Chamberlin Healthcare Center

In the surveyor’s words

From the most serious findings on record at Chamberlin Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 14, 2023

  Based on observations, medical record review, staff interviews, review of a police report, review of guardianship documents, review of the facilities investigation, review of the facilities self-reported incidents (SRIs) and policy review, the facility failed to provide adequate supervision to prevent the elopement of Resident #48 who had severely impaired cognition, was at risk for elopement and resided on a secured memory care unit. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #48 eloped from the facility without staff knowledge. […]

• Actual harm, isolatedF686Apr 3, 2023

  Based on record review, observation, staff interview, review of the facility policy, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to thoroughly assess the resident's skin, failed to timely identify a resident's pressure ulcer until it reached an advanced stage, and failed to ensure pressure ulcer prevention interventions were in place. This resulted in Actual Harm to Resident #110 who was at risk for pressure ulcers and the facility found Resident #110's pressure ulcer as an unstageable pressure ulcer (slough and/or eschar: known but not stageable due to coverage of wound bed by slough and/or eschar) to his left hip and did not assess the wound upon identification of the wound. […]

• Actual harm, isolatedF740Dec 29, 2022

  Based on medical record review, observations, staff interview, review of hospital records, and review of the United States (US) Food and Drug Administration (FDA) for Benadryl (antihistamine/allergies), the facility failed to ensure residents received the necessary behavioral health care and services to maintain the highest practicable physical, mental, and psychosocial well-being. This resulted in Actual Harm when Resident #02 obtained over the counter (OTC) Benadryl on numerous occasions, the resident had an intentional overdose on the Benadryl and the resident was subsequently transferred to the hospital on 12/14/22 and admitted for psychiatric services. This affected one (Resident #02) of three residents reviewed for behavioral health services. […]

• No harm, potential for more than minimal, widespreadF812May 14, 2026

  Based on observation, staff interview, and review of the facility policy, the facility failed to ensure food was stored, served, and prepared in a safe and sanitary manner. This had the potential to affect all of the residents residing in the facility except for one resident that the facility identified with an order for nothing by mouth. The facility census was 157 residents. Findings include: 1.Observation of dry storage on 05/11/26 at 9:39 A.M. revealed the following open and undated items: open bags of gravy mix, spaghetti noodles, macaroni noodles, two containers of peanut butter Interview 5/11/26 at 9:40 A.M. with Dietary Manager (DM) #250 verified the open and undated items. 2. Observation on 05/11/26 at 9:46 A.M. […]

• No harm, potential for more than minimal, widespreadF679Mar 14, 2023

  Based on observation, record review and staff interview, the facility failed to ensure the activities program consisted of group activities that met the interests of residents. This affected 113 out of 113 residents that resided in the facility. The facility census was 113. Findings include: Review of the activity director qualifications on 03/07/23 revealed the facility did not have a activities director or any activities staff employed at the facility. Interview with the Administrator on 03/07/23 at 9:45 A.M. verified the facility did not have an activities director or any current activities staff. The Administrator stated that the facility did not have a current activities calendar, but the facility used staff from other departments to run activities at times. […]