Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Chestnut Hill Health And Rehabilitation Center Llc during CMS and state inspections, most recent first.
A newly admitted resident with multiple chronic and acute conditions did not receive several ordered medications due to unavailability, as nursing staff did not request STAT pharmacy delivery or notify the provider for alternative orders, contrary to facility policy. Documentation and interviews confirmed that required steps to obtain and administer the medications in a timely manner were not followed.
Staff in the kitchen did not consistently wear hair restraints while preparing and cooking food, and failed to monitor and document the final internal temperatures of several hot food items before serving them to residents. Some food items were held and served at temperatures below required standards, and residents reported receiving cold food. The Food Service Director confirmed that these practices did not comply with facility policy or food safety standards.
Staff failed to consistently use appropriate PPE, clean and disinfect surfaces and equipment, and follow contact and enhanced barrier precautions for multiple residents with infections or wounds. These lapses included not wearing gowns and gloves when required, improper cleaning of overbed tables after removal of used urinals, and using shared medical equipment without effective disinfection between residents, as confirmed by staff and management interviews.
A resident with dementia experienced a significant decline in ADLs, becoming dependent on staff for multiple tasks after a fall and discontinuation of therapy. Despite facility policy requiring a Significant Change in Status Assessment (SCSA) for such declines, the assessment was not completed, as confirmed by staff review of the resident's medical record.
A resident with Multiple Sclerosis was admitted without any documented mental illness, but later received several new mental health diagnoses, including adjustment disorder and delusional disorder. Despite these new diagnoses, the facility did not conduct or document a required PASRR Level II Evaluation or referral, as confirmed by staff interviews.
A resident with a history of depression, prescribed antidepressant medications, and who had consented to behavioral health services, did not receive those services as required. Despite documented requests and care plan interventions, the facility failed to ensure the referral process was completed and did not provide the necessary behavioral health support.
Two residents were administered incorrect medications during a medication pass, resulting in a medication error rate of 7.6%, which exceeds the acceptable threshold. An LPN gave one resident a different calcium supplement than ordered and another resident a different laxative than prescribed, documenting both as if the correct medications had been given. The DON confirmed that only prescribed medications should have been administered.
Breakfast items, including pureed scrambled eggs, oatmeal, pancakes, and French toast casserole, were served at temperatures well below the required 135°F, with several staff and residents noting the food was cool or cold. The pureed eggs also had an inappropriate gritty texture due to the addition of thickener, which staff acknowledged was not suitable for eggs.
The facility inaccurately coded MDS assessments for two residents, including one instance where a resident was marked as having a fall with major injury despite no evidence or report of such an event, and another where a resident's discharge destination was incorrectly recorded as a hospital instead of home. These errors resulted in assessments that did not accurately reflect the residents' conditions or discharge locations.
A resident at risk for pressure injuries did not have complete CNA documentation for October 2024, with numerous blank spaces in the Turning and Repositioning, Bed Mobility, Preventative Skin Care, and Skin Observation tasks. Interviews with staff confirmed that documentation was expected to be completed by the end of each shift, but this was not done, leading to an incomplete medical record.
Failure to Provide Timely Medication Administration for New Admission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a newly admitted resident received medications as ordered by their provider. The resident, who had diagnoses including hypertension, COPD, and a urinary tract infection, had physician orders for several medications to treat both chronic and acute conditions. Despite these orders, the resident did not receive multiple scheduled doses of Spiriva, Symbicort, Diltiazem, and Cefpodoxime as documented in the Medication Administration Record (MAR) and corresponding nursing notes, which indicated the medications were not available and were pending arrival from the pharmacy. Facility policies required that when medications were not available, nursing staff should contact the prescriber for directions and request STAT delivery from the pharmacy if needed. The pharmacy confirmed that the medication orders were received after regular hours and that a STAT order could have resulted in delivery within four hours, but no such request was made by the nursing staff. Nurses reported not administering the medications because they were not available in the facility’s medication storage and did not contact the pharmacy for STAT delivery, expecting the medications to arrive with the next scheduled delivery instead. Interviews with facility staff, including nurses, the unit manager, and the director of nursing, confirmed that the process for obtaining new admission medications was not followed as per policy. The staff did not contact the pharmacy for STAT delivery or notify the provider to discuss alternative medications when the ordered medications were unavailable. There was no documentation to show that the provider was contacted regarding the unavailability of the medications or to consider alternative treatments.
