Chardon Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and facility policy review, the facility failed to ensure Residents #67, #189 and #196 were provided with showers as scheduled. This finding affected three residents (#67, #189 and #196) of five residents reviewed for showers. The facility census was 85. Findings include: 1. Review of the medical record revealed Resident #189 was admitted on [DATE] with diagnoses including encounter for orthopedic aftercare following a surgical amputation, diabetes, and generalized weakness. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #189 exhibited moderate cognitive impairment and was dependent on staff for showers/bathing. Review of the activities of daily living (ADL) care plans revealed an intervention dated 03/25/25 for shower/bathing, and Resident #189 was totally dependent on staff. Review of the shower schedules revealed Resident #189 was scheduled for showers Sunday and Thursday during the nightshift. Review of the Documentation Survey…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, interviews and review of the facility policy, the facility failed to ensure oxygen tubing was changed and dated and oxygen was set to the ordered liter flow per minute. This affected five residents (#1, #5, #8, #61, and #65) out of eight residents reviewed for oxygen. The facility census was 85. Findings include: 1. Review of the medical record for Resident #1 revealed an admission date of 09/03/24. Diagnoses included epilepsy, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), chronic diastolic congestive heart failure and atrial fibrillation. Review of Resident #1's Minimal Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had intact cognition. He required setup or clean up assistance with eating and dressing. He was independent with bed mobility, and required supervision or touching assistance with showers, toileting, and personal hygiene. Review of the Care Plan dated 04/09/25 revealed Resident #1 had COPD and chronic respiratory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observation, staff interview and review of the facility policy, the facility failed to ensure staff knocked on Resident #21's room door and/or asked permission to enter the resident's room prior to entering. This affected one resident (#21) of one resident reviewed for privacy. The facility census was 85. Findings include: Review of the medical record for Resident #21 revealed an admission date of 02/07/2024 with diagnoses including epilepsy, respiratory failure, chronic obstructive pulmonary disease, Type 2 diabetes mellitus with diabetic chronic kidney disease, unspecified dementia, psychotic disturbance, mood disturbance, anxiety, depression, and personal history of cerebral infarction without residual deficits. Observation on 04/16/25 at 8:27 A.M. revealed Certified Nurse Aide (CNA) #500 walked into Resident #21's without knocking on the door or asking permission to enter the room. Interview with Resident #21 on 04/15/25 at 9:03 A.M. revealed staff does not respect his privacy. They just walk into the room without knocking or asking permission.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews the facility failed to provide a dignified existence for all residents. This affected one (Resident #36) of 10 residents observed for activities and staff interaction. The census was 66. Findings Include: Review of medical record revealed Resident #36 was admitted on [DATE]. Diagnoses included unspecified dementia, history of falls, and anxiety disorder. Resident #36 was receiving hospice services. Review of the plan of care dated 08/17/21 revealed Resident #36 was at risk for falls due to balance problems, history of falls and weakness. Review of the plan of care dated 12/09/22 revealed Resident #36 had a self-care deficit and required assistance by staff for activities of daily living (ADL). Review of the 01/16/23 quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #36 revealed she had severe cognitive impairment. Observation on 01/18/23 from 10:03 A.M. to 12:00 P.M. revealed Resident #36 dressed in street clothes seated in a Broda (geriatric) chair…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation and interviews, the facility did not ensure foods were served at palatable temperatures. This had the potential to affect all residents in the facility except for one Resident (#35) who did receive food by mouth. The facility census was 77. Findings included: Resident interviews were conducted on 12/15/19 from 9:06 A.M. to 12:45 P.M. with Residents #25, #27, #39, #45 and #52. The residents consistently reported that hot foods were not hot and it could be at any meal the food was not hot. Resident #52 said she expected to get cold eggs when they were ordered. Resident #45 shared he did not eat a full meal a lot of times due to the hot foods being too cool, and he had lost weight. Resident #39 said the longer the trays sit in the hall waiting to get passed the colder the food was to him. Record review was conducted of the Food Committee Meeting Minutes dated 06/2019 which indicated foods were served at the proper temperature based on the floor staffing. On 09/19/19 the minutes reflected foods were served at the proper temperatures most of the time,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, interview and policy review, the facility failed to provide written notification of room changes to Resident #29 prior to conducting the room changes. This affected one Resident (#29) of one resident reviewed for room changes and had the potential to affect all 77 residents residing in the facility. Findings include: Review of the medical record for Resident #29 revealed an admission date of 08/31/18. Diagnoses included intellectual disabilities, cognitive communication deficit, generalized anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/23/19, revealed the resident had no cognitive impairment. The resident required staff supervision and set-up assistance with bed mobility, transfers, walking, locomotion, dressing, eating, toileting, personal hygiene and bathing. Review of the care plan, dated 09/05/18, revealed Resident #29 had impaired cognitive function/dementia or impaired thought processes related to MRDD (Mentally Retarded Developmentally Disabled), and he can get…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure Resident #10 and Resident #29 were free from physical abuse. This affected two residents (Residents #10 and #29) of three residents (Residents #10, #29 and #131) reviewed for abuse and neglect. The facility census was 77. Findings include: 1. Record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including muscular dystrophy, weakness, and bilateral primary osteoarthritis of knee. