Charlene Manor Extended Care Facility

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that appropriate services to maintain or improve range of motion were implemented for two Residents (#21 and #93) out of a total sample of 27 residents. Specifically, 1. For Resident #21, the facility failed to ensure the Physician's orders were followed relative to the use of the right wrist/hand and left-hand orthosis (device used externally that aids in body alignment and/or function), resulting in worsening bilateral hand contractures, and physical pain for the Resident. 2. For Resident #93, the facility failed to ensure the right-hand orthosis recommended by the Occupational Therapist (OT) was being applied for use by the Resident as required, placing the Resident at risk of worsening contractures.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1) who was admitted to the Facility for a short term stay and had a history of aggression, the Facility failed to ensure Resident #1's Comprehensive Care Plan included interventions, goal and outcomes related to his/her inappropriate and aggressive behaviors directed at and involving other residents, and discharge planning.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled Residents (Resident #1), who sustained an unwitnessed fall, the facility failed to ensure they maintained a complete and accurate medical record when nursing did not complete the 72-hour neurological checks following his/her unwitnessed fall, per facility policy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services to prevent and treat pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent further skin and pressure injury for two Residents (#26 and #53), of four applicable residents reviewed for pressure ulcers, out of a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #26: -offload (minimizing or removing any weight or force to help prevent and heal pressure ulcers) pressure on his/her buttocks and provide repositioning and assistance out of bed daily per Resident's plan of care to reduce the risk of developing pressure ulcers per the comprehensive plan of care and Resident preference/request. [...]

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that an appropriate Hoyer pad (seating device used to assist in transferring a resident using a mechanical lift) was available to assist in transferring one Resident (#26), out of a total sample of 25 residents. Specifically, the facility failed to provide an appropriate sized Hoyer Pad to assist in transferring Resident #26 out of bed based on his/her preferences and Rehabilitation recommendations to get out of bed resulting in the Resident remaining bedbound and increasing the risk for discomfort and skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one Unit (Homestead) out of three units observed, had sufficient staff members to meet the needs of the unit residents. Specifically, the facility failed to ensure: -sufficient staff were available to assist with Activity of Daily Living (ADL: basic skills needed in daily life and include eating, bathing, toileting and grooming/personal hygiene) for residents residing on the Homestead Unit.

Inspectors wroteBased on observation, and interview, the facility failed to ensure unit kitchenette cleanliness and safety was maintained on two units (Meadows Unit and [NAME] Unit) out of three unit kitchenettes observed. Specifically, the facility failed to: 1. For the Meadows Unit, ensure the kitchenette refrigerator and toaster were cleaned as required, and broken and/or missing refrigerator equipment were addressed, repaired and replaced. 2. For the [NAME] Unit, ensure the toaster was cleaned as required to maintain the equipment in a clean and safe manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that dignity and privacy was maintained for one Resident (#26), out of a total sample of 25 residents and on one unit (Unit 2) out of three units observed. Specifically, the facility failed to: 1) ensure staff provided privacy for Resident #26 while assessing and providing care to the Resident's buttocks. 2) ensure staff were seated while assisting residents during meals in the Unit 2 dining room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the Physician and/or responsible party of a change in condition for three Residents (#2, #88, and #43) out of a total sample of 25 residents. Specifically, the facility failed to: 1. Notify Resident #2's Physician, in a timely manner, of a change in the Resident's condition when the Resident experienced complications with his/her indwelling (inside one's body) urinary catheter (tube used to drain urine from the bladder into a bag outside of one's body), resulting in a delay in treatment. 2. Notify the Physician and the Resident's Representative timely about a blister that was identified on Resident #88's inner leg. 3. Notify Resident #43''s Resident Representative of multiple dental infections which required medical intervention of several courses of treatment with antibiotics.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the Notice of Medicare Non-Coverage (NOMNC: notice issued to a resident who is receiving benefits under Medicare Part A when all covered services end) and/or Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: notice issued to a resident when a facility determines the beneficiary no longer qualifies for Medicare Part A skilled services and the resident has not used all his/her Medicare benefit days) were issued for one Resident (#107), out of three residents reviewed. Specifically, the facility failed to issue: A. The NOMNC to Resident #107's Health Care Proxy (HCP- the person chosen as the healthcare decision maker when the individual is unable to do so for themself) when the Resident was determined to lack the capacity to make medical decisions. B. [...]

