Chestnut Ridge Retirement Living.

“A resident's bedroom had a strong odor of urine, failing to maintain sanitary conditions as required.”

“A resident admitted to the Secure Dementia Care Unit did not have an initial support plan completed within 72 hours of admission as required.”

“Staff person A repeatedly cursed at and verbally abused a resident who had an accident while trying to reach the bathroom, telling the resident to 'get the out of here' when the resident tried to explain they were experiencing diarrhea. This violated the requirement that residents be treated with dignity and respect.”

“Resident #2 waited 41 minutes (between 21:01 and 21:42) for staff to respond to the call bell. On 11/16/25, Resident #3 waited 39 minutes (06:16 to 06:55) and on 11/17/25, Resident #2 waited 61 minutes (21:04 to 22:05) for call bell response. Staffing was insufficient to meet the needs of residents and respond to call bells within acceptable timeframes.”

“Three bedside mobility devices were found to be non-compliant: Resident #4's device had an uncovered opening measuring 12 by 6 inches, exceeding FDA guideline limits; Resident #5's device used a non-compliant wood plank under mattress creating entrapment zones; and Resident #6's device was not securely attached to bed frame and was loose.”

“Soiled sheets were observed in a bag inside Resident #7's bedroom, causing a foul odor and creating unsanitary conditions in the resident's room.”

“Resident #6 did not have access to a source of light that could be turned on or off at bedside, violating the requirement that each resident have an operable lamp or other bedside lighting source.”

“Staff member engaged in a tug of war with a resident over a call bell pendant, which struck the resident in the right eye causing a cut and bruising. The facility failed to report this incident to the Department within the required 24-hour timeframe.”

“A resident prescribed sublingual medication every 4 hours as needed did not have the medication available in the home. The medication was pulled from the cart by a pharmacy consultant because it was nearing expiration, but no replacement was ordered.”

“A resident-home contract was not signed by the resident as required by regulation. The facility failed to obtain the resident's signature on their contract.”

“A resident in the secured dementia care unit with a requirement for 24-hour supervision exited the building through the main entrance and was found at the end of the parking lot seeking a ride. The resident has documented exit-seeking behaviors that were not reflected in their assessment and support plan, and the main entrance door security was not properly maintained.”

“Four staff members obtained CPR/First Aid certifications from training sources that are not certified as trainers by a hospital or other recognized health care organization. Staff person C, D, and E obtained certifications from American CPR Care Association or similar non-approved sources; Staff person F obtained certification from National CPR Foundation.”

“Direct care staff person B received zero hours of annual training in training year 2024, failing to meet the minimum requirement of 12 hours of annual training relating to job duties.”

“The administrator does not maintain a current list of the names, addresses and telephone numbers of staff persons including substitute personnel and volunteers.”

“Direct care staff person C provided unsupervised ADL services without completing and passing the Department-approved direct care training course and competency test.”

“Direct care staff person D received only 5 hours of annual training, failing to meet the required minimum of 12 hours of annual training relating to job duties.”

“The 5th floor assignment book containing resident names and room numbers with laundry and shower details was unlocked, unattended, and accessible to unauthorized personnel, violating resident record confidentiality requirements.”

“Contracted painters were working in the building unsupervised without completed criminal background checks in accordance with the Older Adult Protective Services Act and 6 Pa. Code Chapter 15.”

“Staff person B did not receive required first-day fire safety and emergency preparedness orientation covering evacuation procedures, staff duties and responsibilities during emergencies, designated meeting places, smoking safety procedures, fire extinguisher use, smoke detectors and fire alarms, and emergency services notification.”

“Staff person B did not complete training in emergency medical plan within 40 scheduled working hours as required.”

“Facility failed to report a serious incident (resident fall with head and face injuries) to the Department within 24 hours. The incident occurred on 4/29/2025 but was not reported until 5/1/2025.”

“Resident confidential records were unlocked, unattended, and accessible in common areas. At 9:32 AM on the 7th floor, resident information was displayed on an open laptop on a medication cart. At 9:42 AM on the 6th floor, resident care assignment sheets were observed on a table in the common living/television room.”

“Resident 1's assessment and support plan dated 9/4/2024 indicated the resident required assistance with being escorted and taken to meals and activities. On 4/29/2025, the resident did not receive this required assistance and suffered a fall down concrete steps causing severe head and face injuries.”

“Resident was discharged from hospital with order to discontinue a medication, but the home failed to discontinue it timely. The incident was not reported to the Department within 24 hours as required.”

“Resident's night time medications were not administered. Staff person stated the resident refused, but staff did not place the medication in the resident's hand, mouth, or other route as ordered by the prescriber, despite the resident requiring assistance with medications.”

“Resident was not administered scheduled medications at 8:00 pm, but staff person signed the medication record falsely indicating the medication was administered.”

