Charlestown Community Inc

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to timely report an allegation of sexual abuse and an allegation of neglect to the state survey agency for 2 (Resident #1 and Resident #2) of 4 sampled residents reviewed for abuse/neglect.

Inspectors wroteBased on interview, record review, document review, and facility policy review, the facility failed to thoroughly investigate an allegation of sexual abuse for 1 (Resident #1) of 4 sampled residents reviewed for abuse/neglect.

Inspectors wroteBased on observation, staff interviews and surveyor record review it was determined that the facility failed to ensure sanitary and safe food service practices. This was found to be evident in 1 out of 2 nourishment refrigerators on the nursing units and in the kitchen.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to appropriately prescribe a psychotropic medication for a resident without a documented need for one and monitor for behaviors and side effects. This was found evident in 3 (Resident #11, #67, & #84) out of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and interviews it was determined that the facility staff failed to complete a thorough investigation of facility reported incidents as evidenced by not including statements from all staff who worked during the time the alleged incidents occurred. This deficient practice was evidenced in 2 (#36, #98) of 5 facility reported incident investigations reviewed during the recertification survey.

Inspectors wroteBased on record review, and interview, it was determined the facility failed to provide the resident's representative with a written notice of reason for transfer. This was found evident of 1 (Resident #92) of 4 residents reviewed for hospitalization during the survey.

Inspectors wroteBased on staff interviews and surveyor record review, it was determined that the facility failed to complete a Minimum Data Set (MDS) assessment accurately for a Resident. This was found to be evident in 1 (Resident #27) out of 36 Residents reviewed for accuracy of MDS assessments.

Inspectors wroteBased on interviews, and record review, it was determined that the facility failed to review and revise a Resident's care plan after a Resident's situation changed and a Minimum Data Set assessment was completed. This was found evident of 1 (Resident #51) out of 1 Residents reviewed for change of condition during the survey.

Inspectors wroteBased on observations and interviews it was determined that the facility failed to provide necessary adaptive equipment to a Resident based on his/her needs. This was found evident in 1 (Resident #86) of 1 resident reviewed for communication.

Inspectors wroteBased on observations, staff interviews and surveyor record review, it was determined that the facility failed to follow appropriate respiratory care and services. This was found to be evident in 2 (Resident #1 and #50) out of 3 Residents reviewed for respiratory care and services.

Inspectors wroteBased on medical record review and interviews it was determined that the facility failed to implement physician instructions for behaviors health needs. This was evident for 1 (Residents #51) out of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, staff interviews, medical records review, review of facility reports, and facility's policy and procedures it was determined that the facility failed to: 1) ensure appropriate processes were followed and adequate supervision was in place to prevent a cognitively impaired resident with exit seeking behaviors and a history of a previous elopement from leaving the building. This was evident for 1 Resident (#55) out of 3 Residents reviewed for actual elopements reviewed during an annual and complaint survey. 2) ensure fall prevention interventions were in place for a resident with a history of falls. This was found evident of 1 (#49) of 7 residents reviewed for falls during an annual and complaint survey. The Findings Include: 1. On 7/11/23 6:56 AM, the surveyor reviewed Resident #55's medical record. Resident #55 was admitted to the facility in September of 2019. [...]

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to complete a quarterly Minimum Data Set (MDS) assessment within 14 days after the assessment reference date. This was evident for 2 of 2 residents (#117 and #1) reviewed.

Inspectors wrote3) On 06/28/2023 at 9:02 AM, an abnormal appearing nickel-sized area was observed by surveyor on Resident #199's left temple area, close to the ear. The Resident was immediately interviewed, and when asked about it, the Resident said that he/she did not know what it was and that it sometimes itched. On 06/29/2023 at 1:30 PM, Resident #199's medical records were reviewed. An order was created on 06/14/2023. The order read: weekly skin assessment on Fridays 7 AM-3 PM. Complete skin assessment using the skin sheet and document findings on wound portal and in progress notes. No assessment that included the area on the left temple could be found in the progress notes written by nursing staff, physicians, or other disciplines. No skin assessment could be found in the wound portal. On 06/30/2023 at 10:00 AM, an interview was conducted with staff #3, a Nurse Practitioner (NP). [...]