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure that two Residents (#99 and #43) out of a total sample of 25 residents, were free of physical restraints, putting the Residents at potential risk of accidental falls and injury. Specifically, the facility failed to: 1. For Resident #99, assess for the use of bilateral half middle (placement in the middle of the bed) side rails (side rails: adjustable position, rigid bars that attach to the sides of a bed, ranging in sizes from full to one-half, one-quarter, or one-eighth lengths) while in bed which prevented the Resident from exiting the bed, and were not the quarter side rails as ordered by the Physician. 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide required documentation to the receiving hospital for one Resident (#73) of one applicable closed record, out of a sample of three closed records, when Resident #73's medical needs could not be met at the facility, and he/she required transfer to the hospital. Specifically, the facility failed to provide evidence that the required transfer documentation to ensure a safe and effective transition of care was provided to the receiving hospital when Resident #73 was transferred to the hospital from the facility.

Inspectors wroteBased on record review and interview, the facility failed to develop a baseline care plan for one Resident (#73) out of a sample of three closed resident records reviewed. Specifically, the facility failed to develop a baseline care plan for Resident #73 within 48 hours of admission to the facility, when a comprehensive care plan was not developed in place of a baseline care plan, to provide effective and person-centered care of the Resident.

Inspectors wroteBased on record review and interview, the facility failed to ensure that care plans were reviewed and revised by the interdisciplinary team (IDT), and included the Resident and/or Resident's Representative for three Residents (#17, #92, and #88) out of a total sample of 25 residents. Specifically, facility failed to provide evidence that: 1. Resident #17 and/or his/her Representative were invited and attended/did not attend two separate care plan meetings held for the Resident. 2. Resident #92's care plan was reviewed and revised by the IDT following one Resident Assessment completed. 3. Resident #88's care plan was reviewed and revised by the IDT following two separate Resident Assessments completed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with personal hygiene for two Residents (#88 and #43) out of a total sample of 25 residents. Specifically, the facility failed to ensure Resident #88 and #43 were offered and/or provided with grooming assistance when both Residents required the assistance of staff for grooming activities.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to ensure one Resident (#88) out of a total sample of 25 sampled residents, received care and services consistent with professional standards of practice relative to completing a timely assessment and obtaining treatment orders for an identified skin issue. Specifically, the facility identified Resident #88 had a quarter sized fluid filled blister on his/her right lower leg and failed to assess the cause of the blister, notify the Physician and Responsible Party timely and obtain treatment orders to assist in healing, increasing the risk of potential further skin decline and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer assistance in scheduling an appointment to ensure good foot health was maintained for one Resident (#78) out of a total sample of 25 residents. Specifically, for Resident #78, the facility failed to offer podiatry services to maintain good foot health when the Resident was at risk for decline in his/her foot health related to a history of Peripheral Vascular Disease (PVD - a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and below the knee amputation (surgically cutting off a limb).

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure that one Resident (#53) out of a total sample of 25 residents, was free from potential accidental hazards when the Resident was allowed to store an Albuterol Sulfate inhaler (aerosolized bronchodilator medication) on his/her bedside table and use the inhaler without assessment or supervision. Specifically, for Resident #53, the facility failed to ensure: -that a prescribed Albuterol Sulfate inhaler was kept in a secured medication cart and not at the Resident's bedside. -the Resident was assessed to self-administer the medication, and was aware of precautions like an increased heart rate and/or difficulty breathing that could result from the medication use or overuse. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide appropriate treatment and services relative to an indwelling urinary catheter, for one Resident (#2) out of a total sample of 25 residents, which increased the Resident's risk for indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body). complications and resulted in a delay in treatment. Specifically, facility staff failed to: -Follow hospital discharge instructions for Resident #2 to attend a scheduled appointment with the Urologist. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure recommendations made by the facility Dietitian were followed for one Resident (#104), out of a total sample of 25 residents, who experienced a significant weight loss and was at risk for further decline. Specifically, for Resident #104, the facility failed to ensure that weekly weights were obtained when recommended by the Dietitian after the Resident experienced a significant weight loss of 13.44% in five months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct use of bed rails (side rails: adjustable position, rigid bars that attach to the sides of a bed, ranging in sizes from full to one-half, one-quarter, or one-eighth lengths) for one Resident (#2) out of a total sample 25 residents. Specifically, facility failed to provide quarter size bed rails for Resident #2, as ordered by the Physician, when facility staff positioned bed rails for Resident #2 in the upward half-rail position at the middle of the bed bilaterally, increasing the Resident's risk for limited mobility and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all Licensed Nurses had appropriate competencies relative to indwelling urinary catheter care and services for one Resident (#2) out of a total sample of 25 residents. Specifically, facility failed to ensure that Nurse #5 was assessed for competency to care for residents with indwelling urinary catheters when: -The Facility Assessment indicated facility staff had been determined to be clinically competent in caring for residents with genitourinary conditions requiring indwelling catheters. -Resident #2 had an indwelling urinary catheter, experienced an indwelling urinary catheter complication of urinary leakage, and required intervention to correct the urinary catheter leakage. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that one Resident (#419) was free from unnecessary drug administration. Specifically, facility failed to administer Oxycodone (highly addictive opioid medication used to treat moderate to severe pain) dosage and pain scale parameters as ordered by the Physician, in accordance with Resident #419's reported pain level, which resulted in the Resident receiving one excessive dose of Oxycodone and increased the Resident's risk for health complications.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that one Resident (#99) out of a total sample of 25 residents, was free from a significant medication error when a dose of Vitamin K medication was administered to the Resident and resulted in sub-therapeutic (dose or concentration of a drug lower than that usually prescribed to treat a disease effectively) laboratory levels. Specifically, for Resident #99, the facility failed to ensure that Vitamin K medication was not administered to the Resident when there was no Physician orders for the medication to be administered after a one time dose order was given.