Failure to Use Hair Restraints and Monitor Food Temperatures in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its main kitchen, specifically regarding the use of hair restraints and the monitoring of food temperatures. Observations revealed that a cook was preparing and cooking food on the grill without wearing any type of hair restraint, in violation of the facility's policy which requires all kitchen staff to keep hair effectively restrained to prevent contamination. The cook admitted to sometimes not wearing a hair restraint and stated that no one had addressed this issue with him. The Food Service Director (FSD) confirmed that all staff were required to wear hair restraints in the kitchen. Additionally, the facility did not consistently monitor or document the final internal temperatures of cooked foods prior to serving them to residents. During breakfast service, it was observed that certain food items, such as pureed eggs and minced and moist pancakes, were held at temperatures below the required standard, with recorded temperatures of 80°F and 100°F, respectively. The cook acknowledged that these were typical holding temperatures and admitted to not checking the final cooked temperatures for these or for special order items like sausage patties. The FSD stated that all hot foods should be held at 135°F and that temperatures must be monitored before serving, but the Food Temperature Log did not reflect proper monitoring for all items. Resident feedback during a council meeting indicated that some breakfast items, including eggs, were served cold. The FSD later confirmed that several residents had been served the under-temperature food items and that the temperature log was updated only after reheating, without documentation of the initial final cooked temperatures. The lack of proper temperature monitoring and failure to use hair restraints represent noncompliance with both facility policy and food safety standards.
Failure to Adhere to Infection Control Standards and PPE Use
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for four residents, resulting in multiple deficiencies related to the use of personal protective equipment (PPE), cleaning and disinfection of surfaces and equipment, and implementation of contact and enhanced barrier precautions. For one resident with a diagnosis of Clostridium Difficile (C-Diff), staff entered the room and handled items such as the breakfast tray and call bell without donning gloves or gowns, despite clear signage and physician orders for contact precautions. The Director of Nursing confirmed that staff should have worn appropriate PPE in these situations due to the highly contagious nature of C-Diff. In another instance, a resident's overbed table was not properly cleaned and disinfected after a used urinal was removed and before a meal tray was placed on it. The staff member used only a dry paper towel rather than a disinfectant wipe, and both the CNA and DON acknowledged that proper disinfection was not performed, which was inconsistent with facility policy and infection control standards. Additionally, shared medical equipment, specifically a portable pulse oximeter, was used on a resident with C-Diff and then on another resident after being wiped with a product not effective against C-Diff spores. The unit manager confirmed that dedicated equipment should have been used and that the cleaning product available was not appropriate for C-Diff. For a resident on Enhanced Barrier Precautions due to pressure ulcers and other conditions, staff failed to wear gowns while providing high-contact care such as feeding, repositioning, and handling bed linens, despite signage and care plan interventions requiring both gowns and gloves. Multiple staff members and the unit manager acknowledged that gowns should have been worn during these activities. These failures were observed directly by surveyors and confirmed in interviews with staff and management, demonstrating lapses in adherence to established infection control policies.
Failure to Complete Significant Change in Status Assessment After Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced a notable decline in activities of daily living (ADLs). According to the facility's policy, an SCSA must be conducted when the interdisciplinary team (IDT) determines that a resident has undergone a significant change, defined as a major decline or improvement affecting more than one area of health status and requiring care plan review. The resident in question, admitted with dementia, initially required partial assistance with some ADLs and supervision for others. Subsequent assessments showed a marked decline, with the resident becoming dependent on staff for multiple ADLs, including upper body dressing, rolling, transferring, and wheelchair mobility. Despite this decline, the medical record did not show that an SCSA was completed after the change in the resident's condition. During an interview, consulting staff acknowledged that after a fall with injury, the IDT believed the decline would be self-limiting. However, by the time of a later assessment, the resident had not improved and was no longer receiving therapy, with continued decline in more than two ADL areas. Staff confirmed that an SCSA should have been completed at that time, but it was not.
Failure to Refer for PASRR Level II Evaluation After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a Preadmission Screening and Resident Review (PASRR) Level II Evaluation after the identification of new mental health diagnoses. The resident was originally admitted with a diagnosis of Multiple Sclerosis and, at the time of admission, had no documented mental illness or disorder, resulting in a negative PASRR screening. However, subsequent diagnoses were made, including Adjustment Disorder, Depression, Anxiety Disorder, and Delusional Disorder, with the first new diagnosis appearing in May 2023 and the most recent in December 2024. Despite these new mental health diagnoses, there was no documented evidence in the resident's medical record that a PASRR Level II Evaluation was conducted or that a referral was made to the PASRR office as required. During an interview, the facility's social worker confirmed that a new PASRR should be completed and submitted whenever a new mental health diagnosis is identified, but the facility was unable to provide evidence that this process occurred for the resident in question.
