Above 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 Chestelm Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a history of constipation and recent rectal bleeding was prescribed hydrocortisone suppositories, but due to a drug interaction alert and lack of follow-up, the medication was not available or administered for several days. Nursing staff did not notify the provider or pharmacy about the missed doses, and supervisors were not informed of the issue. This failure to communicate and follow facility policy resulted in the resident experiencing ongoing symptoms and requiring hospital intervention.
A resident with a history of constipation and other risk factors experienced rectal bleeding, but nursing staff failed to perform a full GI and abdominal assessment or provide continued monitoring as required. The nurse did not review the resident's clinical record prior to assessment, resulting in missed information about the resident's history and current bowel regimen. The resident's condition worsened over several days, leading to hospital transfer for urgent intervention.
The facility failed to perform weekly body audits for 15 residents as per policy and physician orders, leading to gaps in monitoring skin conditions. Residents with various diagnoses, including cerebrovascular disease and diabetes, were at risk for pressure injuries. Despite orders for audits on specific days, many were missed, with some residents going weeks without assessments. Interviews revealed that unit nurses were responsible for audits, but there was no documentation or explanation for the lapses.
A resident with chronic lung disease experienced coughing and spitting up while eating, indicating a change in condition. An LPN observed the incident but failed to document it or notify the supervisor and physician. The facility's policy requires such changes to be reported and documented, which was not adhered to in this case.
A temporary agency LPN administered incorrect medications to a resident after failing to verify the resident's identity, leading to a significant medication error. The facility did not provide medication administration education to agency nurses, contributing to the incident.
A resident with hemiplegia and severe cognitive impairment fell from bed during incontinence care due to the failure of nursing assistants to use side rails as per the care plan. The resident was rolled over without the side rail being raised, resulting in the resident sliding off the bed. The incident highlights a lapse in following the care plan, as confirmed by the DNS.
The facility failed to follow provider orders for weight monitoring and notification of significant weight changes for two residents. One resident experienced a significant weight loss without a reweight or provider notification, while another resident with CHF was not weighed daily as ordered. The facility's Weight Trending Policy was not adhered to, leading to deficiencies in nutritional care.
A resident with a history of gastrointestinal bleeding and an allergy to NSAIDs was mistakenly given another resident's medications, including Aspirin, due to an LPN's failure to verify the resident's identity. The DNS did not document neuro-checks or complete a Medication Error Occurrence Record as required by facility policy, and the APRN's progress note was entered 47 days late.
The facility failed to inform residents about the grievance process, with grievance forms inaccessible and no records maintained for 2023 and 2024. Observations showed the grievance folder was empty and placed at an inaccessible height for wheelchair users. Interviews revealed a misunderstanding of grievances by the Administrator, and residents were unaware of how to file grievances. The facility did not adhere to its policy of maintaining grievance records for three years.
The facility failed to submit SCSA MDS assessments for three residents who experienced significant changes in functional abilities. One resident showed a decline in 14 areas, another had a cognitive decline and a decrease in nine functional areas, and a third resident experienced both decline and improvement in multiple areas. The RN did not realize the extent of changes or the requirement for SCSA submission.
Failure to Notify Provider and Pharmacy of Missed Medication Administration
Penalty
Summary
A deficiency occurred when nursing staff failed to notify the provider and pharmacy regarding the unavailability and non-administration of a newly ordered medication for a resident with a history of constipation, failure to thrive, and aphasia following a stroke. The resident was prescribed hydrocortisone acetate suppositories for rectal bleeding, but a drug interaction alert with aspirin was triggered by the pharmacy. The pharmacy contacted the facility for clarification, faxed a form for completion, and did not send the medication due to lack of response. Despite this, the medication was not administered for several scheduled doses, and there was no documentation that the provider was notified of the missed doses or the medication's unavailability during this period. Nursing staff, including charge nurses and supervisors, did not follow up with the pharmacy or notify the provider each time the medication was not available or administered. Some staff believed the issue had already been reported, while others documented the missed administration in a provider book but did not ensure direct communication. Interviews revealed that staff signed off on medication administration in error and acknowledged they should have contacted the pharmacy and provider but did not do so. Nursing supervisors were also not informed of the ongoing issue and stated they would have assisted if notified. The facility's policy required nursing staff to notify the physician or prescriber for any held medications or suspected adverse drug reactions, but this was not followed. As a result, the resident experienced ongoing rectal bleeding and severe constipation, ultimately requiring transfer to the emergency department for evaluation and urgent intervention. The lack of timely communication and follow-up regarding the medication order and administration led to the identified deficiency.
