Charming Lakes Rehab

In the surveyor’s words

From the most serious findings on record at Charming Lakes Rehab, in the surveyor’s own words.

• Immediate jeopardy, patternF689Jul 27, 2023

  Based on observations, review of medical records, facility policy and procedure review, and interviews with facility staff, the facility failed to provide supervision and identify hazards to prevent an unwitnessed exit from the facility for two (Resident #1 and Resident #8) of three residents sampled as high-risk for elopement. Resident #1 was a long-term care resident who was confused, at risk for elopement, known to wander, and had a wander monitoring device on at the time of his elopement. Resident #1 was unsteady on his feet, had a history of falling and age-related cognitive decline. Resident #1 was known to leave the facility every year on July 4th on a supervised leave of absence however on 07/04/2023, he did not go on his yearly supervised leave of absence. […]

• Immediate jeopardy, patternF726Jul 27, 2023

  Based on observations, review of medical records, facility policy and procedure review, and interviews with facility staff, the facility failed to provide supervision and identify hazards to prevent an unwitnessed exit from the facility for two (Resident #1 and Resident #8) of three residents sampled as high-risk for elopement. Resident #1 was a long-term care resident who was confused, at risk for elopement, known to wander, and had a wander monitoring device on at the time of his elopement. Resident #1 was able to exit the facility unsupervised through the front door which was equipped with a door alarm, a wander monitoring device alarm system and a sign with the words Push Until Alarm Sounds Door Can Be Opened In 15 Seconds. […]

• Actual harm, isolatedF677Aug 21, 2025

  Based on observations, record reviews, and interviews, the facility failed to provide ADL care for fingernails for 3 residents, (Resident #68, Resident #6, and Resident #1), who were sampled for ADLs. The failure to provide ADL care caused harm to 1 Resident, (Resident #68). The findings included: A review of the facility’s policy for Activities of Daily Living (ADLs) effective 04/01/2022, revealed the purpose was to ensure all residents’ needs were met in a manner that promoted their quality of life and preferences. The procedure section included that the facility would provide residents with the appropriate treatment and services to maintain hygiene. This included bathing, dressing, grooming, and oral care. […]

• Actual harm, isolatedF689Dec 28, 2022

  Based on interviews and record review the facility failed to ensure adequate assistance to prevent a fall with injury for one (Resident #3) of two residents reviewed for falls with injury. Resident #3 rolled off her bed onto the floor during incontinence care, sustaining a fracture. Findings included: Facility incident logs and reportable event logs for October 2022 through December 2022 were reviewed. There was an entry of injury of unknown source, event date 12/18/2022 documented for Resident #3 on the reportable event log. A fall was documented for Resident #3 on the incident log, date 12/16/2022. An interview was conducted with Resident #3 on 12/28/2022 at 12:51 p.m. in her room. She was observed seated in a wheelchair in her room between her bed and the door. […]

• No harm, potential for more than minimal, widespreadF880Aug 7, 2025

  Based on record reviews, observations, and interviews, the facility failed to implement an effective infection control program related to 1. Not following local public health recommendations during an investigation of a possible Legionella outbreak. 2. Failed to ensure respiratory equipment was stored in a clean and sanitary manner for two of two observations. 3. Failed to ensure staff, including providers, used appropriate personal protective equipment (PPE) to prevent the transmission of an infectious pathogen for one resident (#5) of two residents sampled for transmission-based precautions. 4. Failed to display signage identifying the type of precautions that should be used for one resident (#3) of two sampled residents.Findings included: 1. […]