Charter House Inc

In the surveyor’s words

From the most serious findings on record at Charter House Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678May 20, 2022

  Based on interview and document review, the facility failed to follow the Provider Orders for Life Sustaining Treatment (POLST), did not initiate cardiopulmonary resuscitation (CPR) as per the residents wishes or follow the American Heart Association guidelines for CPR for 1 of 1 residents (R1). R1 was found without a pulse or respirations and staff did not initiate CPR and expired. This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE], at approximately 4:45 a.m. when R1 had no respirations or pulse, and CPR was not initiated. The administrator and nurse manager (NM)-A were notified of the immediate jeopardy on [DATE], at 2:45 p.m. The facility implemented corrective action and the IJ was removed on [DATE], at 2:45 p.m. […]

• Immediate jeopardy, isolatedF684May 20, 2022

  Based on interview and document review, the facility failed to provide ongoing assessments and monitoring after a respiratory change of condition was identified for 1 of 1 residents (R1) who sustained a medical emergency requiring administration of oxygen. R1 was found without a pulse or respirations, and subsequently died . This resulted in an Immediate Jeopardy (IJ) for R1. The IJ began on [DATE], when the facility failed to provide ongoing assessment of R1 who was having shortness of breath and low oxygen saturation levels. R1 was found deceased on [DATE]. The administrator and nurse manager were notified of the IJ on [DATE], at 2:45 p.m. […]

• Actual harm, isolatedF689Feb 12, 2024

  Based on interview and document review the facility failed to ensure manufacturers recommendations were followed for full body mechanical lift transfers for 1 of 1 resident (R1) who sustained serious injury with hospitalization . This deficient practice was issued at past non-compliance related to corrective action taken to ensure proper use of mechanical body lift prior to the survey. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment with diagoses that included stroke, seizure disorder, dementia, and hemiparesis or hemiplegia both sides of body. R1's MDS further indicated R1 was dependent for all activities of daily living (ADL)'s except for eating which required supervision or touch assist from staff. […]

• No harm, potential for more than minimal, patternF755May 19, 2026

  Based on interview and record review, the facility failed to implement an effective system for medication order transcription, laboratory monitoring, medication availability, and medication administration for 4 of 4 residents reviewed for medication errors (R1, R2, R3, R4). Failures included medication order transcription failures, missed laboratory monitoring, omitted anticoagulants and antiplatelet medications, medication availability failures, failure to implement medication order changes, and delayed medication administration.Findings include:R1:R1's Risk Watch document, incorrectly dated 2/7/26, identified on the future date of 2/19/26, the health care provider (HCP) notified the Director of Nursing (DON) an INR lab ordered for 2/16/26 had not been completed. […]

• No harm, potential for more than minimal, patternF761Apr 7, 2022

  Based on observation, interview, and document the facility failed to ensure a medication brought from home was appropriately labeled and secured for 1 of 1 residents (R122), failed to ensure 2 of 2 medication carts were appropriately secured, and failed to ensure eye drops and insulin were labeled/refrigerated/and discarded in accordance with manufacturer's guidelines for 2 of 2 residents (R3, R13). Findings include: R122's admission Minimum Data Set (MDS) dated [DATE], included cognitively intact with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R122's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During observation on 4/4/22, at 2:56 p.m. an unlabeled, undated, home medication silver tube of [MEDICATION(S)] 1% topical gel was on R122's bedside table in room. […]