Charlene Manor Extended Care Facility

In the surveyor’s words

From the most serious findings on record at Charlene Manor Extended Care Facility, in the surveyor’s own words.

• Actual harm, isolatedF688Feb 26, 2026

  Based on observations, interviews, and record review, the facility failed to ensure that appropriate services to maintain or improve range of motion were implemented for two Residents (#21 and #93) out of a total sample of 27 residents. Specifically, 1. For Resident #21, the facility failed to ensure the Physician's orders were followed relative to the use of the right wrist/hand and left-hand orthosis (device used externally that aids in body alignment and/or function), resulting in worsening bilateral hand contractures, and physical pain for the Resident. 2. For Resident #93, the facility failed to ensure the right-hand orthosis recommended by the Occupational Therapist (OT) was being applied for use by the Resident as required, placing the Resident at risk of worsening contractures. […]

• Actual harm, isolatedF686Nov 6, 2024

  Based on observation, interview, and record review, the facility failed to provide necessary care and services to prevent and treat pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent further skin and pressure injury for two Residents (#26 and #53), of four applicable residents reviewed for pressure ulcers, out of a total sample of 25 residents. Specifically, the facility failed to: 1. […]

• Actual harm, isolatedF600Jan 4, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1, who was dependent on staff to assist him/her with activities of daily living, was free from physical abuse by a staff member. On 11/24/21, two staff members witnessed Certified Nurse Aide (CNA) #1 slap Resident #1 in the face and/or neck area, and then CNA #1 said words to the effect of, Oh my god, I'm so sorry, it was my first reaction. Findings include: The Facility's Policy titled, Resident Abuse Prevention, Investigating and Reporting Policy, revised February 2017, indicated that: - the Facility was responsible to ensure residents had an environment free from abuse, - defined abuse as a willful action by an individual who committed the act… […]

• Actual harm, isolatedF580Jul 30, 2021

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose admission physicians orders included [MEDICATION(S)] extended release (opioid medication for moderate to severe pain) to manage his/her acute pain related to newly diagnosed right tibia and fibula (two bones in the lower leg) fractures and [MEDICATION(S)] (nerve pain medication) for his/her chronic severe pain due to peripheral [CONDITION(S)], the Facility failed to; - ensure that nursing notified the physician that the medications were not available in the Facility, and that prescriptions needed to be sent to the pharmacy in order for the medications to be dispensed and delivered to the Facility. […]

• Actual harm, isolatedF697Jul 30, 2021

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was newly admitted and required management of acute severe pain due to recent right tibia and fibula (bones of lower extremity) fractures, as well as management of his/her chronic pain due a history of severe peripheral [CONDITION(S)], the Facility failed to ensure that his/her pain was adequately treated and effectively managed. - Upon admission to the Facility, two of Resident #1's pain medications from his/her hospital discharge medication list, [MEDICATION(S)] extended release (opioid medication used to treat moderate to severe pain) and [MEDICATION(S)] (nerve pain medication) were not available in the Facility for his/her scheduled 9:00 P.M. […]