“Resident refused to take scheduled medications at 8:00 pm, but the home did not document the refusal in the resident's record and medication record, and did not report the refusal to the prescriber within 24 hours.”

“Resident was prescribed to repeat thyroid function testing in 6 weeks post-discharge from hospitalization, but the facility did not follow this prescribed order. Additionally, resident was discharged with order to discontinue a medication, but the home continued administering it until a later date.”

“Resident was discharged with order to stop one medication and start others, but the home continued administering the discontinued medication for an extended period. The medication error was not immediately reported to the resident, the resident's designated person, and the prescriber.”

“Resident was discharged with order to stop one medication and start others, but the home continued administering the discontinued medication. There is no documentation of the medication error in the resident's record.”

“Staff person B did not receive required first-day orientation on fire safety and emergency preparedness topics including evacuation procedures, staff duties during emergencies, designated meeting places, smoking safety procedures, fire extinguisher location and use, smoke detectors and fire alarms, and telephone emergency procedures.”

“The administrator completed only 21 hours of Department-approved training in 2024, failing to meet the required 24 hours of annual training.”

“Staff person A, hired less than 2 years after moving to Pennsylvania, did not have a completed FBI criminal background check as of the inspection date.”

“Staff person B did not complete required 40-hour orientation training on resident rights, emergency medical plan, mandatory reporting of abuse and neglect under the Older Adult Protective Services Act, and reporting of reportable incidents and conditions.”

“The facility did not display required influenza information in a public place as mandated by the Influenza Awareness Act (NH 1785) of 2016.”

“Staff person A's criminal background check was requested and disseminated in 2018, predating their hire date. Staff person B's criminal background check was not requested until 01/13/2025, after their hire date of 2024.”

“Direct care staff persons B and C do not have a high school diploma from the United States, GED, or active registry status on the Pennsylvania nurse aide registry, and therefore do not meet the educational qualifications required for direct care staff.”

“Staff person B, hired in 2024, was not included on the current staff list maintained by the administrator.”

“No Carbon Monoxide detector was present in the kitchen which uses gas appliances, in violation of the Care Facility Carbon Monoxide Alarms Standards Act of June 23, 2016, which requires detectors to be installed within 15 feet of any fossil-fuel burning device or appliance.”

“A criminal background check was not requested for staff person A prior to employment. This is a repeat violation from previous inspections on 4/8/24, 7/10/24, and 8/20/24.”

“On 11/10/2024 and 11/23/2024, with 85 residents including 30 with mobility needs, the facility required a minimum of 115 hours of direct care staffing but only provided 97.5 hours, failing to meet the requirement of at least 2 hours per day of personal care services for each resident with mobility needs.”

“On 11/10/2024 and 11/23/2024, with 85 residents present, no staff persons were present in the home who were certified in first aid, obstructed airway techniques, and CPR, failing to meet the requirement of at least one staff person for every 50 residents with these certifications present at all times.”

“Prior to or during the first work day, all direct care staff persons including ancillary staff persons, substitute personnel and volunteers did not receive an orientation in general fire safety and emergency preparedness that includes evacuation procedures and staff duties and responsibilities during fire drills and emergency evacuations.”

“Plan of correction submitted for September 9, 2024 inspection was not fully implemented as of follow-up reviews on October 8, 2024 and November 8, 2024.”

“Poisonous materials including hand sanitizer, coco butter, mouthwash, deodorant, anti-perspirant, dry skin treatment, disinfectant wipes, laundry detergent, and disinfection spray were unlocked, unattended, and accessible to residents in multiple locations (5th floor kitchen, room 503, room 417) despite residents in the Secure Dementia Care Units not being assessed as capable of safely recognizing and using poisons.”

“A resident's glucometer was used to take another resident's blood glucose readings on multiple dates (10/8/2024, 10/9/2024, and 10/10/2024), violating sanitary conditions requirements.”

“A Dimplex fireplace portable space heater was observed in resident room 417, in violation of the prohibition on portable space heaters.”

“Medline anti-fungal powder, Day-quil cold and flu, Prolinc callus remover, and Blue Star medicated ointment were unlocked, unattended, and accessible in multiple resident rooms, violating requirements that prescription and OTC medications be kept in locked containers.”

“Multiple OTC medications (Medline remedy anti-fungal powder, Day-quil cold and flu, Prolinc callus remover, and Blue Star medicated ointment) belonging to residents were not labeled with the resident's name.”

“Multiple glucometers were not calibrated to the correct date and time, with readings showing dates and times that did not match the actual times measurements were taken (ranging from one day off to several hours discrepancy).”

“Computer on 7th floor medication cart housing residents' medication records and personal information was unlocked, unattended, and accessible to residents, staff and visitors. This is a repeat violation.”

“A loaded handgun and marijuana were found in a resident's closet in a backpack belonging to Staff Member B. Staff Member B stated they brought the weapon for protection while attending a party after their shift. The resident did not know the backpack was in the closet. Staff Member B was arrested and terminated.”

