Charter Senior Living of Oak Openings

Based on observation, medical record review, staff interview, and review of a facility policy, the facility failed to assist with maintaining resident rooms in a safe and sanitary manner on the memory care unit. This affected two (#1 and #3) of three residents reviewed for physical environment. The facility census was 46.

Findings Include:

1. Review of Resident #1's medical record revealed an admission date of 11/03/23. Diagnoses included dementia, hyperlipidemia, osteoarthritis, and stroke.

Review of Resident #1's functional assessment dated 02/24/26 revealed the resided on the memory care unit and required staff to complete housekeeping tasks. Further review found Resident #1 had additional housekeeping tasks including assistance daily with bed making, light tidying up of the unit, and trash removal every shift.

Observation on 05/08/26 at 7:26 A.M. of Resident #1's room and bathroom found small white debris scattered all over Resident #1's bathroom, next to her bed in her bedroom, and along the walk way between the bed and the bathroom. Further observation found her raised toilet seat to be soiled with a dry yellow substance and dried feces all around the inside of the toilet above the water line.

Interview on 05/08/26 at 7:28 A.M. with Caregiver (CG) #134 verified Resident #1's room and bathroom were unclean with a dirty toilet riser, dried feces in the toilet, and small white debris across her floor in the bedroom and bathroom. CG #134 verified Resident #1 was unable to complete housekeeping tasks and relied on staff to keep her apartment clean.

Observation and attempted interview on 05/08/26 at 7:30 A.M. with Resident #1 found her to be clean, appropriately dressed, and alert. Resident #1 shrugged when asked if her room was kept clean enough and walked away without answering.

Observation on 05/08/26 at 10:45 A.M. of Resident #1's room and bathroom found it continued to be in the same condition as it was previously observed. Closer inspection of the white debris on the floor found it appeared to be flakes of dry skin. Coinciding interview with Licensed Practical Nurse (LPN) #132 verified Resident #1's room was unclean and there were what appeared to be flakes of dry skin on her floor.

2. Review of Resident #3's medical record revealed an admission date of 09/04/25. Diagnoses included Alzheimer's dementia, delirium, anxiety, and osteoarthritis.

Review of Resident #3's functional assessment dated 02/23/26 revealed Resident #3 resided on the memory care unit. Resident #3 was moderately cognitively impaired and required staff assistance with housekeeping. It was noted Resident #3 needed vacuuming, dusting, bathroom cleaning, and trash removal weekly and as needed.

Observation on 05/08/26 at 7:32 A.M. of Resident #3's room and bathroom found the floor was not swept with debris on the floor in the closet area and in the bathroom. Resident #3's toilet had dried feces above the water line, a dried substance on the floor around the toilet, and a strong odor was noted.

Interview on 05/08/26 at 7:34 A.M. with CG #134 verified Resident #3's apartment needed swept, mopped, and the toilet cleaned. CG #134 verified Resident #3 was not able to complete housekeeping tasks and relied on staff to do it for her.

Review of the facility policy titled, Flourish Memory Care Program

Based on staff interview, record review, and review of the facility's electronic records, the facility failed to ensure residents received routine cares during night shift. This affected four (#16, #18, #20, and #21) residents identified to be dependent on staff for toileting and had the potential to affect the remaining six residents (#22, #23, #24, #25, #26, and #27) on the 300-Hall of the Memory Care Unit (MCU). The facility census was 45.

Findings include:

1. Review of the medical record for Resident #16 revealed an admission date of 09/24/25 with diagnoses of Alzheimer's disease, congestive heart failure, and chronic kidney disease.

2. Review of the medical record for Resident #18 revealed an admission date of 08/15/25 with diagnoses of dementia, hypertension, and coronary artery disease.

3. Review of the medical record for Resident #20 revealed an admission date of 10/30/25 with diagnoses of anxiety and memory impairment.

4. Review of the medical record for Resident #21 revealed an admission date of 04/19/23 with diagnoses of Alzheimer's disease, hypertension and type 2 diabetes mellitus.

The facility identified Resident #16, Resident #18, Resident #19, Resident #20 and Resident #21 required assistance from staff for toileting.

Review of the Resident Census revealed Resident #16, Resident #18, Resident #19, Resident #20 and Resident #21 resided on the 300-Hall of the Memory Care Unit (MCU).

Interview on 11/17/25 at 6:12 A.M. with Caregiver #101 revealed she was completing her shift on the 300-Hall of the MCU. Caregiver #101 stated all residents on the 300-Hall were to be checked for toileting needs every two hours. Caregiver #101 stated all residents were mobile and did not wear briefs but required some personal assistance with toileting.

Additional interview on 11/17/25 at 6:29 A.M. with Caregiver #101 revealed she worked third shift on 11/01/25. Caregiver #101 stated one of the caregivers assigned to the 300-Hall in the MCU did not work the shift on 11/01/25. Caregiver #101 stated she checked on the residents throughout the night, in addition to caring for the residents to whom she was assigned. Caregiver #101 stated she was unable to provide any cares to the 300-Hall residents, particularly toileting assistance, on 11/01/25 during the shift from 11:00 P.M. until 7:00 A.M.

Interview on 11/17/25 at 2:57 P.M. with the Executive Director (ED) and the Health and Wellness Director (HWD) and concurrent review of the care tracker (electronic record of cares provided to residents) for third shift on 11/01/25 revealed no care needs were completed on the 300-Hall. The ED and HWD confirmed nurses had access to the system to document when cares were provided. The ED further stated with one nurse and two aides, the care needs for all residents on the 300-Hall should have been completed on the third shift on 11/01/25.

Review of the staff schedule dated 11/01/25 revealed one nurse and three caregivers were scheduled for third shift on 11/01/25. The nurse was assigned to all residents in the facility, one caregiver was assigned to the Assisted Living section, and one caregiver was assigned to each of the two Memory Care Unit hallways.

Interview on 11/17/25 at 12:58 P.M. with Scheduler #300 confirmed only two caregivers and one nurse worked on third shift 11/01/25. Scheduler #300 was notified of the call-off of the third scheduled caregiver and was unsuccessful in finding coverage for the shift. Scheduler #300 stated Caregiver #105 worked second shift on 11/01/25 and volunteered to work third shift, but ultimately did not stay to cover third shift.

Telephone interview on 11/18/25 at 11:45 A.M. with Licensed Practical Nurse (LPN) #201 revealed she worked the third shift on 11/01/25. LPN #201 confirmed one caregiver did not work the shift for the 300-Hall MCU. LPN #201 stated she checked on residents on the 300-Hall and assisted Resident #19 to the bathroom. LPN #201 did not provide any personal care to Resident #16, Resident #18, Resident #20 or Resident #21. LPN #201 stated she was unsure whether the two caregivers who worked the shift provided any personal cares to the residents on the 300-Hall.

This violation represents non-compliance investigated under Complaint Number OH00168759.