Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chestnut Park Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Incomplete controlled substance count documentation was identified when narcotic shift count sheets on multiple nursing units did not consistently show signatures from both the off-going and oncoming nurse. Facility policy required two licensed nurses to count and reconcile narcotics at each shift change, and staff interviews confirmed that signatures were expected, but documentation was missing and one LPN attempted to obtain back-signatures for prior shifts.
Infection control was not maintained when an LPN changed a resident’s wound dressing without gloves and without handwashing, despite the wound care policy requiring both. The facility also had rooms on transmission-based precautions with missing or insufficient signage and no readily available PPE carts, even though staff and the DON stated signage and supplies should be visible and accessible.
Medication Therapy policy did not include time frames for the monthly drug regimen review process. The policy said the Consultant Pharmacist would review each resident's medication regimen monthly or as requested, and that the Medical Director and Consultant Pharmacist would collaborate with practitioners and staff, but it did not specify timing for each step. The DON agreed time frames should have been included and did not know why they were omitted.
Food service safety standards were not followed when the dishwashing machine operated outside the manufacturer's water pressure instructions, the facility lacked a test kit capable of verifying sanitizer concentration above 400 ppm, and a wooden block-style knife rack was used for knife storage. Surveyors also observed a leaking drainpipe under the 3-compartment sink and multiple soiled surfaces and items, including the can opener holder, fire extinguishers, floors, mop bucket and wringer, and kitchenette cabinets.
Improper Disposal and Maintenance of Dumpster: The facility did not ensure garbage and refuse were disposed of properly. During observation, the right dumpster was heavily soiled below the side door, was missing a drain hole plug, and was not rodent proof. An Assistant Food Service Manager stated they would speak with maintenance about having the dumpster cleaned and a drain hole plug installed.
Care plans were not reviewed and revised by the IDT for two residents. One resident’s anticoagulant care plan stayed active after Plavix was discontinued, and another resident’s care plan did not include constipation despite ongoing bowel issues, physician-noted stool burden, and multiple bowel medications/orders. The DON acknowledged the missing constipation focus and the outdated anticoagulant plan.
Unlabeled food brought in for residents was found in the North Wing kitchenette, including deli chicken salad and two homemade sandwiches. An ASM stated the sandwiches were likely for a resident and that brought-in food should be labeled with the resident name and date, but there was no documented policy for labeling such food or for staff assistance with accessing and consuming it when needed.
Two residents with cognitive impairment and a history of frequent falls were not provided with adequate supervision or effective interventions to prevent accidents. One resident experienced multiple unwitnessed falls and was found unresponsive and hypothermic after a fall, later dying in the hospital. Another resident with Parkinson's disease had numerous unwitnessed falls and a wrist fracture, with care plans lacking active interventions and no evidence of increased monitoring. Staff interviews confirmed the absence of formal rounding protocols or additional training, despite facility policies requiring aggressive monitoring for high-risk individuals.
A resident with a history of dementia and respiratory issues did not receive appropriate respiratory care, including consistent monitoring and documentation of nebulizer treatments as ordered by the physician. Nursing staff failed to stay with the resident during treatments, did not document vital signs or treatment effectiveness, and did not communicate significant changes to the provider. The resident's condition deteriorated, resulting in hospitalization for pneumonia and acute hypoxic respiratory failure, and ultimately death.
A resident with severe cognitive impairment and a history of falls was found unresponsive and hypothermic on the floor next to their bed. Staff were unable to obtain vital signs, and the resident was left for an unknown period without care. The facility did not conduct a thorough investigation into the circumstances, failed to reconcile discrepancies in documentation, and did not interview the resident's roommate who may have had relevant information.
Two residents with cognitive impairment and a history of multiple unwitnessed falls did not have comprehensive, person-centered care plans with measurable objectives and timeframes. Despite repeated falls, interventions remained unchanged or were discontinued, and there was no evidence of ongoing monitoring or revision of fall prevention strategies. Staff interviews confirmed a lack of formal protocols for increased monitoring or interdisciplinary review in response to continued falls.
A resident with dementia was involved in an incident where a nurse forcefully moved them after a fall without assessing for injuries, violating their right to be free from abuse and neglect. The incident was captured on video and reported by a CNA, leading to the nurse's termination. The facility's investigation confirmed the abuse, highlighting a significant lapse in resident protection.