Inspectors wroteBased on review of medical records and staff interviews, it was determined that the facility staff failed to: 1) report recommendations to the attending physician and 2) failed to have a process in place that ensured a resident's medication irregularity report was reviewed by the primary care physician and that the recommendations were addressed timely. This was evident for 3 residents (#84, #39, #53) of 5 residents reviewed for medication regimen review.

Inspectors wroteBased on review of medical records, facility policies and interviews it was determined that the facility failed to document the provision of the education and the consent, or refusal, of the pneumonia vaccine. This was found to be evident for 5 (Resident #32, Resident #34, Resident #35, Resident #61, Resident # 69) out 5 residents reviewed for immunizations.

Inspectors wroteBased on observation and interview, it was determined that the facility staff failed to display the results of the annual recertification survey and plan of correction in a place readily accessible to residents, family members, and legal representatives. This was evident in the 1 of 1 survey results book posted in the facility.

Inspectors wroteBased on observation, medical record review and interview, it was determined the facility staff failed to ensure that Resident #24 received assistance with the hearing devices to maintain hearing abilities and the ability to achieve the greatest independence with performing Activities of Daily Living to Resident (#24). This was evident for 1 of 3 residents selected for review during the survey process.

Inspectors wroteBased on medical record review and resident and staff interviews it was determined the facility staff failed to ensure that dependent resident's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 of 66 (#17) residents reviewed during the survey process.

Inspectors wroteBased on observation, record review and interview with facility staff, it was determined that the facility failed to obtain informed consent prior to the use of bedrails. This was evident of 1 of 2 Residents (Resident #60) reviewed for bedrails during an annual survey.

Inspectors wroteBased on observations, interviews and record reviews, the facility staff failed to follow the facility's infection control policy. This was evident for 2 (# 10 and # 8) out of 2 observations for infection control.

Inspectors wroteBased on resident interview and observation, it was determined that the facility staff failed to ensure that a shower chair was safe for use. This was evident for 1 (#46) of 66 residents reviewed during the recertification survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that the resident and/or resident's representative were notified in writing of the resident's transfer and the rationale for the transfer. This was found to be evident for 3 of 7 (#140, #142, #132) residents reviewed for hospitalization during the investigative portion of the survey.

Inspectors wroteBased on staff interview and review of medical record documentation, the facility failed to ensure that staff fully adhered to Resident Assessment Instrument (RAI) process. In a pattern, this concern was evident in 17 of 44 residents reviewed for RAI Minimum Data Set (MDS) concerns (Residents 1, 6, 7, 8, 9, 10, 12, 14, 18, 19, 20, 23, 26, 43, 49, 122, and 146). Specifically 1) facility staff failed to incorporate Care Area Assessment CAA findings into care planning; 2) facility staff opened care plans without goals, interventions and/or rationales; 3) facility staff signed off that CAAs were completed before the MDS screening had been done (the MDS screening must be finished before CAAs because the screening is what triggers the CAAs); [...]

Inspectors wroteBased on review of medical record documentation, the facility failed to adhere to the mandated schedule for conducting quarterly Resident Assessment Instrument (RAI) assessments. The failure to reassess residents at least every 92 days, as required, increased the risk for serious harm related to care planning and care delivery that was not predicated on a full and complete understanding of each resident's status and each resident's evolving needs which can change over time. This concern was evident for 14 of 44 (Residents #2, 7, 8, 13, 15, 20, 21, 25, 26, 27, 49, 56, 145 and 146) residents reviewed for survey-triggered concerns in MDS coding.

Inspectors wroteBased on staff interviews and review of medical record documentation, the facility failed to follow the prescribed Resident Assessment Instrument (RAI) process when assessments were not completed timely and were then not transmitted timely into the Federal Quality Improvement Evaluation System (QIES). This concern was evident for 13 of 44 residents reviewed (Residents #4, 5, 6, 8, 9, 11, 17, 23, 24, 25, 26, 27 and 32) for survey-triggered MDS coding concerns.

