Charlotte Health & Rehabilitation Center

Inspectors wroteBased on observations, record review, and resident, staff and Nurse Practitioner interviews, the facility failed to provide a safe transfer for a dependent resident that required the use of a mechanical lift. After the fall, Resident #56 was complaining of unbearable left hip pain and was transferred to the emergency department (ED) by emergency medical services (EMS) for further evaluation. A computed tomography (CT) scan obtained in the ED revealed Resident #56 had a nondisplaced greater trochanteric fracture of the left femur (the hard boney protrusion on the upper outer side of the thigh bone). An orthopedic evaluation completed in the ED determined non-operative management of the fracture was appropriate due to Resident #56's non-weightbearing status prior to the injury. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to label and date leftover food items stored for use, keep a food preparation area clean and orderly, store a scoop without the potential for cross-contamination, discard dented canned goods stored for use and maintain a pipe of a steamer appliance and floor tiles in good repair. These practices occurred in 2 of 3 reach-in coolers, 1 of 1 dry goods storage area, and 1 of 1 food preparation areas.

Inspectors wroteBased on observations, record review, and staff and Pest Control Technician interviews, the facility failed to maintain a pest free environment in 1 of 1 kitchen and 1 of 2 nourishment rooms observed for maintaining an effective pest control program.

Inspectors wroteBased on record reviews, and resident and staff interviews, the facility failed to treat a resident in a respectful and dignified manner when 1 of 2 staff (Nurse Aide (NA) #1) failed to provide incontinent rounding resulting in urine saturated pants, mechanical lift pad and wheelchair seat for 1 of 3 reviewed for dignity and respect (Resident #56). Resident #1 indicated it made him feel bad to have to sit in urine-soaked pants.

Inspectors wroteBased on record review and staff interviews, the facility failed to submit the results of an investigation of an allegation of alleged employee to resident abuse that included the date/time of the alleged incident, the patients full name/room number, details of the allegation, names of the accused and any witnesses, name of facility staff who investigated the allegation, results of the investigation, and any corrective action that was taken by the facility to the Division of Health Service Regulation (DHSR) within 5 working days of the allegation for 1 of 3 sampled residents reviewed for abuse (Resident #113).

Inspectors wroteBased on record review and staff, Adult Protective Services (APS) Intake Social Worker, Medical Director and Resident Representative interviews, the facility failed to implement an effective discharge planning process for Resident #95 in order to sufficiently prepare the resident for a safe and orderly discharge that ensured his needs were met, home health services were coordinated, a safe discharge location was identified, and necessary medical supplies were provided. This deficient practice was identified for 1 of 3 residents reviewed for discharge (Resident #95).

Inspectors wroteBased on observations, staff interviews, and record reviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of wounds (Resident #40), and medications. This deficient practice was identified for 2 of 19 sampled residents (Resident #75).

Inspectors wroteBased on record review and interviews with staff, the Operations Manager for the transportation provider, and Medical Director, Nurse Aide (NA) #8 failed to report Resident #114's pain to Nurse #11 prior to transferring the resident to another Skilled Nursing Facility (SNF) and as a result no assessment was completed. The deficient practice occurred for 1 of 3 residents reviewed for quality of care (Resident #14).

Inspectors wroteBased on observations, record review and staff, Resident Representative and Medical Director interviews, the facility failed to follow hospital discharge orders for a resident to perform urinary self-catheterization (Resident #95) and failed to keep a urinary catheter drainage bag from touching the floor to reduce the risk of infection (Resident #9) for 2 of 3 residents reviewed for urinary catheters.

Inspectors wroteBased on record reviews, observations and staff interviews, the facility failed to follow their infection control policies and procedures for Enhanced Barrier Precautions (EBP) when Nurse #4 did not wear Personal Protective Equipment (PPE) while providing gastric tube care for Resident #89. In addition, Nurse Aide (NA) #5 failed to wear PPE while providing tracheostomy (trach) care for Resident #5. This deficiency occurred for 2 of 10 staff members observed for infection control practices (Nurse #4 and NA #5).

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to maintain a clean floor and failed to maintain baseboards in good repair in a resident's room and bathroom (Resident #27). Additionally, the facility failed to maintain a window screen in a resident's room (Resident #109). The deficient practice affected 2 of 19 rooms on 2 of 4 halls observed for environmental concerns.

Inspectors wroteBased on record review, and staff, resident and family member interviews, the facility failed to develop and implement effective discharge planning that ensured a resident would have the necessary durable medical equipment when she was discharged home to include a hospital bed, gel bed overlay with mattress, half side rails, a trapeze bar, and oxygen supplies for 1 of 4 residents reviewed for discharge (Resident #1). Resident #1 stated she was not provided with equipment for oxygen therapy and would get short of breath, and it would wake her up. Resident #1 reported she would cough, and it made her throw up at night. In addition, Resident #1 indicated that the hospital bed was not delivered, and she was sleeping in a recliner due to the shortness of breath which resulted in edema in her ankles and worsening of gastroesophageal reflux disease (GERD) symptoms.