Failure to Provide Timely Behavioral Health Services for Resident on Antidepressants
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident who had a diagnosis of depression and was prescribed antidepressant medications. The resident had consented to receive behavioral health services, as documented in the clinical record and care plan, and had expressed a willingness to speak with a therapist or counselor about increased feelings of sadness and loss of independence. Despite a request for behavioral health services being made and consent obtained, there was no evidence in the clinical record that the resident received any behavioral health services during their stay. Interviews with the resident confirmed ongoing symptoms of depression and a desire for additional support, while interviews with facility staff revealed that the process for referring the resident to behavioral health services was not completed as required. The consent form for behavioral health services was not properly sent to the psychiatric consultant, and there was a lack of follow-up to ensure the resident was seen. The facility's own audit later identified that the resident had not received the requested behavioral health services, but no evidence was found that services were provided prior to this discovery.
Medication Pass Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication pass error rate below five percent, as required, resulting in a 7.6% error rate during the survey. Specifically, two residents received incorrect medications during observed medication administration passes. One resident, with a history of Multiple Sclerosis and osteoporosis, was ordered to receive Calcium 1200 mg daily but was instead given Calcium + Vitamin D 600 mg/10 mcg, as this was the medication available in the cart. The nurse documented administration of the ordered medication despite giving a different product. Another resident, with diagnoses including metabolic encephalopathy and a colostomy, was ordered Senna-S (Sennosides-Docusate Sodium) 8.6 mg/50 mg for constipation but was administered Senokot 8.6 mg instead. The nurse again documented administration of the ordered medication, though the correct product was not given, citing unavailability of the prescribed medication. The Director of Nursing confirmed that only the medications prescribed by the provider should have been administered and that the nurse should have obtained the correct medications if unavailable.
Deficient Food Temperature and Texture During Breakfast Service
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature for one of its units, as required by its Meal Presentation/Refusal Policy. During a Resident Council meeting, three out of seven residents reported that breakfast items intended to be hot were served cold, with one specifically mentioning cold eggs. A test tray conducted by a surveyor, with participation from the unit manager, a nurse, and the MDS nurse, revealed that several breakfast items, including pureed scrambled eggs, oatmeal, pureed pancakes, and French toast casserole, were served at temperatures significantly below the required 135 degrees Fahrenheit for hot foods. The eggs were also noted to have a gritty texture, and both the eggs and oatmeal were described as cool or cold to taste. Interviews with staff confirmed these findings, with the unit manager and nurse both stating that the eggs were cool, and the MDS nurse indicating that the eggs and oatmeal would need to be reheated. The Food Service Director acknowledged that all hot foods should have been served at 135 degrees Fahrenheit and that the pureed eggs should not have had a gritty texture. It was further revealed that the cook had added thickener to the eggs due to their thin consistency, which the Food Service Director explained was inappropriate for eggs as it alters their texture.
Inaccurate MDS Coding for Falls and Discharge Destinations
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents out of a sample of 24. For one resident with a diagnosis of Diabetes Mellitus, the MDS assessment was coded to indicate that the resident had experienced a fall with major injury since the prior assessment. However, both the resident and consulting staff confirmed through interviews that no such fall or injury had occurred, and a review of the clinical record did not show evidence of any fall with major injury during the relevant period. For another resident admitted with Atrial Flutter, the MDS assessment was inaccurately coded to reflect a discharge to a short-term general hospital. In contrast, the clinical nurse progress note documented that the resident was actually discharged home with medications and services. The MDS nurse confirmed in an interview that the discharge destination had been coded incorrectly on the MDS assessment. These inaccuracies resulted in assessments that did not accurately reflect the residents' actual health status and discharge locations.
Incomplete CNA Documentation for Resident Care
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who was at risk for pressure injuries and required assistance with bed mobility and Activities of Daily Living (ADLs). The Certified Nurse Aide (CNA) documentation for October 2024 was found to be incomplete, with numerous blank spaces in the Turning and Repositioning (T&R) Flowsheet, ADL Flowsheet for Bed Mobility, Preventative Skin Care, and Skin Observation tasks. These omissions occurred across various shifts, indicating a lack of proper documentation of the care provided to the resident. Interviews with CNAs, nurses, the Unit Manager, and the Director of Nursing (DON) confirmed that the documentation was expected to be completed by the end of each shift. The incomplete documentation gave the appearance that the resident did not receive the required care, as evidenced by the blank spaces in the records. The facility's policy on Charting and Documentation, revised in July 2017, required that all services provided to residents and any changes in their condition be documented, which was not adhered to in this case.
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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.
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Nursing homes near East Longmeadow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Care One At Redstone | 1.5 mi | ★★★★★ | 13 | 0 |
| East Longmeadow Skilled Nursing Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Julian J Levitt Family Nursing Home | 2.6 mi | ★★★★★ | 0 | 0 |
| Sixteen Acres Health And Rehabilitation Center Llc | 2.8 mi | ★★★★★ | 10 | 0 |
| Vantage At Hampden Llc | 3.3 mi | ★★★★★ | 0 | 0 |
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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.