Failure to Perform GI Assessment and Monitoring After Rectal Bleeding
Penalty
Summary
A deficiency occurred when nursing staff failed to conduct a comprehensive gastrointestinal (GI) and abdominal assessment and provide continued monitoring for a resident following an incident of rectal bleeding. The resident, who had a history of constipation, impaired mobility, opiate use, and a prior ileus, was identified as being at risk for constipation and was dependent on staff for toileting. Despite these risk factors and a care plan that included monitoring for constipation and following a bowel protocol, the nurse's note documented only a visual assessment after the resident was found with bright red rectal bleeding. No abdominal assessment or evaluation of bowel sounds was performed at that time. Further review of the clinical record and nurse's notes revealed that, over the following days, there was a lack of documentation indicating that a GI or abdominal assessment was performed, even as the resident continued to experience rectal bleeding and discomfort. The hydrocortisone suppository ordered for suspected internal hemorrhoids was inconsistently administered due to unavailability, and there was no evidence of ongoing monitoring or reassessment of the resident's condition. The situation escalated when the resident exhibited worsening symptoms, including dark red rectal bleeding, nausea, and abdominal discomfort, eventually leading to the expulsion of a large blood clot and transfer to the emergency department for evaluation and urgent intervention. Interviews with facility staff confirmed that the nurse responsible did not review the resident's clinical record prior to the initial assessment and was unaware of the resident's history of constipation and current bowel regimen. Both the APRN and DON acknowledged that a full GI assessment should have been performed and that a more thorough review of the resident's history was necessary to ensure appropriate care and communication with the provider. Facility policy required monitoring and assessment for changes in condition, but these steps were not followed in this case.
Failure to Conduct Weekly Body Audits
Penalty
Summary
The facility failed to perform preventative weekly body audits according to facility policy and physician orders for 15 of 70 residents reviewed. These residents had various diagnoses, including cerebrovascular disease, congestive heart failure, and diabetes, and were at risk for developing pressure injuries. The facility's policy required weekly body audits to be conducted on specific days and shifts, with instructions to inspect for altered skin integrity and report findings to the provider. However, the audits were not completed on multiple occasions for each resident, leading to gaps in monitoring their skin conditions. For instance, one resident with severe cognitive impairment and at risk for pressure injuries had a provider order to perform a weekly body audit on Fridays. However, audits were not completed on several specified dates, resulting in a 21-day gap without an audit. Another resident with rheumatoid arthritis and anemia also had missed audits, with a 14-day period where no body audit was performed. These lapses in conducting body audits were consistent across multiple residents, with some residents going weeks without the required assessments. Interviews with nursing staff and the Director of Nursing revealed that the responsibility for completing these audits lay with the unit nurses, who were expected to perform them on shower days. Despite this, there was a lack of documentation and explanation for why the audits were not completed as ordered. The facility's failure to adhere to its policy and physician orders for weekly body audits resulted in deficiencies in monitoring and documenting the skin conditions of residents, potentially impacting their care and treatment.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician of a change in condition for Resident #45, who was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety, and pneumoconiosis. The resident was on a regular diet at dysphagia level 2, but an incident occurred where the resident was observed coughing and spitting up while eating meat. Despite this, there was no documentation in the nurse progress notes about the resident's trouble swallowing or coughing during meals. Licensed Practical Nurse (LPN) #3 witnessed the incident and requested a new meal without meat, but did not document the event in a progress note, nor did she notify the supervisor or the provider about the resident's condition. The Director of Nursing Services identified that LPN #3 failed to write a progress note, update the supervisor and provider, and monitor the resident for signs of aspiration. The Advanced Practice Registered Nurse (APRN) was not informed of the resident's difficulty swallowing and indicated that if notified, he would have assessed the resident's swallowing status and possibly ordered a speech screen and monitoring for aspiration. The facility's Change in Condition policy requires changes in a resident's baseline condition to be monitored, assessed, reported to the physician/APRN, and documented, which was not followed in this case.
