Chadwick Community Care Center

Inspectors wroteBased on record review, facility policy review and interviews, the facility failed to consult with the primary care provider regarding the psychosocial status of the resident which resulted in missed dialysis treatments for one (1) of three (3) residents dependent on dialysis treatments. Resident #1. Findings Included:Record review of the facility policy, Change in a Resident's Condition or Status revised February 2021 revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .1. The nurse will notify the resident's attending physician or physician on call when there has been .significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; [...]

Inspectors wroteBased on record review, facility policy review, and interview the facility failed to develop a person-centered comprehensive care plan to meet and address the resident's psychosocial needs for one (1) of four (4) sampled residents. Resident #1. Findings Included:Record review of the facility policy, Interdisciplinary Comprehensive Care Planning with effective date 6/02/16 revealed, The comprehensive care plan is an interdisciplinary communication tool It must include measurable objectives and time frames and must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The interdisciplinary team in conjunction with the resident and his/her family and/or responsible party as appropriate will develop, evaluate and amend as needed. [...]

Inspectors wroteBased on facility policy review, record review and interviews, the facility failed to provide the appropriate treatment and services to address known psychosocial concerns in order to attain the highest practicable mental and psychosocial well-being for one (1) of four (4) sampled residents. Resident #1. Findings Included:Record review of the facility policy, Behavioral Health Services with Revised Date February 2019 revealed, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care .Residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care. [...]

Inspectors wroteBased on observations, interviews, record review and facility policy review, the facility failed to consistently provide necessary activities of daily living (ADL) care, including daily oral hygiene, routine nail care, and regular shaving of facial hair for one (1) of (19) residents reviewed. Resident #78.

Inspectors wroteBased on observation, interviews, record reviews and facility policy review the facility failed to implement a comprehensive care plan related to Activities of Daily Living (ADL) and wound care for two (2) of six (6) care observations. Resident #60 and Resident #78. Findings Include: Record review of the facility policy Comprehensive Person Centered, revised 03/2022, revealed, A comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's physical, psychosocial, and functional needs is developed and implemented for each resident . Resident #60 Record review of Resident #60's Care Plan Report with a date initiated of 12/29/2025 revealed .Approaches/Tasks: Cleanse site with wound cleanser, pat dry, apply skin preparation and barrier cream, and cover with a dry dressing daily and as needed . [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to follow standards of practice during medication administration and wound care for two (2) of five (5) residents observed for medication administration and wound care. Residents #8 and #60. Findings Include: Record review of the facility policy Wound Care, revised 1/9/22, revealed The purpose of the procedure is to provide guidelines for the care of wounds to promote healing . Record review of the facility policy Administering Medications through an Enteral Tube, undated, revealed, General Guidelines. Administer each medication separately and flush between medications . Resident #8 On 01/28/2026 at 8:30 AM, Licensed Practical Nurse (LPN) #1 was observed administering medications to Resident #8 via percutaneous endoscopic gastrostomy tube. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure an indwelling urinary catheter was secured with a leg strap for one (1) of four (4) residents reviewed with urinary catheters. Resident #2. Findings Include:Record review of the facility policy Catheter Care, Urinary, undated, revealed .Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site .On 01/29/2026 at 10:53 AM, during an observation and interview of foley catheter care conducted by Certified Nursing Assistant (CNA) #3, assisted by CNA #4 revealed upon removal of Resident #2's pajamas a leg strap to secure the catheter was not in place. CNA #3 and CNA #4 confirmed there was not a leg strap in place to secure the catheter. CNA #4 stated Resident #2 should have a leg strap. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were clinically indicated and free from unnecessary use for one (1) of seven (7) sampled residents reviewed for unnecessary medications. Resident #5. Findings Include:Record review of Resident #5's medication orders revealed an active order for Narcan Nasal Liquid 4 milligrams per 0.1 milliliters, spray alternating nostrils every two minutes as needed for signs and symptoms of overdose including unresponsiveness, shallow breathing, and cyanosis, with instructions to notify the Medical Doctor and Emergency Medical Services immediately. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide alternative menu choices and ensure meal preference options were communicated for one (1) of (19) sampled residents reviewed for food service choices. Resident #70. Findings Include:On 01/27/2026 at 12:32 PM, during an interview, Resident #70 stated he sometimes does not like the food he is served. He stated he did not know alternate meals were available. He stated when he tells the Certified Nursing Assistants (CNAs) he does not like the meal served, sometimes they bring something else and other times they do not. He stated he is not aware of what foods are being served daily and would like to know what is being served. On 01/28/2026 at 11:06 AM, during an interview, Resident #70 stated he still did not know what foods would be served that day. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to follow infection prevention and control guidelines during medication administration for one (1) of four (4) residents reviewed for medication administration. Resident #8. Findings Include:Record review of the facility policy, revised October 2018, revealed This facility's infection control policies and practices are intended to. help prevent and manage transmission of disease and infection. On 01/28/2026 at 8:30 AM, medication administration was observed for Resident #8 via percutaneous endoscopic gastrostomy tube. Prior to administration, Licensed Practical Nurse (LPN) #1 removed the stopcock plunger from the feeding tube syringe and placed it on top of the plastic container it came in. [...]

