed gums with thick plaque accumulation, indicating a lack of proper oral hygiene. Interviews with staff and the resident confirmed that oral care was not consistently provided, especially on days when the resident complained of pain. Resident #49, admitted with hemiplegia and hemiparesis following a cerebral infarction, was dependent on staff for grooming and other activities of daily living. Observations showed that Resident #49 had unshaven facial hair, which was not addressed by the facility staff. The facility's policy stated that residents who are unable to perform activities of daily living independently should receive necessary services to maintain grooming and personal hygiene, which was not adhered to in this case. Interviews with the Director of Nursing Services (DNS) confirmed that the facility should have been providing the necessary assistance for oral care and grooming based on the residents' needs as identified in their assessments. The failure to provide these services resulted in deficiencies in the care provided to both residents, as they did not receive the necessary support to maintain their personal hygiene and comfort.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with a history of pressure injuries and an active pressure injury on the right heel. The resident, who was severely cognitively impaired and dependent on staff for mobility and care, was not repositioned in their wheelchair according to the 24-hour positioning plan. Despite a provider order for offloading the right heel with a pillow and applying offloading boots, the resident was observed without an offloading boot on the right foot, which was resting directly on the wheelchair footrest. This oversight was confirmed by staff interviews and observations, indicating a lack of adherence to the care plan and provider orders. Additionally, the resident's care plan did not include interventions for offloading the heels, and the resident was not included in the facility's wound report for November due to an oversight. The facility's policy on positioning and repositioning emphasizes the importance of avoiding pressure on existing pressure injuries, yet the resident's right heel was not adequately offloaded, potentially impeding healing. Staff interviews revealed a lack of awareness and implementation of the necessary interventions, contributing to the deficiency in care for the resident's pressure injury.
Failure to Provide Social Services Follow-Up After Resident's Hospitalization
Penalty
Summary
The facility failed to provide adequate social services follow-up for a resident after a change in condition that resulted in hospitalization. The resident, who was admitted in August 2022, had diagnoses including spinal stenosis, dementia, and protein-calorie malnutrition, and was identified as severely cognitively impaired. After a hospitalization, the resident was deemed eligible for hospice care, and a change in code status to Do Not Resuscitate (DNR) was made following discussions with the family. Despite these significant changes, the social worker did not follow up with the resident's representatives regarding goals of care after the resident's readmission to the facility. The social worker acknowledged not being present for the care conference on October 16, 2024, and admitted that the last discussion with the resident's representatives about goals of care was during a care conference in July 2024. The facility's Director of Nursing Services (DNS) confirmed that either a registered nurse supervisor or the social worker should have followed up with the resident's representatives regarding goals of care after the resident's readmission. The social worker recognized the importance of being present at care conferences to support the resident's representatives, especially given the resident's severe cognitive impairment and the differing goals of care among the representatives.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for a resident with significant pressure ulcers. The resident, admitted in October 2024, had a history of complete paraplegia, osteomyelitis, and stage 3 and 4 pressure ulcers on the buttocks. The care plan included specific interventions for skin integrity and wound management. However, during an observed dressing change, the LPN did not follow the facility's wound care policy. The LPN performed hand hygiene and donned gloves initially but failed to maintain a clean field and did not change gloves or perform hand hygiene after removing the dirty dressing. Additionally, the LPN did not wear gloves while preparing and applying the new dressing, and used unclean scissors to cut the dressing. The LPN admitted to not knowing the dressing change policy and acknowledged the mistakes made during the procedure. The facility's wound care policy requires establishing a clean field, using gloves appropriately, and ensuring all items used are clean. The LPN's actions were inconsistent with these guidelines, leading to a deficiency in infection control practices. The surveyor intervened during the procedure to remind the LPN of the correct protocol, highlighting the lapse in adherence to established infection control measures.
Residents Unaware of Survey Results Location
Penalty
Summary
The facility failed to ensure that residents were aware of the location of the state inspection results, which is a deficiency in providing residents with their right to access this information. During a resident council meeting, multiple residents and the Ombudsman expressed that they were unaware of the availability and location of the state inspection results. A review of the resident council minutes from the past three months showed no mention of the residents' right to access inspection results. Additionally, postings on bulletin boards and recreation calendars did not indicate where the inspection results were located. An observation confirmed that the survey binder was placed in the lobby entrance, but the administrator was unaware that residents did not know its location.
Failure to Document and Address Resident Grievances
Penalty
Summary
The facility failed to properly document and address grievances for two residents, leading to a deficiency in honoring residents' rights to voice grievances without discrimination or reprisal. Resident #3, who was severely cognitively impaired, had multiple concerns raised by their representative regarding personal belongings and cleanliness issues. Despite these concerns being communicated to various staff members, including the administrator, no grievance forms were filled out, and the representative was not familiar with the grievance process. Observations confirmed the presence of labels on dresser drawers and items stored in the bathroom shower stall, indicating ongoing issues. Resident #39, who was cognitively intact, expressed frustration over another resident wandering into their room. Although the issue was discussed in Resident Council meetings and with the administrator, no grievance was filed on behalf of Resident #39. The Director of Nursing Services (DNS) offered a room change and emotional support through a behavioral health provider, but again, no formal grievance documentation was completed. The facility's policy required that any concerns or complaints brought to the attention of the charge nurse or nursing supervisor be documented on a grievance form and submitted to the social worker. However, interviews with staff revealed that emails were sent to administration instead of completing the required grievance forms. The administrator did not consider the complaints as grievances, resulting in a failure to adhere to the facility's grievance policy.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Essex Meadows Health Center | 5.6 mi | ★★★★★ | 2 | 0 |
| Chestelm Health And Rehabilitation Center | 6 mi | ★★★★★ | 2 | 0 |
| Gladeview Health Care Center | 8.4 mi | ★★★★★ | 1 | 0 |
| Apple Rehab Saybrook | 8.6 mi | ★★★★★ | 5 | 0 |
| Autumn Lake Healthcare At Madison | 11.5 mi | ★★★★★ | 26 | 0 |
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