Inspectors wroteBased on interview, record and policy review, the facility failed to ensure that dental services were provided for two Residents (#88 and #43), out of a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #88, provide regular bi-annual dental visits as requested by the Resident Representative. 2. For Resident #43, ensure dental services were offered to the Resident's Representative when the Resident had complaints of mouth and dental pain and required antibiotic treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to infection control standards to prevent the potential transmission of communicable diseases and infections for two Residents (#108 and #2) out of a total sample of 25 Residents. Specifically, the facility failed to: 1) ensure Resident #108's over-bed table was cleaned and disinfected before used to eat and drink off after a used urinal was set on the table. 2) ensure Resident #2's indwelling urinary catheter (a device inserted into the bladder to drain urine) was maintained off the floor.

Inspectors wroteBased on record review and interview, the facility failed to provide evidence that updated COVID-19 vaccines were offered to three Residents (#5, #92, and #61) out of five applicable sampled residents, in a total sample of 25 residents, which increased the Residents' risks for illness. Specifically, the facility failed to provide evidence that a second dose of 2023-2024 COVID-19 vaccine was offered to Resident's #5, #92, and #61, according to National Standards, when: -Each Resident received one dose of the 2023-2024 COVID-19 vaccine. -the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommended an additional dose of updated (2023-2024 formula) of COVID-19 vaccine be administered for older adults,aged [AGE] years and older. -Each Resident met criteria for a second dose of the 2023-2024 COVID-19 vaccine. [...]

Inspectors wroteBased on observation and interview, the facility failed to post nursing staff data daily, at the start of each shift, relative to licensed and unlicensed nursing staff directly responsible for resident care per shift. Specifically, the facility failed to post this data, in a prominent place readily accessible to residents and visitors, to include: a) total number and hours for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), Certified Nurse Aides (CNAs), and b) resident census.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that Significant Change in Status Minimum Data Set [MDS] Assessments (SCSA) were completed for three Residents (#104, #84, and #88) out of a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #104, ensure a SCSA was completed when the Resident had a decline in his/her memory, activities of daily living (ADLs), and bowel and bladder. 2. For Resident's #84 and #88, ensure SCSAs were completed when both Residents signed onto Hospice (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) services.

Inspectors wroteBased on record review and interview, the facility failed to accurately complete Minimum Data Set (MDS) Assessments for one Resident (#17), out of a total sample of 25 residents. Specifically, for Resident #17, the facility failed to accurately code the indication for use of an antipsychotic (medication that alters brain chemistry to reduce psychotic symptoms) medication and an antidepressant (medication that treat Depression and other conditions) medication on one MDS Assessment.

Inspectors wroteBased on observations (which included taking photographs) interviews and records reviewed, for three out of three resident units, the facility failed to ensure it provided a safe, clean, comfortable and homelike environment for it's residents, when during the course of the survey observations conducted in common areas, resident rooms and resident care areas, the surveyors observed obvious signs of various stages of disrepair, aging and unclean conditions, in carpets, flooring, walls and moldings, and furniture, all of which were in areas accessed and utilized by residents in their daily lives, and were either unclean, unsafe, in need of immediate repair and/or created potentially hazardous conditions, none of which supported that a homelike environment was being provided for facility residents.

Inspectors wroteBased on records reviewed, interviews, and observations, the Facility failed to ensure they developed, implemented and maintained a Quality Assurance and Performance Improvement (QAPI) program that was comprehensive, ensured the residents' environment was maintained to promote a clean, safe, homelike environment, and was focused on indicators of quality of life for residents in the facility.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), who was severely cognitively impaired, the Facility failed to ensure staff implemented and followed their Abuse Prohibition Policy, when on 10/30/23 Certified Nurse Aide (CNA) #1 witnessed an alleged incident of physical abuse involving Nurse #1 and Resident #2 but did not immediately report the incident to his or her supervisor per facility policy, therefore placing Resident #2 and other residents at risk for abuse. Findings Include: Review of the Facility's Policy, dated as revised 02/27/17, titled Resident Abuse Prevention, Investigation and Reporting indicated that all staff who suspect abuse, neglect, mistreatment and or misappropriation must immediately make an oral report to his or her supervisor. The Policy indicated the following: [...]