Inspectors wroteBased on interviews, record review, and facility statement review the facility failed to issue a bed-hold notice when a resident went out on therapeutic leave for one (1) of two (2) residents reviewed for discharge. (Resident #1). Findings Include:Record review of a typed statement on facility letterhead and signed by the Executive Director (ED) revealed, The facility does not have a policy for Bed Hold. On 09/15/25 at 4:42 PM, in an interview the ED stated Resident #1 was discharged due to escalating behavior. She would pull her dress while walking down the hall and go into male residents' rooms. She stated Resident #1 was discharged for her safety and welfare. She stated the facility could not meet her needs. She stated Resident #1's family declined the 30-day notice. Resident#1 left on 5/30/25 and family decided to take resident home. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement the comprehensive care plan while providing perineal care for one (1) of two (2) residents observed for activities of daily living (ADL) care (Resident #4). Findings Include:A record review of the facility's Comprehensive Person-Centered Care Plans dated 1/25 revealed, Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences and goals that will identify how the interdisciplinary team will provide care .A record review of Resident #4's Care Plan Report revealed a care plan with an initiation date of 10/2/24, Focus: (Proper name of Resident #4) is incontinent of bladder and bowel. Interventions. Incontinent checks/care every two (2) hours and as needed (PRN) x (times) 2-person assistance for total dependence . [...]

Inspectors wroteBased on observation, interviews, record reviews and facility policy review the facility failed to provide perineal (peri-care) according to acceptable standards for one (1) of two (2) observations. Resident #4. Findings Include:A record review of the facility's Incontinent Care dated 07/12 revealed .10. Wash the resident's entire perineal area, and all areas affected by incontinence with a washcloth, soap, warm water, peri-wash or wipes. 11. When washing perineal area, wash the entire perineal, wash the entire area. On 09/16/25 at 4:03 PM, in an observation, Certified Nursing Assistant #1 (CNA) provided perineal care for Resident #4. CNA #1 placed the feeding pump on hold. He used three wipes and wiped front to back in the groin area on the right side. He then folded the wipe and wiped the same area again. He retrieved three (3) more wipes and wiped the left side front to back. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide perineal care in a manner that would prevent the possible spread of infection for one (1) of two (2) residents observed for perineal care. (Resident #4).

Inspectors wroteBased on observation, interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision of Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. On 5/09/25, at approximately 7:45 AM, Resident #1 exited the facility while unsupervised wearing a wander alarm device. The resident was out of the facility unsupervised and walked approximately one (1) mile crossing a four-lane highway for approximately two (2) hours before being located and returned to the facility. The facility's failure to provide adequate supervision for Resident #1, who was an elopement risk, put this resident and all other residents at risk for wandering and elopement, at risk for serious injury, serious harm, serious impairment, or death. [...]

Inspectors wroteBased on observation, staff and resident interview and record review, the facility failed to have sufficient nursing staff to meet the needs of residents as evidenced by failure to answer call lights and provide incontinent care in a timely manner for three (3) of 19 sampled residents, with the potential to affect all residents residing in the facility. (Residents #48, #87 and #23) Findings Include: Resident # 48 On 06/02/24 at 12:50 PM, an observation and interview of Resident #48, revealed a Certified Nurse Aide (CNA) entered the resident's room and turned off the resident's call light and exited the room. When the resident's room was entered, there was a strong unpleasant odor. Resident #48 stated the CNA turned off her call light and said that she would be back. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to honor resident's rights to have a choice of having bedrails for assistance with turning and bed mobility for two (2) of 19 sampled residents.

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure timely incontinent care was provided for one (1) of two (2) residents observed for incontinent care.

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review, the facility failed to ensure oxygen was delivered in a manner to prevent potential complications as evidenced by not following physician orders or facility policies related to oxygen therapy when a resident's oxygen tubing was not dated and there was no humidification provided for one (1) of 19 sampled residents. Resident #52 Findings Include: Record review of the facility's policy titled, Oxygen Therapy, reviewed 1/15, revealed, Oxygen is administered to promote adequate oxygenation and provide relief of symptoms of respiratory distress . Equipment: . 2. Humidifier, if needed . Procedure: .8. Change tubing weekly. 9. Date tube when changed (weekly). [...]

Inspectors wroteBased on observation, facility policy review and staff interviews the facility failed to provide safe and secure storage of medications for one (1) of three (3) medications carts observed. Findings Include: Record review of the facility provided Medication Administration-General Guidelines dated 8/16, revealed, . 4. Medications are administered at the time they are prepared for each resident. Medications are not pre-poured .16 . No medications are left unattended on top of the cart. The cart is to be locked if not clearly visible and under the control of the personnel administering medications . On 11/09/23 at 8:20 AM, an observation revealed the medication cart outside room [ROOM NUMBER] was unattended, unlocked, and had three medication packets, containing four pills lying on top of the medication cart. There were no residents in the hallway. [...]

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure that residents who do not have an Advance Directive (AD) received information or assistance in formulating an AD for ten (10) of ten (10) residents reviewed for ADs. This deficient practice had the potential to affect all residents who do not have an AD. Resident #11, Resident #14, Resident #21, Resident #31, Resident #45, Resident #55, Resident #65, Resident #67, Resident #86, and Resident #90.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to date an opened insulin vial and failed to a remove an expired insulin pen and insulin vial from medication carts for two (2) of three (3) medication carts reviewed.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure a written notification of transfer was sent to the Resident's Responsible Representative, included the reason of transfer for one (1) of two (2) records reviewed. Resident #88.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to implement a care plan to include providing the necessary behavioral health services per physician orders for one (1) of two (2) residents reviewed for behaviors.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary behavioral health services per physician orders for one (1) of two (2) residents reviewed for behaviors.