Charming Lakes Rehab

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide ADL care for fingernails for 3 residents, (Resident #68, Resident #6, and Resident #1), who were sampled for ADLs. The failure to provide ADL care caused harm to 1 Resident, (Resident #68).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide dining in a manner to preserve the dignity for 3 of 33 residents in the final sample, Residents #11, 14 and 9.

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow orders for fluid restrictions for 1 of 1 resident reviewed for Dialysis, Resident #3.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide nutrition via enteral feedings per physician orders for 1 of 3 residents (Resident #68), reviewed for enteral feeding. This had the potential to affect 3 residents who were dependent on enteral feeding for nutrition.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 1 sampled resident for respiratory care (Resident #24).

Inspectors wroteBased on observations, interviews and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing, and administering of all drugs for, 7 of 9 residents reviewed for controlled substances (Residents #7, #104, #32, #14, #48, #69, and #85) and failed to establish a system of records of all controlled drugs to ensure discontinued controlled medications are removed from the medication carts for 2 of 9 residents reviewed for controlled medications (Residents #104 and #14).

Inspectors wroteBased on interviews and record review the facility failed to ensure adequate monitoring of behaviors and side effects for residents on psychotropic medications for 3 of 5 residents reviewed for unnecessary medications (Residents #24, #2, #3).

Inspectors wroteBased on observations, interviews and record review the facility failed to secure medications at all times during 2 of 4 medication pass observations (Residents #73 and #45), failed to secure medications at all times for over the counter medications in 1 of 2 unit manager's offices (unit manager for south), and failed to store medications according to facility policy for 1 of 3 medication carts reviewed for medication storage (Med Cart 500 Hall).

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to provide pureed foods in appropriate consistency for 3 residents (Resident #30, Resident #78, Resident #76) on Dysphagia Puree texture diets and for one resident (Resident #108) who was on a diet with an order for nectar thickened fluids. This had the potential to affect 27 residents who were on mechanically altered diets.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that potentially hazardous foods were held and reheated in a manner to prevent the growth of pathogens that cause foodborne illness and in a manner consistent with professional standards for food safety for 1 of 33 residents in the final sample, Resident #3.

Inspectors wroteBased on observations, and interviews, the facility failed to dispose of garbage and refuse appropriately.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to implement an effective infection control program related to 1. Not following local public health recommendations during an investigation of a possible Legionella outbreak. 2. Failed to ensure respiratory equipment was stored in a clean and sanitary manner for two of two observations. 3. Failed to ensure staff, including providers, used appropriate personal protective equipment (PPE) to prevent the transmission of an infectious pathogen for one resident (#5) of two residents sampled for transmission-based precautions. 4. Failed to display signage identifying the type of precautions that should be used for one resident (#3) of two sampled residents.

Inspectors wroteBased on observations, interviews, and policy review, the facility did not ensure a safe, clean, and homelike environment related to proper cleaning and maintenance in nine resident bathrooms (400, 401, 402, 403, 404, 405, 406, 407, and 409) out of ten bathrooms reviewed, two resident room baseboards (402 and 407) out of ten resident rooms observed, and one resident room wall (407) out of ten resident rooms observed.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR's) were completed accurately for 5 of 6 residents reviewed, (#60, #18, #68, #16 and #1).

Inspectors wroteBased on interviews, record review and review of facility policy, the facility did not ensure one resident (#60) of one reviewed had access to his personal funds.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure proper treatment of newly identified skin impairments and failed to ensure proper treatment of existing skin conditions were implemented for one (Resident #12) of three residents sampled for skin conditions.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide adequate nutrition to maintain acceptable parameters of nutritional status for one (Resident #32) of two residents sampled for nutritional requirements.

Inspectors wroteBased on interviews, and record reviews the facility failed to provide pain medication to one (#40) of two residents surveyed for pain management.

Inspectors wroteBased on record reviews and interviews, the facility failed to monitor behaviors and side effects of psychotropic medications for two (Resident #23 and 68) of the sampled five residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication error rate of less than 5%. A total of thirty medication opportunities were observed with three errors for two (Resident #56 and Resident #70) of five residents observed for medication administration, resulting in a medication error rate of 10%.

Inspectors wroteBased on interviews and record reviews, the facility failed to document complete and accurate medical records for one (Resident #32) of forty-two sampled residents.