Medication Administration Error Due to Lack of Agency Staff Training
Penalty
Summary
The facility failed to provide medication administration education to a temporary agency staff nurse, leading to a significant medication error. A temporary agency LPN administered the wrong medications to a resident after entering the incorrect room and failing to verify the resident's identity. The resident received another resident's medications, which included a range of drugs such as Amlodipine, Aspirin, Depakote, Cymbalta, Gabapentin, and others. The LPN did not use any resident identifier to confirm the correct resident and assumed the identity based on a name call, which the resident did not respond to. The error was realized when the LPN noticed the absence of an ordered medical device for the resident. The facility's Human Resources Director confirmed that agency staff are required to acknowledge receipt of the facility's Orientation for Pool Staff document, which does not include medication administration competency. The Director of Nursing Services (DNS) admitted that the facility does not provide orientation for agency nurses on medication administration competency. Although the DNS claimed that the LPN was educated on the 5 rights of medication administration after the error, there was no documentation to support this. The facility also did not implement any education for agency staff nurses related to medication administration following the incident.
Failure to Use Side Rails Leads to Resident Fall
Penalty
Summary
The facility failed to ensure the proper use of side rails for a resident with hemiplegia, dementia, anxiety, and generalized muscle weakness, resulting in a fall. The resident, who was severely cognitively impaired and dependent on assistance for activities of daily living, was being provided incontinence care by two nursing assistants. During this care, the resident was rolled over without the side rail being raised, leading to the resident sliding off the bed and onto the floor. The resident was found with their torso on the floor and legs still on the bed, and although no injuries were noted, the resident complained of pain. The incident occurred because the nursing assistants did not follow the resident's care plan, which required the use of two quarter side rails for positioning and bed mobility. Both nursing assistants acknowledged that the side rail was down at the time of the fall and that it could have helped prevent the resident from falling. The Director of Nursing Services confirmed that the care plan was not followed, but could not explain why the side rails were not used during the incident.
Failure in Weight Monitoring and Provider Notification
Penalty
Summary
The facility failed to adhere to provider orders for weight monitoring and notification of significant weight changes for two residents, leading to deficiencies in nutritional care. Resident #22, who was admitted with multiple diagnoses including heart failure and anemia, had a provider order for weekly weights. Despite a significant weight loss recorded on 11/19/24, a reweight was not obtained as ordered, and the provider was not notified of the weight change. The Director of Nursing confirmed the oversight and acknowledged that the reweight was not conducted, and the weight loss was not communicated to the provider. Resident #34, diagnosed with congestive heart failure and other conditions, had a physician's order for daily weights to monitor potential weight gain due to fluid retention. However, daily weights were not recorded for several days, and there was no documentation of weight refusals or any communication to the provider regarding the lack of weight monitoring. Both the RN and the Director of Nursing confirmed the failure to obtain daily weights as ordered, which was crucial for managing the resident's cardiac condition. The facility's Weight Trending Policy and Procedures were not followed, as evidenced by the lack of reweights and failure to notify providers of significant weight changes. The policy required reweights for discrepancies and communication of weight changes to the provider, family, and weight committee, which did not occur in these cases. This oversight in weight monitoring and communication contributed to the deficiencies identified during the survey.
