Chardon Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Feb 2, 2023

  Based on observation, interview, and review of facility policy, the facility failed to ensure staff were not re-using N95 masks during a COVID-19 outbreak. This had the potential to affect all 74 residents residing in the facility. Findings include: Observation on 02/01/23 at 9:04 A.M. of Licensed Practical Nurse (LPN) #107 revealed she donned a gown, N95 mask with surgical mask overtop, gloves, and face shield to enter Residents #38 and #51's room. Signs on the door indicated droplet isolation precautions should be followed. Upon exiting the room, LPN #107 doffed her gown, gloves, and surgical mask in the room and performed hand hygiene. She did not change her N95 mask. Interview on 02/01/23 at 9:10 A.M. with LPN #107 verified she did not change her N95 mask. […]

• No harm, potential for more than minimal, patternF677Apr 17, 2025

  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. […]

• No harm, potential for more than minimal, patternF695Apr 17, 2025

  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 admitted [DATE]. 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. […]

• No harm, potential for more than minimal, isolatedF583Apr 17, 2025

  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 admitted [DATE] 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. […]

• No harm, potential for more than minimal, isolatedF550Jan 24, 2023

  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). […]