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 June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chesterwood Atc during CMS and state inspections, most recent first.
The facility failed to manage a COVID-19 outbreak effectively by not posting outbreak signage at entrances and delaying notification to the local health department. Additionally, several staff members were not fit-tested for N95 masks, despite working with COVID-19 positive residents. These deficiencies affected the facility's ability to control the outbreak and protect its 113 residents.
A facility failed to refer a resident with a new mental disorder diagnosis to the appropriate state authority, affecting PASARR compliance. The resident had multiple mental health diagnoses, including psychosis, which was overlooked in PASARR screenings. Staff interviews revealed a lack of knowledge and oversight in the PASARR process.
A facility failed to ensure accurate PASARR screenings for a resident with mental disorders, including psychosis, depression, and PTSD. The screenings did not reflect the resident's psychotic disorder, despite it being an active diagnosis. Interviews revealed a lack of knowledge and responsibility among staff regarding the PASARR process.
Two residents in an LTC facility were found with unclean and untrimmed fingernails, despite requiring assistance with personal hygiene. One resident with severe cognitive impairment and another with moderate impairment expressed the need for nail care, which was not provided. Staff interviews confirmed the importance of nail hygiene for infection control, yet the facility failed to adhere to its policies, resulting in the deficiency.
A facility failed to maintain communication with a dialysis center for a resident with end-stage renal disease, resulting in missing communication forms over several months. Despite the resident's intact cognition, staff interviews revealed inconsistencies in the communication process, with the DON acknowledging the lack of follow-up when forms were not received. The facility's policy and agreement with the dialysis center required ongoing monitoring and coordination, which was not adhered to, leading to a deficiency.
A facility failed to maintain accurate records for a resident's dialysis access site, with assessments inconsistently documenting the location. The resident, with end-stage renal disease, confirmed their access was in the arm, while records varied. Interviews with staff and the resident highlighted these discrepancies, contrary to the facility's policy for accurate medical records.
A resident with osteomyelitis and peripheral vascular disease experienced a delay in receiving pain medication due to staffing issues. Despite orders for oxycodone and acetaminophen, the resident did not receive timely pain relief, with a significant delay between doses. Staff interviews revealed inadequate staffing as a contributing factor, with a nurse not showing up and another leaving after training. The facility's pain management policy was not followed, leading to the deficiency.
Inadequate COVID-19 Outbreak Management and N95 Fit Testing
Penalty
Summary
The facility failed to implement its infection prevention and control program effectively during a COVID-19 outbreak. Specifically, the facility did not post outbreak signage at entrances to alert visitors of the presence of COVID-positive residents. This oversight occurred despite the facility's policy that required such signage when a single positive case was identified. Interviews with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed a lack of clarity and communication regarding the notification of the local health department about the outbreak. The local health department was not informed of the positive COVID-19 test result within the required timeframe, which was by the end of the following business day. Additionally, the facility did not ensure that all staff were fit-tested for N95 masks, which are essential for protecting against COVID-19 transmission. Several staff members, including nurse aides and registered nurses, reported that they had not been fit-tested for N95 masks, even though they were required to wear them while working with COVID-19 positive residents. The ADON and the Administrator were unaware that some staff had not been fit-tested, despite the facility's policy requiring fit testing upon hire and annually. The facility's failure to adhere to its infection control policies and procedures, including timely notification of the health department and ensuring staff were fit-tested for N95 masks, had the potential to affect all 113 residents. The lack of outbreak signage and delayed communication with the health department, combined with inadequate fit testing, demonstrated significant lapses in the facility's infection control practices during the COVID-19 outbreak.
Failure to Refer Resident for Mental Health Review
Penalty
Summary
The facility failed to refer a resident to the appropriate state-designated mental health or intellectual disability authority when the resident received a new diagnosis of a mental disorder. This deficiency affected one resident who was reviewed for Preadmission Screening and Resident Review (PASARR) requirements. The resident, admitted on March 6, 2024, had a medical history that included unspecified psychosis, major depressive disorder, PTSD, conversion disorder with motor symptom or deficit, and disassociation and conversion disorder. Despite these diagnoses, the PASARR screenings conducted on March 7, 2024, and February 11, 2025, did not indicate the presence of a psychotic disorder. Interviews with facility staff revealed gaps in the PASARR process. The Licensed Social Worker (LSW) responsible for tracking PASARR screenings acknowledged that the diagnosis of psychosis, added on July 19, 2024, was overlooked during the significant change PASARR screening. The Director of Nursing and the Administrator were not knowledgeable about the PASARR screenings or their completion process. The facility's policy required a Resident Review for individuals experiencing a significant change of condition, but this was not properly executed in this case.
Inaccurate PASARR Screening for Resident with Mental Disorders
Penalty
Summary
The facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASARR) for a resident with a history of mental disorders. The resident was admitted with diagnoses including unspecified psychosis, major depressive disorder, PTSD, conversion disorder with motor symptom or deficit, and disassociation and conversion disorder. The PASARR screenings conducted on two separate occasions did not accurately reflect the resident's diagnosis of psychotic disorder, despite the resident having active diagnoses of depression, psychotic disorder, and PTSD as per the Minimum Data Set (MDS) assessment. Interviews with facility staff revealed a lack of knowledge and responsibility regarding the PASARR process. The Licensed Social Worker (LSW) responsible for tracking PASARR screenings acknowledged the oversight but did not provide a clear explanation for the discrepancy. The Director of Nursing and the Administrator both deferred to the social worker, indicating a lack of involvement or understanding of the PASARR process. The facility's policy on PASARR screenings, revised in 2016, outlines the requirements for resident reviews, but it appears these were not adequately followed in this case.