Incomplete Controlled Substance Count Documentation
Penalty
Summary
The facility did not ensure it maintained an accurate system for controlled drugs because nursing unit narcotic counts were not consistently documented as being completed by two licensed staff members and signed on the narcotic record sheets. The facility policy required all narcotics to be counted and reconciled at the beginning of every shift by the outgoing and oncoming nurse, with both staff members signing the controlled substance log to attest to the count. Review of the Narcotic and Controlled Substance Shift Count Sheets for the first-floor nursing unit, North side, showed missing signatures on multiple date ranges, and the South side sheet also had inconsistent documentation of the off-going and oncoming nurse signatures. During interviews, an LPN stated the sheets were supposed to be signed by two licensed nurses and attempted to have another LPN sign prior shift sheets, but that LPN refused because they were in training on the days in question. Another LPN stated the outgoing nurse counted, the oncoming nurse wrote the count, and both signed together. The DON stated both oncoming and off-going nurses needed to sign to ensure the count was complete and accurate and said they would not ask someone to back sign narcotic sheets.
Infection Control Program Not Maintained
Penalty
Summary
The facility did not maintain an infection control program in accordance with professional standards of care. For Resident #7, who was admitted with iron deficiency anemia, a pressure ulcer of the left buttock, and peripheral vascular disease, and whose MDS dated 8/19/2025 documented moderate cognitive impairment, an LPN removed a dressing from the right lateral ankle and replaced it without wearing gloves during an observation on 9/25/2025 at 1:43 PM. The LPN also did not wash hands during the observed dressing change. The facility policy titled Wound Care dated 1/2025 stated hands should be washed and dried before and after a dressing change, and gloves should be worn. During interview, the LPN verbalized the steps to changing a wound dressing and did not include handwashing as part of the process. The facility also did not ensure signage and supplies for transmission-based precautions were readily available and visible. During observations, a room had a PPE cart outside the door without signage, and two other rooms had enhanced barrier precaution signs on the doors but no readily available carts containing PPE. Staff interviews indicated signage should be visible and PPE carts should be available for rooms on transmission-based precautions. The DON stated appropriate signage should always be posted on each room under transmission-based precautions and supplies should be available, with extra carts and supplies stored in the conference room and accessible through unit managers and supervisors.
Medication Therapy Policy Lacked Required Time Frames
Penalty
Summary
The facility did not ensure development of policies and procedures for the monthly drug regimen review that included time frames for the different steps in the process. The facility policy titled Medication Therapy, reviewed in 01/2025, stated that the Consultant Pharmacist would review each resident's medication regimen monthly, as requested by staff or a practitioner, or when a clinically significant adverse consequence was confirmed or suspected, and that the Medical Director and Consultant Pharmacist would collaborate to address issues of medication prescribing and monitoring with practitioners and staff. However, the policy did not identify time frames for each step in the process. During an interview, the DON agreed there should be time frames for each step of the medication review process and did not know why the policy did not include them.
Food Service Sanitation and Equipment Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, or served in accordance with professional standards for food service safety. During observation, the automatic dishwashing machine final rinse measured 197 degrees Fahrenheit at 7 pounds per square inch of water pressure, while the machine's data plate stated that water pressure should be between 15 and 25 pounds per square inch. The facility also did not have a chemical test kit with graduations above 400 parts per million, even though the sanitizer concentrate bottle label stated that sanitizing food contact surfaces required a dilution between 200 and 400 parts per million. Additional observations showed a wooden block-style knife rack that could not be disassembled being used for knife storage. The drainpipe below the three-compartment sink was leaking. Surfaces and equipment were soiled with food particles, grime, or dirt, including the can opener holder, fire extinguishers, the floor under the dishwashing machine, the floor right of the stove, the dry storage area floor, and the mop bucket and wringer. The North Wing kitchenette cabinets and South Wing kitchenette cabinets were also soiled with food particles.
Improper Disposal and Maintenance of Dumpster
Penalty
Summary
The facility did not ensure garbage and refuse was disposed of properly. During observation on 09/21/2025 at 12:02 PM, the right dumpster was heavily soiled below the side door, was missing a drain hole plug, and was not rodent proof. During interview on 09/21/2025 at 12:07 PM, the Assistant Food Service Manager stated that they would speak with the maintenance department about having the dumpster cleaned and a drain hole plug installed.
Care Plans Not Updated for Medication Change and Constipation
Penalty
Summary
The facility did not ensure Comprehensive Care Plans were reviewed and revised by the interdisciplinary team after assessments and changes in resident needs for two residents. The facility policy stated care plans were to be revised when a resident’s condition changed, when the desired outcome was not met, when the resident returned from a hospital stay, and at least quarterly with the MDS assessment. During the recertification survey, surveyors found that one resident admitted with cerebral infarction, COPD, and peripheral vascular disease had a Comprehensive Care Plan for anticoagulant use that remained active even though Plavix had been discontinued in 05/2023. The resident’s 7/13/2025 MDS documented the resident was cognitively intact and able to understand and be understood. The DON stated the care plan should not have remained active if the resident was no longer on the medication. Surveyors also found that another resident admitted with bilateral primary osteoarthritis of the knee, type 2 diabetes, and morbid obesity had physician-noted constipation with ongoing bowel issues, stool burden on KUB, and orders for Senna, Colace, MiraLax, manual disimpaction, fleet enema, and bisacodyl suppository. The resident was observed crying out in bed and stated they were in severe pain because they had not had a bowel movement in several days. Although the resident had a Comprehensive Care Plan for bowel incontinence and anxiety related to bowels, there was no documented evidence that the care plan was updated to include constipation or the constipation-related treatments and orders. The DON reviewed the care plan and acknowledged there was no care plan related to constipation or the medications used for constipation.
