Future Care Charles Village

Inspectors wroteBased on record review and interview it was determined that the facility staff failed to complete a thorough investigation of an allegation of abuse as evidenced by staff who worked during the time of the alleged incident were not interviewed. This deficient practice was evidenced in 1 (Resident #8) of 5 investigations reviewed for the allegation of abuse during the compliant survey.

Inspectors wroteBased on record review and interview, it was determined the facility failed to accurately document contact attempts for notification of a change in condition with resident representatives. This was evident for 1 of 2 complaints (Resident #3) reviewed during the survey.

Inspectors wroteBased on observations, record review, and interviews with facility staff, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations to prevent possible foodborne illness. This was evident during the initial tour of the kitchen.

Inspectors wroteBased on surveyor observations and facility staff interview it was determined that the facility failed to provide a safe, clean, comfortable, homelike environment for Residents. This finding was found to be evident in 9 (Resident #1, 2, 4, 7, 10, 11, 29, 58, and #105) out of 9 Resident rooms and the 1st floor shower room on tours of the facility during the annual/recertification survey.

Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to ensure Resident meals were palatable and hot foods were maintained above the food danger zone of 135 degrees Fahrenheit. This was evident for 6 (Resident #2, 9, 10, 11, 13 and #87) of 6 residents interviewed during the annual survey. This failure had the potential to affect all residents receiving meals from the facility's kitchen.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment to minimize or eliminate the spread of potential cross-contamination and to implement proper hand hygiene practices to prevent the spread of possible communicable diseases and infections. This was evident in 5 of 5 infection control areas reviewed throughout the facility during the annual survey.

Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to maintain essential equipment in proper operating conditions. This was evident for 3 of 3 pieces of equipment reviewed during the annual survey.

Inspectors wroteBased on observations and interviews with facility staff, it was determined that the facility failed to maintain clean and effective ventilation systems, thereby impeding proper airflow throughout the premises. This was evident in 3 of 3 areas reviewed during the annual survey.

Inspectors wroteBased on medical record review and staff interview it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment (#5). This was true for one of residents reviewed during the annual survey.

Inspectors wroteBased on Resident interview, facility staff interview and surveyor record review, it was determined that the facility failed to revise a Resident's care plan for antipsychotic drug use timely. This finding was found to be evident for 1(Resident #14) out of 1 Resident reviewed for care plan timing and revision.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to provide activities to meet the needs and preferences of residents. This was evident for 2 (Resident #13 and #119) of 2 residents interviewed for activities during the annual survey.

Inspectors wroteBased on observation, medical record review and interviews with residents, residents' family members and facility staff, it was determined that the facility failed to: 1) ensure ordered splints were in place, 2) failed to get an X-ray and the appropriate higher level of care for a resident who had sustained a fall that had resulted in a hip fracture in a timely manner, 3) failed to get a resident who was experiencing abdominal pain and had made multiple request for the facility to call 911 transported to the hospital in a timely manner. This was evident for 2 (Resident #2 and #15) of 2 residents reviewed for neglect during the annual survey.

Inspectors wroteBased on surveyor observation, facility staff interview, 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 1 (Resident #30) out of 2 Residents reviewed for respiratory care and services.

Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to provide sufficient physician-ordered thickened drinks to maintain resident hydration needs and preferences. This deficiency was evident for 1 (Resident #13) of 1 resident reviewed during the annual survey.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to ensure that the resident's Treatment Administration Record was documented in accordance with physician's orders. This was evident for 1 (Resident #114) of 1 resident's records reviewed during the survey.

Inspectors wroteBased on observations and interviews with facility staff, it was determined that the facility failed to provide a call bell system accessible to residents in the restrooms. This was evident for 3 of 3 restroom call bell systems reviewed during the annual survey.

Inspectors wroteBased on medical record review, observations, and interview it was determined that the facility staff failed to: 1) consistently document whether a resident was having psychotropic medication side effects or behaviors. This deficient practice was evidenced in 1 (Resident #32) of 3 Behavioral Records reviewed during the survey; and 2) document in the progress notes, the consent of the resident or the resident representation prior to the installation of the side rails. This was evident for 3 out of 3 residents, (#2, #28, and #80) reviewed for siderail consent.

Inspectors wroteBased on staff interviews and observations, it was determined the facility staff failed to: 1) provide a resident with a locked cabinet to secure valuables, and 2) maintain residents' shower rooms to be operational, usable, and in good repair. This was evident in 1(#59) of 1 resident records reviewed for accommodation of needs during the survey and 6 out of 9 resident shower stalls observed during the survey.

Inspectors wrote3) An observation was made on 1/18/24 at 11:00 AM of a resident room during an interview with the resident to discuss concerns. Resident #141 stated that a mouse was seen in the room and that the mouse retreated in a hole that is in the wall behind the toilet. At that time an observation was made of the bathroom and there was a hole in the wall next to the toilet and above the base board. It was approximately the size of 3 silver dollars. Review of the maintenance logs that were provided to the survey team indicated that the building was treated on 1/5/24 by a pest control company for mouse complaints on the first floor. An interview was conducted with the Maintenance Director on 1/18/24 at 3:40 PM and he was made aware of the resident concern regarding the mice and the observation of the hole in the resident bathroom and he stated that he would repair the hole. [...]

Inspectors wroteBased on record review and interview it was determined that the facility failed to protect a resident from verbal abuse. This deficient practice was evident in 1 (#241) of 4 facility reported incidents investigated during the survey.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to report allegations of abuse to the state agency within the two hour timeframe. This was found to be evident for 4 of 22 facility reported abuse investigations reviewed during the facility's survey.

