Charter Senior Living of Charlotte

The facility failed to ensure therapeutic diets were served as ordered. Specifically, a resident with a physician-ordered 'no straws' diet was observed being fed water through a straw by a Personal Care Aide who was unaware of the restriction.

The facility failed to ensure therapeutic diets were served as ordered for one resident who had a 'no straws' order due to a history of aspiration pneumonia. During a meal observation, a Personal Care Aide was observed using a straw to feed the resident water. Staff interviews revealed a lack of awareness regarding the specific dietary restriction and a failure in communication from dietary staff.

The facility failed to ensure physician-ordered therapeutic diets were served correctly for a resident requiring nectar-thickened liquids. Specifically, a resident was served water that was not nectar/mildly thickened, which resulted in the resident coughing after swallowing.

The facility failed to ensure that physician-ordered therapeutic diets were served correctly for a resident requiring nectar-thickened liquids. Specifically, a resident was provided with thin water that was not thickened, resulting in the resident coughing during consumption. Staff members were aware of the diet order but failed to follow the required thickening protocol.

The facility failed to ensure that medication administration was in accordance with physician orders for one resident. Specifically, for multiple instances between 10/06/23 and 10/18/23, the amount of sliding-scale insulin administered following finger stick blood sugar tests was not documented in the electronic Medication Administration Record (eMAR).

The facility failed to ensure medication was administered as ordered for a resident with a physician's order for sliding scale insulin. Specifically, multiple instances were identified where finger stick blood sugar readings were recorded, but the corresponding amount of insulin administered was not documented in the electronic Medication Administration Record.

The facility failed to ensure Resident #1's care plan was properly maintained and implemented. Specifically, the plan lacked a primary care provider signature and failed to document specific interventions to address the resident's documented behaviors, such as wandering, verbal abuse, and refusal of care. Additionally, there was no documentation of interventions to manage the resident's refusal of medications and personal care.

The facility failed to ensure necessary referral and follow-up to meet the routine healthcare needs of a resident. Specifically, the facility did not notify the physician regarding a resident's change in condition, including refusals for medication, food, hydration, and personal care assistance.