Chadwick Community Care Center

In the surveyor’s words

From the most serious findings on record at Chadwick Community Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689May 14, 2025

  Based on observation, interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision of Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. On 5/09/25, at approximately 7:45 AM, Resident #1 exited the facility while unsupervised wearing a wander alarm device. The resident was out of the facility unsupervised and walked approximately one (1) mile crossing a four-lane highway for approximately two (2) hours before being located and returned to the facility. […]

• Immediate jeopardy, isolatedF689Jun 10, 2021

  The State Agency (SA) conducted a complaint investigation (CI), Cl MS # on 6/9/2021 through 6/10/2021 and substantiated CI MS # related to an elopement due to the facility's failure to provide adequate supervision to prevent Resident #1's elopement from the facility on 5/31/2021 at approximately 5:54 AM. Resident #1 was away from the facility and unsupervised for approximately one (1) hour 28 minutes. The facility staff were unaware of Resident #1's absence until the breakfast trays were being delivered and discovered that Resident #1 was not in her room. The facility completed a facility wide search and began to search the surrounding roads. The Resident was located at 7:26 AM by Maintenance Staff #1 approximately 0.5 miles from the facility standing at the corner of a major intersection. […]

• No harm, potential for more than minimal, widespreadF725Jun 5, 2024

  Based on observation, staff and resident interview and record review, the facility failed to have sufficient nursing staff to meet the needs of residents as evidenced by failure to answer call lights and provide incontinent care in a timely manner for three (3) of 19 sampled residents, with the potential to affect all residents residing in the facility. (Residents #48, #87 and #23) Findings Include: Resident # 48 On 06/02/24 at 12:50 PM, an observation and interview of Resident #48, revealed a Certified Nurse Aide (CNA) entered the resident's room and turned off the resident's call light and exited the room. When the resident's room was entered, there was a strong unpleasant odor. Resident #48 stated the CNA turned off her call light and said that she would be back. […]

• No harm, potential for more than minimal, patternF677Jan 29, 2026

  Based on observations, interviews, record review and facility policy review, the facility failed to consistently provide necessary activities of daily living (ADL) care, including daily oral hygiene, routine nail care, and regular shaving of facial hair for one (1) of (19) residents reviewed. Resident #78.Findings include: Record review of the facility policy, Activities of Daily Living (ADL's) Supporting revised March 2018, revealed, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.On 1/27/26 at 11:51 AM, during an interview with Certified Nursing Assistant (CNA) #1, he stated that he had been assigned to provide ADL care to Resident #78 for the past two… […]

• No harm, potential for more than minimal, patternF628Sep 17, 2025

  Based on interviews, record review, and facility statement review the facility failed to issue a bed-hold notice when a resident went out on therapeutic leave for one (1) of two (2) residents reviewed for discharge. (Resident #1).Findings Include:Record review of a typed statement on facility letterhead and signed by the Executive Director (ED) revealed, The facility does not have a policy for Bed Hold. On 09/15/25 at 4:42 PM, in an interview the ED stated Resident #1 was discharged due to escalating behavior. She would pull her dress while walking down the hall and go into male residents' rooms. She stated Resident #1 was discharged for her safety and welfare. She stated the facility could not meet her needs. She stated Resident #1's family declined the 30-day notice. […]