“Criminal background check for Staff Member B was returned with "request under review" status and was never followed up on until an incident occurred at the facility. A second background check also came back as "request under review." It is unclear if Staff Member B has a criminal record. This is a repeat violation.”

“The ceiling in the common living room outside of the main elevators on the 8th floor was in disrepair from a leak with peeling paint and water spots observed.”

“The door to a bathroom in the hallway where the physical therapy room is located was unable to shut properly or lock. This bathroom is available for use by residents, visitors and staff members.”

“Medication cards were observed with punctured blister foil with medication still present in the spots, exposing medications to contamination or improper sanitation. Resident #2 had multiple affected medication blister packs. This is a repeat violation.”

“Alleged abuse incident where staff member sprayed Lysol on resident's face twice was not reported by the home in accordance with the Older Adult Protective Services Act and 6 Pa. Code § 15.21-15.27, despite being reported internally to supervisors and Director of Nursing.”

“The home did not follow written policies and procedures on the reporting, notification, and investigation of an incident of abuse reported by a resident to staff on 4/6/2024 at approximately 9:00 am.”

“Violation of 55 Pa Code § 2600.82 (Class II) cited during inspections conducted April 8 and May 8, 2024, July 10 and 11, 2024, and August 5, 2024.”

“Violation of 55 Pa Code § 2600.185 (Class II) cited during inspections conducted April 8 and May 8, 2024, July 10 and 11, 2024, and August 5, 2024.”

“The home did not follow written policies and procedures on the reporting, notification, and investigation of an incident of abuse reported by a resident to staff on 4/6/2024 at approximately 9:00 am.”

“Violation of 55 Pa Code § 2600.82 (Class II) cited during inspections conducted April 8 and May 8, 2024, July 10 and 11, 2024, and August 5, 2024.”

“Violation of 55 Pa Code § 2600.185 (Class II) cited during inspections conducted April 8 and May 8, 2024, July 10 and 11, 2024, and August 5, 2024.”

“Alleged abuse incident where staff member sprayed Lysol on resident's face twice was not reported by the home in accordance with the Older Adult Protective Services Act and 6 Pa. Code § 15.21-15.27, despite being reported internally to supervisors and Director of Nursing.”

“Alleged abuse incident where staff member sprayed Lysol on resident's face twice was not reported by the home in accordance with the Older Adult Protective Services Act and 6 Pa. Code § 15.21-15.27, despite being reported internally to supervisors and Director of Nursing.”

“The home did not follow written policies and procedures on the reporting, notification, and investigation of an incident of abuse reported by a resident to staff on 4/6/2024 at approximately 9:00 am.”

“Violation of 55 Pa Code § 2600.82 (Class II) cited during inspections conducted April 8 and May 8, 2024, July 10 and 11, 2024, and August 5, 2024.”

“Violation of 55 Pa Code § 2600.185 (Class II) cited during inspections conducted April 8 and May 8, 2024, July 10 and 11, 2024, and August 5, 2024.”

“The first aid kit in the fourth floor nursing station did not include antiseptic, breathing shield, eye coverings, or scissors as required.”

“The home did not provide a preadmission screening form for a resident. This is a repeat violation from 01/30/2023 and 12/14/2023.”

“A resident was admitted to the Secure Dementia Care Unit without a written cognitive preadmission screening completed within 72 hours prior to admission as required.”

“Two direct care staff persons working in the Secure Dementia Care Unit did not receive the required 6 hours of annual dementia care training. Staff person A received only 1 hour and staff person B received 3 hours of dementia care training.”

“Purell hand sanitizer dispensers with poison warnings were mounted and accessible in the fourth-floor common kitchenette and a resident room of the Secure Dementia Care Unit. A spray bottle of Lysol all-purpose cleaner with poison control warning was unattended and accessible in a resident bathroom shower. Residents in the memory care unit are diagnosed with dementia and assessed as unable to safely use or avoid poisons.”

“The facility did not provide complete resident and staff records to a Department representative upon request. The administrator initially provided only partial resident files (contract, pre-screen, DME, RASP) and incomplete staff files (only background checks, certifications, and DHS certification) when training records and disciplinary actions were requested. Complete files were not provided before the licensing representative left the facility.”

“The home suspended staff persons C and D following an abuse allegation but allowed staff person D to return to work before the Department completed its investigation, without implementing a supervision plan.”

“A reportable incident involving a restrained resident in the memory care unit was not reported to the Department within 24 hours. The incident was discovered, photographed, and reported internally through multiple staff members, but the Director of Health and Wellness did not see the pictures until returning to work, causing a delay in reporting to the Department. This was a repeat violation from 02/09/23.”

“A resident did not have a resident-home contract completed within 24 hours of admission. The resident's contract was not completed until after an audit discovered the omission, although the resident's admission date could not be verified during the investigation.”