Inspectors wroteBased on records reviewed and interviews, for one of four sampled residents (Resident #1), who sustained a fall that resulted in a right hip fracture, and several weeks later sustained a large hematoma (a collection or pooling of blood outside of the blood vessel) to his/her left lower leg the Facility failed to 1) ensure nursing assessed Resident #1 after the fall and before transferring him/her up off of the floor, placing him/her at an increased risk for injury, 2) ensure nursing monitored Resident #1's left lower leg hematoma for any changes or deterioration and 3) ensure nursing completed an incident/injury report when staff identified Resident #1's new left lower leg hematoma.

Inspectors wroteBased on records reviewed and interviews, for one of two sampled employee personnel files (Certified Nurse Aide, CNA #1), the Facility staff failed to ensure CNA #1 received training on the facility procedures for reporting suspected abuse, neglect, exploitation, and misappropriation of resident property as required by Federal Regulations, and in accordance with Facility Policy.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure the resident designated smoking area complied with the Centers for Medicare and Medicaid Services (CMS) guidance for a safe smoking area. Specifically, the facility failed to provide readily available safety equipment including access to a fire extinguisher and a safe, designated smoking area for all smoking residents.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure over that over the counter medications (OTC-medications that can be purchased without a prescription) and medical supplies that included needles were secured and accessible to authorized personnel only. Specifically, the facility failed to ensure that the first floor medical supply room was safe and secure and did not provide an accidental and safety hazard to residents.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to maintain a safe, functional, sanitary and comfortable environment for residents, staff, and the public. Specifically, the facility failed to ensure that: 1) the main dining room provided a homelike environment for the residents and their visitors. 2) the kitchenettes on two out of the three Units (Meadows Rehab and [NAME]) remained sanitary.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) Assessments were accurately coded for the use of an anticoagulant (medication that help prevent blood clots), for two Residents (#8 and #95), out of five applicable resident records.

Inspectors wroteBased on observation, interview, and records reviewed for one Resident (#58) out of a total sample of 24 residents, the facility failed to ensure that services provided met professional standards of quality. Specifically, the facility failed to ensure a medication was given on an empty stomach per manufacturer guidance.

Inspectors wroteBased on record review and interview, the facility failed to ensure Hospice services were ordered and provided for one Resident (#122), out of two applicable closed records. Specifically, the facility staff failed to enroll Resident #122 for Hospice Care and ensure the provision of appropriate end-of-life services.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide care and services consistent with professional standards for one Resident (#109), out of one applicable resident, out of a total sample of 24 residents. Specifically, the facility failed to coordinate delivery of medications with Resident #109's dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment schedule to ensure the Resident received all medications as ordered by the Physician.

Inspectors wroteBased on interviews, record and policy reviewed for two Residents (#3 and #8) out of a total sample of 24 residents, the facility failed to ensure residents who are trauma survivors received trauma informed care in accordance with professional standards. Specifically, the facility failed to conduct a trauma-informed assessment per facility policy for Resident #3 and Resident #8, who were both diagnosed with Post Traumatic Stress Disorder (PTSD).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents were free of significant medication errors for one Resident (#119), out of a total sample of 24 sampled residents. Specifically, the facility failed to administer daily regimen medications as ordered by the Physician putting the Resident at risk for pain, elevated blood pressure, blood clots and alteration in mood.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure accurate medical records were kept for two Residents (#99 and #95), out of a total sample of 24 residents. Specifically, 1. For Resident #99, the facility staff failed to correctly transcribe a medication dose into the Narcotic Log Book. 2. For Resident #95, the facility staff failed to ensure the Resident's care plan matched the Massachusetts Medical Orders for Life Sustaining Treatment (MOLST-a medical form that relays instructions about life sustaining treatment).

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain appropriate infection control measures related to the maintenance of respiratory equipment for one Resident (#32), out of a total sample of 24 residents. Specifically, the facility staff did not ensure that Resident #32's nebulizer equipment was maintained in a sanitary manner, to decrease the risk of contamination and infection.

Inspectors wroteBased on interview and records reviewed for one Resident (#19) out of a sample of three residents, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN - A notice issued to inform a resident and/or resident representative of his/her financial liability to the facility when he/she transitioned off Medicare benefits and remains in the facility).