Chardon Woods

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview, the facility failed to protect Resident #6 from resident to resident abuse. This affected one resident (#6) of three residents reviewed for abuse prohibition. The facility census was 95. Findings include: Record review for Resident #6 revealed he was admitted to the facility on [DATE] with diagnoses including unspecified intracranial injury, bipolar disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was rarely or never understood. Review of a social worker note dated 04/01/25 revealed there had been an incident of Resident #6 being kissed by another resident (Resident #80) and Resident #6 did not respond when asked about being kissed by another resident. Review of the initial physician assessment, dated 04/01/25, revealed Resident #6 was being seen for the admission assessment. The incident regarding Resident #6 being kissed by another resident was not noted in this assessment, and there were no…

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, record review and policy review, the facility did not provide structured and routine activities on the memory care unit as scheduled. This affected all 27 residents (#1, #10, #11, #31, #32, #35, #37, #41, #42, #45, #54, #59, #62, #63, #74, #76, #77, #79, #83, #87, #90, #91, #92, #93, #99, #103, #108) that resided on the memory care unit. The facility census was 99. Findings include: Review of the activities calendar for January 2024 through November 2024 revealed no concerns with the scheduled activities; however, there was no activity calendar specific to the residents residing on the memory care unit. Review of the December 2024 activity calendar revealed on Tuesdays and Wednesdays only one activity was listed for the day between 10:30 A.M. and 11:00 A.M. and there were no activities after 3:00 PM on Saturdays. Review of the January 2025 activity calendar revealed there was no activity calendar specific to the residents residing on the memory care unit (unit G). The calendar reflected exercise took place on weekdays Monday through Friday at 11:00…

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 facility policy review, the facility failed to ensure residents and/or resident representatives were able to participate in quarterly care plan conferences for Residents #10 and #62. This affected two residents (#10 and #62) of two resident records reviewed for participation in care planning. The facility census was 99. Findings include: 1. Review of Resident #62's medical record revealed an admission date of 01/30/24. Diagnoses included Alzheimer's disease with late onset, generalized anxiety disorder, major depressive disorder, and fracture of right ulna styloid process. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #62 had a Brief Interview for Mental Status (BIMS) score of 00 meaning she was severely cognitively impaired. Resident #62 required partial to moderate assistance with toileting, transfers, and bed mobility, maximal assistance with dressing and personal hygiene. Review of the current care plan revealed Resident #62 was…

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, record review and review of the facility policy, the facility did not ensure Resident #102 was offered to rinse his mouth after administration of steroidal (anti-inflammatory) based respiratory inhaler. This affected one resident (#102) out of one resident observed for respiratory inhaler use. This had the potential to affect eight residents (#2, #6, #19, #20, #33, #65, #82 and #102) identified by the facility with orders for respiratory inhalers. The facility census was 99. Findings include: Review of the medical record for Resident #102 revealed an admission date of 11/06/24 with diagnoses including hypertension, allergic rhinitis, and congestive heart failure. Review of the care plan dated 11/18/24 revealed Resident #102 had altered health maintenance related to progressive physical and mental status including congestive heart failure. Interventions included administering medications as ordered and monitoring for signs of distress including respiratory symptoms. There was nothing in the care plan regarding rinsing the resident's mouth after…

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 observations, record reviews, interviews and reviews of the facility policy revealed the facility did not ensure the Physician's Order and the Care Plan for the use of oxygen were in place for Resident #94. This affected one resident #94 out of four. This had the potential to affect 14 Resident's(#3, #14, #17, #20, #27, #44, #46, #48, #51, #65, #68, #70, #71, #100) that was identified by the facility utilizing oxygen. Findings Include: Review of medical record for Resident #94 revealed an admission date of 06/26/24 and his diagnoses included chronic kidney disease, vascular dementia without behavioral or psychotic disturbance, heart failure, fluid overload, primary hypertension, and atrial fibrillation. Review of Quarterly Minimum Data Set (MDS) 3.0 dated 12/16/24 revealed that in Section O - Special Treatments, Procedures and Programs, Letter C1 Oxygen Therapy was marked that resident was not receiving oxygen therapy. Review of undated comprehensive care plan revealed Resident #94's care plan did show the focus, goals and interventions for oxygen use. Review of January,…

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, record review and review of the facility policy, the facility did not ensure medications were administered utilizing proper infection control standards including not touching medications with ungloved hands and hand hygiene between residents. This affected two residents (Resident #69 and #102) out of five residents reviewed for medication administration. The facility census was 99. Findings included: 1. Review of the medical record for Resident #69 revealed an admission date of 05/16/23 with diagnoses including chronic kidney failure, pulmonary embolism, and protein-calorie malnutrition. 2. Review of medical record for Resident #102 revealed an admission date of 11/06/24 with diagnoses including hypertension, allergic rhinitis, and congestive heart failure. Observation on 01/14/25 at 8:37 A.M. revealed Resident Nurse (RN) #553 was preparing Resident #102's medications, and the following infection control issues were identified: • RN #533 reached into the ascorbic acid (vitamin C) bottle with her ungloved fingers to obtain two 500 milligram (mg)…

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 the kitchen and nursing unit refrigerators were maintained in a clean and sanitary manner. This had the potential to affect 117 of 127 residents as eleven residents (#2, #8, #17, #29, #68, #73, #85, #103, #104, #118, and #132) received nothing by mouth. The facility census was 127. Findings include: Observations during the initial tour of the kitchen on 10/03/22 from 9:05 A.M. through 9:20 A.M. with Dietary Supervisor (DS) #504 revealed a large white bin with a clear lid that was dirty with food splatter and the scoop was stored inside of the bin with the oatmeal. There was black, dirty scum-like substance dried on the floor under the prep table near the oatmeal bin and under the stove across from the prep table. On the prep table next to the stove there were three clear containers of scoops stored on the top shelf of this prep table that had various food crumbs on inside bottom. Observation of the ice machine had whitish drippings and blackish stains on the front, side, and back of it. Observation 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.