Inspectors wroteBased on record reviews, and Psychiatric Mental Health Nurse Practitioner, Resident Representative (RR) and staff interviews, the facility failed to protect a resident's right to be free from resident-to-resident abuse. In January 2025, Resident # 2 was observed touching Resident # 1's breasts. On Saturday, 2/1/25 Resident #1 was positioned in a reclining wheelchair in the dayroom when Resident #2 was observed sitting next to Resident #1 with his right arm on her reclining wheelchair in the day room. Nurse Aide (NA) #1 intervened asking Resident #2 to give Resident #1 space and observed the blanket used to cover Resident #1 had been removed, Resident #1's pants and brief were pulled down, the brief was torn on the right-side exposing Resident #1's private area. [...]

Inspectors wroteBased on record review, and staff, Adult Care Home admission Director, and Ombudsman interviews, the facility failed to provide a complete written notice of transfer/discharge including a statement of the resident's appeal rights for 1 of 3 residents (Resident #2) reviewed for discharge.

Inspectors wroteBased on record review, and Hospital Case Manager, Resident Representative, and staff interviews, the facility failed to allow a resident to return to the facility after being sent to the hospital for evaluation using the resident's inappropriate sexual behaviors prior to discharge as a basis for their decision for 1 of 3 residents reviewed for transfer and discharge (Resident #2).

Inspectors wroteBased on record review and interviews with staff, Nurse Practitioner and Medical Director, the facility failed to immediately consult with the on-call Nurse Practitioner on [DATE] when Resident #1 had a significant change in condition. Resident #1 showed signs of restlessness, agitation, crawling onto the floor and verbally expressed to staff that she had experienced difficulty breathing. The facility also failed to notify the provider that Resident #1 had received a medication for anxiety for which she had a documented allergy on [DATE] at 7:44 AM. On [DATE] at 8:13 AM Resident #1 was found in her room unresponsive with seriously abnormal vital signs. Resident #1 was pronounced deceased by Emergency Medical Services (EMS) staff at 8:30 AM on [DATE]. The deficient practice affected 1 of 3 residents reviewed for physician notification (Resident #1).

Inspectors wroteBased on record review, and facility staff, Nurse Practitioner (NP), and Medical Director (MD) interviews, the facility failed to protect Resident #1's right to be free of neglect when the facility failed to: 1) immediately consult with the on-call Nurse Practitioner on [DATE] when a resident had a significant change in condition during the 3:00 PM to 11:00 PM shift that included signs of restlessness, agitation, crawling onto the floor and verbally expressing to staff that she had difficulty breathing; 2) complete ongoing thorough assessments for the change in condition that continued through the 11:00 PM to 7:00 AM shift; [...]

Inspectors wroteBased on observations, record review, and resident, staff, Nurse Practitioner (NP), and Medical Director (MD) interviews, the facility failed to identify the seriousness of a significant change in condition, complete ongoing thorough assessments and identify the urgent need for medical attention for a resident with a history of chronic obstructive pulmonary disease who reported she could not breathe. On [DATE] during the 3:00 PM to 11:00 PM shift, Resident #1 was restless, agitated, crawling onto the floor and verbally expressed to staff she could not breathe. During the night shift (11:00 PM to 7:00 AM) the difficulty breathing, anxiety and agitation continued and Resident #1 asked staff repeatedly to help her. [...]

Inspectors wroteBased on record review, and interviews with staff, Medical Director and Pharmacist, the facility failed to provide effective training and orientation for new hires including preceptorship, skills validations and specific training related to pharmacy services and resident allergies in the electronic medical record (EMR) system alerts. On [DATE] Unit Manager #1, who had not received a complete orientation, was scheduled to precept Nurse #2. Under Unit Manager #1's direction Nurse #2 administered Ativan to Resident #1 who had a documented allergy to Ativan. At 8:13 AM Resident #1 was noted in her room unresponsive and vital signs were blood pressure 94/60 (normal blood pressure reading 120/80), pulse 111(normal pulse range 60-100), respiratory rate 4 (normal respiratory rate 12-20) and oxygen saturation level 54% (normal oxygen saturation level greater than 92%). [...]