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/01/19 revealed Resident #10 had no cognitive impairment. Review of the care plan dated 06/26/19 revealed Resident #10 has a behavior problem related to bully-like, disrespectful behaviors towards other residents, and she tends to manipulate, and verbally express unsolicited, negative comments to peers. Record review revealed Resident #131 was admitted to the facility on [DATE] with dementia with behavioral disturbance, persistent mood…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview and policy review, the facility failed to implement the policy and procedure for reporting alleged physical abuse for Resident #29. This affected one Resident (#29) of three residents reviewed for abuse and neglect. The facility census was 77. Findings include: Review of the medical record for Resident #29 revealed an admission date of 08/31/18. Diagnoses included intellectual disabilities, cognitive communication deficit, generalized anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/23/19, revealed the resident had no cognitive impairment. The resident required staff supervision and set-up assistance with bed mobility, transfers, walking, locomotion, dressing, eating, toileting, personal hygiene, and bathing. Review of the care plan, dated 09/05/18, revealed Resident #29 had impaired cognitive function/dementia or impaired thought processes related to MRDD (Mentally Retarded Developmentally Disabled), and he can get argumentative at times and get in altercations. Interventions…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interview and policy review, the facility failed to report alleged physical abuse for Resident #29. This affected one Resident (#29) of three residents reviewed for abuse and neglect. The facility census was 77. Findings include: Review of the medical record for Resident #29 revealed an admission date of 08/31/18. Diagnoses included intellectual disabilities, cognitive communication deficit, generalized anxiety disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/23/19, revealed the resident had no cognitive impairment. The resident required staff supervision and set-up assistance with bed mobility, transfers, walking, locomotion, dressing, eating, toileting, personal hygiene, and bathing. Review of the care plan, dated 09/05/18, revealed Resident #29 had impaired cognitive function/dementia or impaired thought processes related to MRDD (Mentally Retarded Developmentally Disabled), and he can get argumentative at times and get in altercations. Interventions included to keep his routine consistent,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to thoroughly investigate a physical abuse incident involving Resident #10 and Resident #29. This affected two Residents (#10 and #29) of three residents reviewed for abuse and neglect. The facility census was 77. Findings include: Record review revealed Resident #29 revealed an admission date of 08/31/18 with diagnoses including intellectual disabilities, cognitive communication deficit, generalized anxiety disorder, and major depressive disorder. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive impairment and required staff supervision and set-up assistance with with activities of daily living (ADL). Review of the care plan, dated 09/05/18, revealed Resident #29 had impaired cognitive function/dementia or impaired thought processes related to MRDD (Mentally Retarded Developmentally Disabled), and he can get argumentative at times and get in altercations. Record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and policy review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) recommendations were incorporated into Resident #53's plan of care. This affected one (Resident #53) of two residents reviewed for PASRR status. The facility census was 77. Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, bipolar type, a history of bullet to the brain with fragmentation, and diabetes mellitus type 2. Review of the PASRR determination from the Ohio Department of Mental Health dated 05/03/19 revealed Resident #53 was approved for a sixty day nursing facility stay to expire on 07/02/19, and that any further stay beyond sixty days would require a new PASRR request and subsequent approval by the Ohio Department of Mental Health. Review of the PASRR determination from the State Department of Mental Health revealed Resident #53 had a history of serious mental illness and noted a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure a valid Pre-admission Screen and Resident Review (PASRR) was in place for Resident #53. This affected one (Resident #53) of two residents reviewed for PASRR status. The facility census was 77. Findings include: Record review revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, bipolar type, a history of bullet to the brain with fragmentation, and diabetes mellitus type 2. Review of the PASRR determination from the Ohio Department of Mental Health dated [DATE] revealed Resident #53 was approved for a sixty day nursing facility stay to expire on [DATE], and that any further stay beyond sixty days would require a new PASRR request and subsequent approval by the Ohio Department of Mental Health. Review of the medical record revealed no evidence a new PASRR was submitted for approval to the State agency prior to admission on [DATE]. Interview on [DATE] at 4:36 P.M. with Social Worker #376 verified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident #52 had a current discharge plan of care and failed to have documented evidence of care plan meetings. This affected one (Resident #52) of two (Residents #52 and #79) reviewed for discharge. The facility census was 77. Findings include: Review of the medical record for Resident #52 revealed an admission date of 02/02/19. Diagnoses included dementia, diabetes, difficulty in walking, acute embolism and thrombosis of left lower extremity. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/03/19, revealed the resident required the extensive assistance of one person for bed mobility, dressing, toilet use and personal hygiene. Extensive assistance of two people was needed for transfers. Supervision was needed for locomotion in a wheelchair. Review of the annual MDS 3.0 assessment, dated 10/11/19, revealed the resident had impaired cognition. Review of the care plans for Resident #52 revealed there was no discharge plan in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure Resident #52 was wearing a wander/elopement alarm per physician's order. This affected one (Resident #52) of two (Residents #52 and #8) reviewed for wandering/elopement. The facility census was 77. Findings include: Review of the medical record for Resident #52 revealed an admission date of 02/02/19. Diagnoses included dementia, diabetes, difficulty in walking, acute embolism and thrombosis of left lower extremity. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/03/19, revealed the resident required the extensive assistance of one person for bed mobility, dressing, toilet use and personal hygiene. Extensive assistance of two people was needed for transfers. Supervision was needed for locomotion in a wheelchair. A wander/elopement alarm was used daily. Review of the annual MDS 3.0 assessment, dated 10/11/19, revealed the resident had impaired cognition. Review of the Wandering Observation Tool dated 10/15/19 revealed the resident was at risk for elopement. Review of the plan of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.