Inspectors wroteBased on staff interviews and review of medical record documentation the facility failed to ensure sufficient coordination of the Resident Assessment Instrument (RAI)process when comprehensive assessments were not completed timely, quarterly assessments were not completed timely, discharge assessments were not completed timely, care area assessments were not completed timely, care planning staff did not have access to ensure CAA findings could be incorporated into care planning, and resultant care plans were missing, inaccurate, inconsistent and incomplete. The failure to ensure the staff followed the prescribed resident assessment process contributed to increased risk for serious resident harm when care planning did not reflect or support individualized needs of residents.

Inspectors wroteBased on observation of an interaction between resident and staff, it was determined that the facility failed to maintain an environment that enhanced a resident's dignity and respect. and care for each resident in a manner and in an environment that promotes enhancement of his or her quality of life. This was evident in 1 observation of Resident #140.

Inspectors wroteBased on record review, and resident and staff interviews, it was determined that the facility failed to afford a resident the opportunity to participate in his/her care planning process. This as evident for 1 out of 5 residents (Resident #117) reviewed for care planning.

Inspectors wroteBased on medical record review and staff interview it was determined that facility staff failed to initiate and conduct a thorough investigation after a resident sustained an injury of unknown origin. This was evident for 1 of 1 residents (Resident #66) reviewed during survey investigation.

Inspectors wroteBased on medical record review and staff interview it was determined that facility staff failed to report a resident' injury of unknown origin to the State Agency immediately or within 2 hours of discovery. This was evident for 1 of 1 residents (Resident #66) residents reviewed during survey investigation.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to reassess a resident following a significant change in condition related to hospice services. This was evident for 1 of 53 residents (Resident #79) selected for review during the survey process.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to 1) code the correct stage of a resident's pressure ulcer on the Minimum Data Set (MDS) correctly, 2) code correctly a resident's restraints use or functional status. This was evident in 2 of 28 residents reviewed (Resident #127 and #59).

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to revise a care plan related to a resident's 1A) identified skin wounds, 1B) history of falls, 2) A residents activities of daily living status and 3) follow a resident care plan when transferring a resident. This was found to be evident for 2 of 5 residents reviewed for care plans and 1 in 5 facility self reports reviewed. (Residents #140, #82, and # 412).

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions for resident. This was evident for 1 of 53 residents (Resident#59). selected for investigation during the survey process.

Inspectors wroteBased on medical record review and interview with residents and staff, it was determined that the facility failed to provide a resident with the identified assistance for activities of daily living (ADL) as identified in the resident's care plan. This was evident for 1 of 3 residents (Resident #2) reviewed for ADL's.

Inspectors wroteBased on observation, record review and staff interview it was determined that the facility failed to follow a physician order for Resident #117 which stated staff were to maintain Resident's surgical boot to left foot at all times except bathing. This was evidence for 1 of 11 residents reviewed.

Inspectors wroteBased on medical record review and interview, the facility staff failed to perform and/or document weekly skin assessments for a resident with pressure ulcers (Resident #79). This was evident for 1 out of 53 residents selected for review during the survey process.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to 1) keep residents safe and free of accidents and hazards while providing care 2) failed to maintain a unit free of potential accident hazards. This was found to be evident during the tour of unit 2 on the north side and a review of 2 residents (Residents #88 and #412) reviewed for falls and 3) failed to ensure Resident #8 remained as free of accident hazards as possible when it failed to conduct the required quarterly assessment to evaluate the resident's needs after four documented falls had already occurred in the prior 92 days (assessment window). [...]

Inspectors wroteBased on medical record review and interview with facility staff it was determined that the facility failed to 1) correctly document the placement of a residents wander guard, 2) document weekly in the wound portal the status of a residents wound and 3) failed to follow a physician order for daily nursing skin assessments. This was evident during the review of 3 of 28 resident records (Residents #82, #127 and #95).

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to develop and implement a care plan to manage hospice services for a resident. This was evident for 1 of 53 residents (Resident #79) selected for review during the survey process.

Inspectors wroteBased on staff interviews, review of other pertinent documentation and survey findings, it was determined the facility staff failed to ensure that effective quality assessment and assurance performance improvement interventions were implemented to address identified quality deficiencies. This was found to be evident during the facility's annual Medicare/Medicaid survey.