Medication Error Due to Resident Misidentification
Penalty
Summary
The facility failed to administer medications to the correct resident, resulting in a significant medication error. A resident with a history of gastrointestinal bleeding and an allergy to NSAIDs was mistakenly given another resident's medications, including Aspirin, which is contraindicated for them. The error occurred because the LPN did not verify the resident's identity, as the resident was not wearing a name identification bracelet, and the LPN assumed the identity based on incorrect assumptions. The Director of Nursing Services (DNS) and the Advanced Practice Registered Nurse (APRN) were notified of the error. The APRN assessed the resident and initiated a monitoring protocol due to the potential for adverse effects from the medication error. However, the DNS failed to document the neuro-checks as directed by the APRN and did not complete a Medication Error Occurrence Record according to the facility's policy. Additionally, the DNS did not obtain a written statement from the LPN regarding the incident. The facility's policy requires that medication errors be documented and reviewed to identify risks and implement corrective actions. However, the DNS did not follow this policy, and the APRN's progress note regarding the incident was entered into the medical record 47 days late. The lack of proper documentation and adherence to protocol highlights deficiencies in the facility's handling of medication errors and staff education.
Deficiency in Grievance Process and Record Maintenance
Penalty
Summary
The facility failed to adequately inform residents about the grievance process, as evidenced by the lack of accessible grievance forms and the absence of completed grievance records for the years 2023 and 2024. Observations revealed that the grievance folder and suggestion box were placed at a height inaccessible to residents using wheelchairs, and the folder was empty, lacking necessary forms. Interviews with the facility's Administrator indicated a misunderstanding of what constitutes a grievance, as she considered grievances to be only unresolved complaints, which led to the absence of documented grievances. During a Resident Council meeting, 12 cognitively intact residents expressed unawareness of how to complete a grievance form or where to find them. The facility's grievance policy requires the Grievance Officer to acknowledge grievances promptly and maintain records for three years, which was not adhered to. This lack of awareness and accessibility to grievance forms, combined with the facility's failure to maintain grievance records, highlights a significant deficiency in upholding residents' rights to voice grievances without discrimination or reprisal.
Failure to Submit SCSA for Residents with Significant Changes
Penalty
Summary
The facility failed to submit significant change in status (SCSA) Minimum Data Set (MDS) assessments for three residents who experienced a decline in more than two functional ability areas. Resident #45, who was admitted in February 2021 with diagnoses including dementia and COPD, showed a decline in 14 functional mobility areas between quarterly MDS assessments. Despite this, no SCSA was submitted, as the registered nurse (RN) believed the decline was due to the progression of dementia and did not realize the extent of the decline in functional areas. Resident #58, admitted in January 2023 with conditions such as traumatic hemorrhage of the cerebrum and diabetes, experienced a significant decline in cognition and nine functional mobility areas. The resident's cognitive status deteriorated from being cognitively intact to severely impaired, yet the facility did not submit an SCSA. The resident's care plan included interventions for impaired cognition and activities of daily living (ADL) function, but the necessary assessment to document the significant change was not completed. Resident #61, admitted in April 2023 with dementia and macular degeneration, showed a decline in 15 functional mobility areas and later an improvement in 12 areas. Despite these changes, the facility did not submit an SCSA for either the decline or the improvement. The RN acknowledged understanding the requirement for SCSA submission within 14 days but had not realized the need for submission in cases of improvement in functional mobility areas.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 552 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Moodus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aaron Manor Nursing & Rehabilitation | 6 mi | ★★★★★ | 0 | 0 |
| Cobalt Lodge Health Care And Rehabilitation Center | 7.6 mi | ★★★★★ | 8 | 1 |
| Apple Rehab Colchester | 8.7 mi | ★★★★★ | 6 | 0 |
| Complete Care At Harrington Court | 8.7 mi | ★★★★★ | 8 | 1 |
| Essex Meadows Health Center | 10.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Chestelm Health And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.