Based on observation, interview, and record review, the facility failed to ensure staff properly wore personal protective equipment (PPE) while entering a resident room that was positive with COVID-19 and while in resident care areas. This had the potential to affect 46 residents (#2, #5, #8, #10, #17, #20, #21, #23, #27, #29, #33, #34, #36, #37, #39, #48, #50, #51, #53, #55, #59, #65, #66, #68, #71, #73, #75, #83, #85, #93, #103, #104, #105, #110, #116, #117, #118, #121, #125, #128, #129, #130, #131, #132, #133, and #378) who all resided on units C and D. The facility census was 127. Findings include: Observation on 10/03/22 at 11:18 A.M. of Licensed Practical Nurse (LPN) #507 sitting at nurses' station on unit C with no mask on face but wearing goggles. Observed in the common area near the nurse's station but greater than six feet were Residents #34 and #116. Interview at this time with LPN #507 verified the identified finding and stated she will put it on when around residents. Observation on 10/03/22 at 11:45 A.M. of State Tested Nurse Aide (STNA) #508 don a gown and gloves but…

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 observation, record review, and interview, the facility failed to ensure all resident rooms had call lights in place. This affected two of ten residents on the secured G unit reviewed for accessible call lights (Resident #4 and #40). The total census was 127. Findings include: 1. Record review of Resident #40 revealed she was admitted [DATE] and had diagnoses including dementia, major depressive disorder, and unspecified psychosis. Review of her care plan revealed no mention of any prohibition against keeping a call light in the room. Observation of Resident #40's room on 10/03/22 at 9:36 A.M. revealed she had no bedside call light or cord either plugged into the bedside socket or visible elsewhere in the room. Observation of Resident #40 at this time revealed she was not interviewable. The surveyor confirmed the above observation with Licensed Practical Nurse (LPN) #401 on 10/03/22 at 9:40 A.M. 2. Record review of Resident #4 revealed she was admitted [DATE] and had diagnoses including dementia,…

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 and interview the facility failed to ensure the kitchenette on the G unit was maintained in a clean and sanitary manner and in good repair to prevent contamination and/or food borne illness. This had the potential to affect 30 residents (#3, #9, #10, #12, #22, #25, #30, #35, #37, #38, #39, #40, #50, #67, #69, #70, #73, #76, #77, #78, #79, #80, #85, #88, #92, #94, #113, #114, #118 and #123) of 142 residents residing in the facility. Findings include: During a kitchen tour on 11/20/19 at 9:24 A.M. two kitchenette were observed on the G unit. The left side which contained higher room numbers had a toaster with loose debris and water mark type stains, the outside of the microwave had smears of food residue on the top and sides The counter tops in both kitchenettes were stained with multiple round brown and red stains and the finish on the top of the counter had worn away leaving an unclean surface. In addition, a refrigerator with a broken off door handle that left behind sharp broken hard plastic was also observed. The dish washing and storage area contained an ice…

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 and interview the facility failed to ensure confidential medical information was maintained in a safe and secure manner. This affected one resident (#137) of one resident reviewed for privacy. Findings include: Review of the medical record for Resident #137 revealed an admission date of 10/30/19 with diagnoses including major depressive disorder, dementia, heart disease, mass and/or lump in neck, obstructive and reflux uropathy, anemia, moderate protein-calorie malnutrition. Review of most current Minimum Data Set (MDS) 3.0 assessment, dated 11/06/19 revealed the resident exhibited cognitive impairment with a Brief Interview for Mental Status (BIMS)score of three. Interview on 11/18/19 at 10:54 A.M. with Resident #137's daughter revealed when she arrived to take her mother to a cardiologist appointment her packet of information was not available. Licensed Practical Nurse (LPN) #269 told her it was given to the family that left earlier to another appointment. Resident #137's information was printed again and she left to the appointment with her mother.…

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 observation, record review and interview the facility failed to ensure Resident #118, who sustained significant weight loss, was cued to eat or offered a substitute during meals. This affected one resident (#118) of four residents reviewed for nutrition. Findings include: Record review revealed Resident #118 was admitted to the facility on [DATE] with diagnoses including dementia, depression and non-infective gastroenteritis. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/17/19 revealed the resident was cognitively impaired and required the assistance of one staff for eating. The assessment also indicated the resident had a weight loss of 5% or more in one month and or a loss of 10% over six months. Review of the resident's care plan, dated 10/17/19 revealed the staff were to offer meal substitutes when foods were refused. Review off the physician's orders revealed the resident was ordered a regular diet, and supplements of fortified cereal (11/18/19), frozen nutritional treat…

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.