Deficiency Records for Charlene Manor Extended Care Facility
Updated as of March 01, 2024
A list of the most recent deficiencies for Charlene Manor Extended Care Facility. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-12-13 | 2024-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-13 | 2024-01-27 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-12-13 | 2024-01-27 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-09-18 | 2023-11-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-18 | 2023-11-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-18 | 2023-11-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-18 | 2023-11-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-18 | 2023-11-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-18 | 2023-11-04 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-09-18 | 2023-11-04 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-18 | 2023-11-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-09-18 | 2023-11-04 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-18 | 2023-11-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-18 | 2023-11-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-09-18 | 2023-11-04 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-30 | 2022-05-12 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-03-30 | 2022-05-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-03-30 | 2022-05-12 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-30 | 2022-05-12 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-03-30 | 2022-05-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-30 | 2022-05-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-30 | 2022-05-12 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-30 | 2022-05-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-30 | 2022-05-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-30 | 2022-05-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-30 | 2022-05-12 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-30 | 2022-05-12 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-30 | 2022-05-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-30 | 2022-05-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-30 | 2022-05-12 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-04-06 | 2022-04-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-04 | 2022-02-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-04 | 2022-02-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-04 | 2022-02-15 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-01-04 | 2022-02-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-04 | 2022-02-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-30 | 2021-09-13 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-07-30 | 2021-09-13 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-07-30 | 2021-09-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-04 | 2019-10-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-04 | 2019-10-25 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-10-04 | 2019-10-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-04 | 2019-10-23 | N |