Inspectors wroteBased on record review and interview it was determined that the facility staff failed to send a copy of a resident's transfer to the hospital to the Ombudsman. This deficient practice was evident in 1 (#20) of 2 resident records reviewed for transfer/discharge paperwork during the survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility staff failed to: 1) initiate a patient centered care plan for a resident who was ordered oxygen therapy, 2) initiate a care plan for a resident who had a significant weight loss, and 3) establish a care plan specific to one of the resident's primary diagnosis. This deficient practice was evident in 3 (#20, #32, #12) out of 6 resident records reviewed for the initiation of care plans for residents.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to: 1) update a resident care plan to address the resident specific needs (Resident #63), 2) have quarterly care plan meetings including the dietician for a resident who had a significant weight loss (Resident #89), 3) initiate a diagnosis specific care plan for a resident during the resident's length of stay (Resident #12). This was found to be evident for 3 of 62 residents, reviewed for care plan timing.

Inspectors wroteBased on record review and interviews it was determined that the facility staff failed to provide a summary of a resident's stay and a copy of the most recent comprehensive assessment to a resident who initiated a discharge. This deficient practice was evident in 1 (#241) of 1 resident-initiated discharge record reviewed.

Inspectors wroteBased on medical record reviews, observations, and interviews it was determined that the facility failed to ensure that residents requiring assistance with activities of daily living (ADL's) such as bathing and/or showering were provided these services. This was found to be true for 3 of 3 residents (#32, #38, and #82) reviewed for activities of daily living.

Inspectors wroteBased on medical record review, observation and interview, the facility staff failed to prevent new pressure ulcers/in-house acquired wounds from occurring. This was evident for 2 (Resident #242 and #92) out of 3 residents reviewed for new pressure ulcers during the survey.

Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to: 1) ensure annual staff performance reviews were completed as required, 2) ensure an annual performance review for the facility Geriatric Nurse Aides (GNAs), 3) provide performance related outcomes based staff education. This was found to be evident for 1 of 7 clinical employee files reviewed and for 1 of 5 GNA's that were reviewed during the survey.

Inspectors wroteBased on observations, interviews and review of facility documentation the facility failed to properly store medications and biologicals under proper temperature controls according to professional standards. This was evident in 1 out of 3 medication storage refrigerators observed during the survey.

Inspectors wroteBased on interview, observation and record review, it was determined that the facility failed to follow a resident's food intolerance list and to honor requested double-portion meals. This was evident for 1 (Resident #391) out of 9 residents reviewed for food preference and nutritional adequacy.

Inspectors wroteBased on observation and interview regarding the facility kitchen's operation, it was determined that the facility failed to store food in accordance with professional standards for food service to prevent the potential for contamination. This was evident for 2 out of 3 observations in the kitchen.

Inspectors wroteBased on observation and interview it was determined that the facility staff failed to maintain infection control practices as evidenced by a resident's oxygen tubing being uncovered and draped over the oxygen concentrator and five used, unlabeled, and undated urinals being left in the bathroom cabinet. The deficient practice had the potential to affect Resident #20 and the residents who reside in room [ROOM NUMBER].

Inspectors wroteBased on observations and interviews of facility staff it was determined the facility failed to ensure an effective pest control as flying gnats were observed throughout the building. This was found to be evident during the survey.

Inspectors wroteBased on medical record review and interviews it was determined that the facility failed to ensure the resident, or the resident's representative, was notified in writing regarding the reason for a hospital transfer. This was found to be evident for two out of four residents (Resident #85 and #52) reviewed for hospitalization during the survey.

Inspectors wroteBased on medical record review and interviews it was determined that the facility failed to ensure the resident, or the resident's representative, was notified in writing of the bed-hold policy at the time of a hospital transfer. This was found to be evident for two out of four residents (Resident #85 and #52) reviewed for hospitalization during the survey.

Inspectors wroteBased on medical record review, and interview with facility staff it was determined that the facility failed to develop person-centered comprehensive care plans as evidenced by 1) failure to develop a care plan to address a resident diagnosis and 2) failure to develop a care plan to address the prevention and treatment of pressure ulcers. This was found to be evident for two out of twenty-four residents (Resident #78 and #398) reviewed during the investigative stage of the survey.

Inspectors wroteBased on medical records review and interview with staff it was determined that the staff failed to 1) revise care plans with appropriate goals and interventions and 2) review and revise the care plan for a resident after a significant change. This was found to be evident for two of twenty-nine residents (Resident #78 and #397) reviewed for care plan timing and revisions during the investigative stage of the survey.

Inspectors wroteBased on record review and staff interview it was determined that the facility failed to follow their policy for proper notification of a physician when Resident #62 left the facility. This was evident for one out of one residents (Resident #62) reviewed during closed record reviews.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to: 1) have an effective system in place to ensure that the hand off communication regarding resident consultations and prescriptions were clearly and effectively communicated with staff and 2) make a referral to hospice in a timely manner. This was evident for two of twenty-nine residents (Resident #78 and #93) reviewed during the investigation process of the long-term care process.

Inspectors wroteBased on medical record review and staff and resident interviews it was determined that the facility failed to properly assess and implement interventions to prevent the development of a pressure ulcer for Resident #398. This was evident for one out of five Residents investigated for pressure ulcers.

Inspectors wroteBased on record review and staff interviews it was determined that the facility failed to provide Resident #397 with the necessary behavioral health care in the expected time frame. This was evident for one out of two residents (Resident #397) noted to be receiving behavioral health services.

Inspectors wroteBased on medical record review and interview with facility staff it was determined that the facility failed to maintain records that were legible. This was evident during the review of two of two medical records (Resident #38 and #93) reviewed during the annual review.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to properly label and date leftover food that was in the refrigerator. This was true of on out three observations made in the kitchen's walk-in refrigerator.