Unlabeled Food Brought in for Residents
Penalty
Summary
The facility failed to ensure food brought to residents by family or visitors was stored safely and kept separate or easily distinguishable from facility food on one of two resident units. During observation of the North Wing kitchenette, deli chicken salad was found without a resident name label, and two homemade sandwiches were also unlabeled. During interview, the Assistant Food Service Manager stated the homemade sandwiches were likely for a resident and that food brought to residents should be labeled with the resident name and dated. The record review found no documented policy requiring food brought in for residents to be dated and labeled with the resident name, and no documented policy requiring staff to assist residents in accessing and consuming brought-in food if the resident could not do so independently.
Failure to Prevent Falls and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of effective interventions to prevent accidents and falls for two residents with cognitive impairment and a history of frequent falls. One resident with severe dementia experienced five unwitnessed falls over a period of time, with the facility failing to update or modify care plan interventions after each incident. The interventions remained limited to environmental reminders, such as signage and call bell placement, despite the resident's known tendency to self-transfer and not use the call bell. Staff interviews confirmed that the resident was impulsive, required assistance with transfers, and was becoming increasingly weak, yet no new or enhanced interventions were documented or implemented following repeated falls. On one occasion, the resident was found unresponsive, unclothed, and cold on the floor of their room after an unwitnessed fall. The resident's body temperature was unmeasurable, oxygen saturation was critically low, and they were subsequently hospitalized with hypothermia, acute respiratory failure, and septic shock, ultimately resulting in death. Staff interviews revealed that the resident was not being monitored more frequently despite illness and a history of falls, and there was no formal protocol for increased checks or rounding for high-risk residents. Documentation showed that staff were not provided with additional training or guidance following the incident, and care plans were not revised to address the ongoing risk. A second resident with moderate cognitive impairment and Parkinson's disease sustained 30 falls, 20 of which were unwitnessed, over a documented period. The care plan lacked active interventions for transfer and ambulation status, and there was no evidence of monitoring the effectiveness of interventions or modifying them as necessary. Staff interviews indicated that there was no formal rounding protocol or increased monitoring for residents with repeated falls. The facility's own policies required aggressive monitoring and intervention for high-risk residents, but these were not followed, resulting in substandard quality of care and actual harm.
Removal Plan
- Reviewed fall care plans for residents identified as having a high risk for falls.
- Reviewed care Kardex for residents identified as having a high risk for falls.
- Educated staff on the systematic changes and policy review (accidents and incidents prevention, investigation, hourly checks, communicating to the emergency management system and hospital system).
- Educated all active employees on these systemic changes and policy reviews.
- Ensured no staff reported to active duty without having this education.
- Held a Quality Assurance Performance Improvement meeting.
- Educated Certified Nurse Aides, Licensed Practical Nurses, and Registered Nurses 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.
- Nursing staff verified 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.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, falls, and anxiety disorder, who was admitted with wheezing, did not receive safe and appropriate respiratory care as needed. The resident had physician orders for nebulizer treatments for shortness of breath or wheezing, but there was no comprehensive care plan developed for respiratory care, and interventions were not documented. The care plan for respiratory function was initiated and resolved on the same day without interventions, and documentation related to respiratory monitoring and effectiveness of treatments was lacking throughout the resident's stay. Multiple records, including 24-hour reports and medication administration records, showed that the resident's respiratory status was not consistently monitored as ordered by the physician. Nursing notes failed to document the effectiveness of nebulizer treatments or ongoing assessment of the resident's respiratory condition. Interviews with staff revealed that nurses often left the resident unattended during nebulizer treatments, did not always document vital signs or treatment effectiveness, and did not consistently communicate changes in the resident's condition to the physician. The Director of Nursing confirmed that while there was a policy for nebulizer administration, there was no specific policy for monitoring residents' conditions, and expectations for monitoring were not clearly defined or followed. The resident experienced worsening respiratory symptoms, including labored breathing, wheezing, and changes in mental status, which were not adequately assessed or reported. On the night of the incident, the resident was found unresponsive with a critically low oxygen saturation and was transferred to the hospital, where they were diagnosed with pneumonia, acute hypoxic respiratory failure, and septic shock, and subsequently died. Emergency services and hospital staff noted a lack of detailed information from the facility regarding in-facility respiratory care and monitoring prior to transfer.