Failure to Maintain Residents' Nail Hygiene
Penalty
Summary
The facility failed to ensure that residents' fingernails were clean and trimmed, affecting two residents. Resident #18, who has severe cognitive impairment due to Alzheimer's disease and dementia, was observed multiple times with dirty fingernails. Despite requiring substantial assistance for personal hygiene, staff interviews revealed that Resident #18 did not refuse nail care, yet their fingernails remained unclean over several days. Staff members, including nurse aides and licensed practical nurses, acknowledged the importance of maintaining clean nails for infection control but were unaware of the resident's ongoing issue. Resident #55, with moderate cognitive impairment and a history of atherosclerotic heart disease and diabetes, also had long and dirty fingernails. The resident expressed a desire for their nails to be cleaned and trimmed, stating that they had requested this from staff but it was not done. Observations confirmed the presence of a brown substance under the nails, and staff interviews indicated that nail care should be part of the routine hygiene provided during baths. Despite this, the resident's nails remained unclean, highlighting a lapse in the facility's adherence to its own policies regarding personal hygiene care. The facility's policy on Activities of Daily Living (ADL) care specifies that staff should ensure residents receive necessary services to maintain grooming and personal hygiene. The job description for nurse aides also includes responsibilities for ensuring nails are clean and manicured. However, the observations and interviews indicate a failure to consistently implement these policies, resulting in the deficiency noted in the report.
Failure to Maintain Communication with Dialysis Center
Penalty
Summary
The facility failed to maintain ongoing communication with a dialysis center for a resident requiring dialysis services. The resident, who had a medical history of end-stage renal disease, major depressive disorder, and essential hypertension, was admitted to the facility and required hemodialysis three times a week. Despite the resident's intact cognition, as indicated by a BIMS score of 15, there was a lack of communication forms sent to or received from the dialysis center over several months, as evidenced by missing communication sheets in the resident's medical record. Interviews with facility staff, including the Licensed Social Worker, Director of Nursing (DON), and Licensed Practical Nurse (LPN), revealed inconsistencies in the communication process. The DON acknowledged that the dialysis center typically sent communication forms via fax, but there was no follow-up when forms were not received. The LPN admitted to not sending or receiving communication forms and was unaware of the need to follow up with the dialysis center. The Administrator confirmed that some communication forms were missing and stated that the facility policy required communication with the dialysis center only as needed. The facility's policy on hemodialysis coordination and resident monitoring emphasized the need for ongoing monitoring and coordination with the dialysis center and physicians. However, the Memorandum of Agreement with the dialysis center outlined specific responsibilities for both parties, including the need for assessments and communication prior to each dialysis session. The lack of adherence to these protocols resulted in a deficiency in maintaining proper communication and coordination for the resident's dialysis care.
Inaccurate Dialysis Access Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident undergoing dialysis, as evidenced by discrepancies in the documentation of the dialysis access site. The resident, who was admitted with a history of end-stage renal disease, major depressive disorder, and essential hypertension, had a series of dialysis assessments that inconsistently recorded the location of the hemodialysis access. These assessments varied, indicating the access site as being in different quadrants and extremities, which was not consistent with the resident's actual condition. Interviews with the resident and staff further highlighted the inaccuracies in the documentation. The resident confirmed that their current dialysis access site was in their arm, contrary to the records. An LPN corroborated this by stating the access site was on the resident's left arm. The Director of Nursing admitted to being unfamiliar with the resident's access site, despite the facility's policy requiring accurate and complete medical records. This deficiency in documentation was identified through a review of the facility's policy, which mandates that medical records should accurately reflect the resident's experience and care status.
Failure to Administer Pain Medication Promptly Due to Staffing Issues
Penalty
Summary
The facility failed to ensure prompt administration of pain medication for a resident with a history of osteomyelitis and peripheral vascular disease. The resident, who had intact cognition, frequently experienced severe pain, rating it at an 8 out of 10 during a five-day period. Despite having orders for oxycodone and acetaminophen to manage pain, the resident reported not receiving pain medication as ordered on the evening of 02/08/25. The medication administration record confirmed a significant delay in administering oxycodone, with a gap of over seven hours between doses, despite the resident requesting pain relief. Interviews with staff revealed that the delay was due to inadequate staffing, as a nurse did not show up for their shift, and another nurse left after two days of training. The LPN responsible for administering narcotics was overwhelmed, covering multiple units, and could not promptly respond to the resident's needs. The Assistant Director of Nursing acknowledged the staffing issues and emphasized the responsibility of nurses to administer PRN medications. The facility's pain management policy required timely administration and assessment of pain relief, which was not adhered to in this instance.
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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.
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Nursing homes near West Chester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritagespring Healthcare Center Of West Chester | 1.3 mi | ★★★★★ | 3 | 1 |
| Mcv Health Care Facilities, Inc | 2 mi | ★★★★★ | 2 | 0 |
| Majestic Care Of Cedar Village. | 2.4 mi | ★★★★★ | 4 | 0 |
| Mason Health Care Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Brookwood Care Center | 4.1 mi | ★★★★★ | 16 | 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 June 2026) and official state health department websites.