Inspectors wroteBased on record review, and interviews with staff, Medical Director and Pharmacist, the facility failed to prevent a significant medication error when Resident #1 received a dose of Ativan (a benzodiazepine, used as a sedative medication) as a one-time dose. Resident #1 had an allergy to Ativan documented on the Allergy List in the electronic medical record (EMR) on [DATE]. The medication order was entered into the electronic health record by Nurse #3. She stated the electronic medical record flagged the order due to the allergy, but she bypassed the alert and entered the order in the EMR, which was then pulled from the automated system for medication management. Nurse #2, a nurse who was orienting under the supervision of the Unit Manager, administered the medication on [DATE] at 7:44 AM. On [DATE] at 8:13 AM Resident #1 became unresponsive with seriously abnormal vital signs. [...]

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to treat a resident in a dignified manner while providing incontinent care and failed to effectively respond to a call light for 1 of 3 residents reviewed for dignity (Resident #3). Resident #3 stated that she felt disrespected and upset that she was ignored and made to stay in a soiled brief.

Inspectors wroteBased on observations, record review, review of Resident Council minutes, and resident and staff interviews, the facility failed to follow their planned menus for 1 of 1 sampled resident reviewed for preferences (Resident #65). The deficient practice had the potential to affect other residents who received food from the kitchen.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to label and date leftover food items stored for use, keep a food storage area clean and orderly, and failed to dry serving trays prior to stacking. These practices occurred in 1 of 7 reach-in coolers, 1 of 1 walk-in freezer, 1 of 1 dry goods storage area, and had the potential to affect food served to residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain the food steamer, which leaked water onto the floor in the main kitchen, in safe operating condition.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to maintain a resident's privacy by not providing full visual privacy during tracheostomy (hole that surgeons make through the front of the neck and into the windpipe) care for 1 of 1 resident (Resident #187) reviewed for personal privacy. The reasonable person concept was applied as a reasonable person would expect privacy in their home when being cared for.

Inspectors wroteBased upon observation, record review, and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 1of 1 resident (Resident #187) reviewed for special services.

Inspectors wroteBased on observations, record reviews, and staff interviews, Nurse #1 failed to follow the procedure for tracheostomy (hole that surgeons make through the front of the neck and into the windpipe) care when she did not use the sterile gloves from the sterile tracheostomy kit when cleaning the tracheostomy site and changing the inner canula. In addition, the facility failed to have a physician order for continuous oxygen for Resident #187. This deficient practice occurred for 1 of 1 resident requiring tracheostomy care (Resident #187).

Inspectors wroteBased on observations and staff interviews the facility failed to remove loose garbage, food, and debris from around 2 of 2 trash receptacles located outdoors behind the kitchen. This practice had the potential to impact sanitary conditions and attract pests/rodents.

Inspectors wroteBased on observations and staff interviews the facility failed to maintain ceiling vents in the kitchen free from accumulation of fuzzy grayish matter and failed to clean 2 of 3 ice machines (the kitchen ice machine and 200 Hall nourishment room ice machine). These practices had the potential to affect food and beverages served to residents.

Inspectors wroteBased on observation, record review and interviews the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the complaint survey and recertification conducted on 4/14/22. Four repeat deficiencies were originally cited on the 4/14/22 survey under the areas of Resident Rights (F558), Comprehensive Resident Centered Care Plan (F657), Pharmacy Services (F761), and Food and Nutrition Services (F812) and were subsequently recited on the current recertification and complaint survey of 8/10/23. These repeat deficiencies during the 2 federal surveys show a pattern of the facility's inability to sustain an effective QAA Program.

Inspectors wroteBased on observation, record review and interviews with resident and staff, the facility failed to ensure a dependent resident could access the light switch located behind the bed for 1 of 1 resident reviewed for accommodation of needs. (Resident #48) Resident #48 was admitted to the facility on [DATE]. Review of Resident #48's medical records revealed she had moved to her current bedroom (room [ROOM NUMBER]A) on 06/27/23. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #48 with intact cognition. The MDS indicated walking between locations inside or outside the room did not occur for Resident #48 during the assessment periods. During an observation conducted on 08/07/23 at 1:25 PM, the switch for the light fixture behind Resident #48's bed was attached with a broken cord approximately 3 inches in length. [...]

Inspectors wroteBased on observations, record review, staff interview, and resident interview the facility failed to provide privacy for a resident when the resident was transferred in a common area with their brief exposed. This occurred for one of one resident reviewed for personal privacy. (Resident #50)

Inspectors wroteBased on observation, record review, and interviews with resident and staff, the facility failed to maintain a wheelchair in good repair for 1 of 2 residents reviewed for mobility device (Resident #18).

Inspectors wroteBased on observations, record review, resident interview and staff interviews the facility failed to review and revise the care plan for 1 of 2 residents reviewed for comprehensive resident centered care plans (Resident #239).

Inspectors wroteBased on observations, record review, resident and staff interviews the facility failed to provide nail care for 1 of 2 residents ( Resident #77) reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observations and staff interviews the facility failed to secure a controlled substance in a permanently affixed compartment of the refrigerator in one of two facility medication rooms. (200 hall medication room)