Failure to Thoroughly Investigate Resident Accident and Change in Condition
Penalty
Summary
The facility failed to thoroughly investigate an accident involving one of four residents reviewed for accidents. On the night in question, a resident with severe cognitive impairment, a history of falls, and generalized anxiety disorder was found unresponsive on the floor next to their bed. The resident was only responsive to painful stimuli and exhibited uncontrollable shaking. Staff were unable to obtain vital signs, including body temperature, which was too low to be read by a thermometer. The resident was left for an undetermined amount of time without care, and there was no documentation of a thorough investigation to determine if abuse or neglect had occurred. Facility policy required that all accidents or incidents be investigated and reported, including details such as the date, time, nature of injury, circumstances, and the resident's condition. However, the investigation report did not address key factors such as the length of time the resident was on the floor or the cause of the resident's hypothermia. There were discrepancies between the physician's progress note and the nursing documentation, particularly regarding the resident's vital signs and mental status, which were not reconciled in the investigation. Additionally, the facility did not interview the resident's alert and oriented roommate, who may have provided relevant information about the incident. Interviews with staff revealed that critical information, such as the resident being found naked, cold, and shivering, was not communicated to the DON during the initial investigation. The hospital emergency department documented that the resident presented with hypothermia, tachycardia, tachypnea, and hypoxia, and the receiving nurse noted there was no plausible explanation provided for the hypothermia. The facility failed to conduct a comprehensive investigation as required by its own policies and regulatory requirements.
Failure to Develop and Implement Person-Centered Fall Prevention Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes to address the needs of two residents with a history of multiple unwitnessed falls related to self-ambulation. Despite documented policies requiring individualized interventions, ongoing monitoring, and evaluation of fall prevention strategies, the care plans for these residents lacked evidence of appropriate and updated interventions following repeated falls. Interventions were limited to environmental reminders, such as signage and call bells, without documented reassessment or modification in response to continued incidents. One resident with severe cognitive impairment, dementia, and a history of falls experienced five unwitnessed falls over a three-month period. The care plan interventions remained unchanged after each event, focusing only on encouraging call bell use and providing partial assistance, despite staff acknowledging the resident's reluctance to use the call bell. Interviews with staff and the physician confirmed the resident was a frequent faller and required frequent checks, but there was no documentation of increased monitoring or revised interventions in the care plan. Another resident with moderate cognitive impairment, Parkinson's disease, and a history of repeated falls experienced 30 falls, 20 of which were unwitnessed, over a two-year period. The care plan lacked active interventions for transfer or ambulation, and previously implemented strategies such as walker assistance and scheduled toileting had been discontinued without evidence of ongoing monitoring or revision. Staff interviews revealed there was no formal protocol for increased checks or monitoring for frequent fallers, and the interdisciplinary team did not consistently review or update interventions in response to continued falls.
Resident Abuse and Neglect Incident
Penalty
Summary
The facility failed to protect a resident from abuse and neglect, as evidenced by an incident involving a registered nurse and a resident with dementia. The resident, who had diagnoses of non-Alzheimer's dementia with behaviors, osteopenia, and adjustment disorder, was found urinating on the floor at the nurse's station. The registered nurse attempted to redirect the resident to their room, during which the resident became unsteady and fell. The nurse then forcefully lifted the resident by their left arm without assessing for injuries, which is a violation of the resident's right to be free from abuse and neglect. Video footage from the facility confirmed the incident, showing the nurse grabbing the resident from behind, causing them to fall, and then pulling them up by the arm. The nurse did not perform an assessment before moving the resident, which is a critical step in ensuring the resident's safety and well-being. The incident was witnessed by a certified nurse aide, who reported the suspected abuse to a licensed nurse, leading to the nurse's removal from the facility. The facility's investigation corroborated the certified nurse aide's report, and the nurse was subsequently terminated. The resident was assessed for injuries, and although no physical harm was found, the incident highlighted a significant lapse in the facility's duty to protect residents from abuse and neglect. The facility's failure to follow proper procedures and ensure the resident's safety resulted in a deficiency citation.
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Illustrative
What surveyors actually found near you
We read the 18 citations issued within 25 miles in the last 12 months — 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.
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Nursing homes near Oneonta
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aurelia Osborn Fox Memorial Hospital | 2.1 mi | ★★★★★ | 0 | 0 |
| Delhi Rehabilitation And Nursing Center | 15.3 mi | ★★★★★ | 0 | 0 |
| Cooperstown Center For Rehabilitation And Nursing | 16.4 mi | ★★★★★ | 0 | 0 |
| Chasehealth Rehab And Residential Care | 17.2 mi | ★★★★★ | 0 | 0 |
| Valley View Manor Nursing Home | 22.5 mi | ★★★★★ | 12 | 0 |
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