Inspectors wroteBased on observation, record review, interviews and the facility policy review, and the Plan of Correction review, the facility failed to ensure that it had a functioning Quality Assurance Committee. The facility was actively involved in the effective creation, implementation and monitoring of the plan of correction for deficient practice during a recertification survey that was conducted on 5/22/23 through 5/25/23 and was cited F692. On 7/27/23 the facility was recited for F692. The facility had developed a Plan of Correction with a completion date 6/24/23.

Inspectors wroteBased on observations, interviews, and review of facility policy and procedures, the facility failed to ensure medications and biologicals were stored, secured, and disposed of in accordance with professional standards related to 1.) not ensuring 1 of 2 treatment carts in the facility remained secured and locked, 2.) not ensuring that 1 of 5 medication carts in the facility remained secured and locked, 3.) not ensuring medications had proper labeling in 1 of 3 medication carts observed, 4.) not ensuring that medications were disposed of and stored properly during observation of medication administration for 1 (Resident #503) of 7 residents observed during medication administration and 5.) not ensuring medications were properly secured during a tour of the facility on 1 of 4 days.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure resident and non-resident areas were maintained in a safe and sanitary manner at the North EXIT door area in Hallway 200, and in six out of ten resident rooms in hallway 200 for three of four days of the survey (08/10/21, 08/11/21 and 08/12/21).

Inspectors wroteBased on record review, interview, and review of facility policy, the facility did not ensure that two residents (Resident #94 and Resident #97) out of 3 residents sampled for pre-admission screening had a correctly completed Pre-admission Screening and Resident Review (PASRR).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement care plan interventions related to oxygen use, and proper oxygen flow rate for one (Resident #38) of thirty-one sampled residents, during two of four days observed (8/10/2021, and 8/11/2021).

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure assistance with Activities of Daily Living (ADL)s was provided for one (Resident # 54) of three residents sampled.

Inspectors wroteBased on record review, interviews, observation, and policy review the facility did not ensure a hospice care plan and/or assessment and appropriate communication related to hospice services including updates for a change of condition were in the medical record for one resident (#64) of nine residents receiving hospice care at the facility. Also based on interview and policy review the facility did not ensure there was a contract with the hospice provider for one resident (#64) of nine residents receiving hospice care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide respiratory care in accordance with professional standards for 2 (Resident #499 and Resident #17) of 3 residents sampled for respiratory care.

Inspectors wroteBased on observations and staff interviews, the facility failed to post the current Nurse Staffing Information to include all shifts for the day/night, the resident census, and numbers of each disciplined nursing staff for each shift, during one of four days observed, (8/10/2021). It was observed that the facility had the Daily Staffing Sheet posted and displayed with a date of four days prior.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication administration error rate below 5%. A total of 31 administration opportunities were observed with 4 errors for 4 (Resident #2, Resident #81, Resident #92 and Resident #502) of 5 residents observed for medication administration, resulting in a medications administration error rate of 12.9%.

Inspectors wroteBased on record review, interviews, observation, and policy review the facility did not ensure services were obtained to determine the appropriate therapeutic diet for one resident (#64) of nine residents receiving hospice care at the facility.

Inspectors wroteBased on observations, interviews, record reviews, review of facility policy, and review of the Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of COVID-19 by 1.) failing to post appropriate signage related to transmission based precautions on 2 resident rooms (406 and 408) of 11 resident rooms under transmission based precautions, 2.) failing to ensure that two staff members (H, A) donned appropriate Personal Protective Equipment (PPE) before entering the rooms of 2 resident's rooms (606 and 608) of 11 resident rooms on transmission based precautions, 3.) failing to ensure that PPE was doffed by 3 staff members (G, H, A) prior to exiting the rooms of 2 residents (406 and 606) of 11 resident rooms under transmission based precautions, 4.) two staff members (H, W) [...]

Inspectors wroteBased on observations, and staff interviews, the facility failed to ensure resident traffic areas and resident spaces were kept safe during three of four days observed (8/10/2021, 8/11/2021, and 8/12/2201). It was determined that a large remote air conditioner handler was plugged into an extension cord, which was stretched out causing a non-safe walking area. Two (#65, #69) of seven total residents that were ambulatory were observed to be walking near the cords.