Deficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 31, 2025
Visit Reason
Annual survey inspection of Charter House Inc nursing home to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 2
Date: Oct 16, 2024
Visit Reason
The inspection was conducted to assess compliance with infection prevention and control programs and vaccination policies in the nursing home.
Findings
The facility failed to implement transmission-based precautions for a resident suspected of having Clostridioides difficile and failed to ensure 3 of 5 residents were appropriately vaccinated against pneumococcal disease per CDC recommendations.
Deficiencies (2)
F 0880: The facility failed to ensure transmission-based precautions were initiated for 1 resident suspected of having Clostridioides difficile. No personal protective equipment or signage was noted outside the resident's room despite orders and interdisciplinary team discussions.
F 0883: The facility failed to ensure 3 of 5 residents were appropriately vaccinated against pneumococcal disease upon admission or offered updated vaccination per CDC guidelines. Documentation lacked evidence of vaccine discussion or offer for PCV-20.
Report Facts
Residents affected: 1
Residents affected: 3
Residents reviewed for vaccination: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN)-A | Interviewed regarding resident's loose stools and antibiotic treatment | |
| Nursing Assistant (NA)-A | Interviewed regarding resident care and reporting of loose stools | |
| Infection Preventionist (IP) | Interviewed regarding infection control practices and vaccination review | |
| Director of Nursing (DON) | Interviewed regarding expectations for transmission-based precautions and vaccination policies |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 29, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of abuse involving a resident (R1) at the facility.
Complaint Details
The complaint involved an allegation of rough care abuse by nursing assistant (NA)-A toward resident R1 on 8/12/24. The allegation was not reported to the State Agency within the required two-hour timeframe. The resident was visibly upset and had a bruise on her foot. The implicated staff continued to provide care to other residents unsupervised after the allegation was made. The facility acknowledged the failure and planned to revise policies and provide staff education.
Findings
The facility failed to have a policy consistent with federal requirements for timely reporting of abuse allegations and failed to immediately report an allegation of abuse to the State Agency. Additionally, the facility failed to protect all residents by allowing the implicated staff to work unsupervised with other residents after the abuse allegation.
Deficiencies (3)
F 0607: The facility failed to have a policy consistent with federal requirements for reporting allegations of abuse to the state agency immediately but no later than two hours. This deficient practice had the potential to affect all residents.
F 0609: The facility failed to immediately report an allegation of abuse to the State Agency for one resident reviewed. The abuse involved rough care by a nursing assistant and was not reported within the required two-hour timeframe.
F 0610: The facility failed to ensure all residents were protected after an abuse allegation was made. The implicated nursing assistant was allowed to work unsupervised with other residents after the allegation.
Report Facts
Date of abuse allegation: Aug 12, 2024
Date of report to state agency: Aug 12, 2024
Time delay in reporting: 3.33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-A | Nursing Assistant | Named in abuse allegation involving resident R1 |
| LPN-A | Licensed Practical Nurse | Night shift nurse during abuse allegation, reported incident to charge nurse |
| IDON | Interim Director of Nursing | Acknowledged policy deficiencies and planned immediate revisions and staff education |
| RN-A | Registered Nurse | Reviewed progress notes and identified abuse allegation as a red flag |
| RN-B | Registered Nurse | Charge nurse on night of incident, unsure of abuse reporting timeline |
| OS-A | Operations Specialist | Provided information on abuse reporting policies and facility confusion |
Inspection Report
Deficiencies: 1
Date: Feb 12, 2024
Visit Reason
The inspection was conducted to investigate a serious injury incident involving a resident (R1) who fell during a mechanical lift transfer, to assess compliance with safety protocols and manufacturer recommendations for full body mechanical lifts.
Findings
The facility failed to ensure proper use and maintenance of a full body mechanical lift, resulting in a resident falling due to a sling strap detaching from the lift. The resident sustained serious injuries requiring hospitalization. Staff were re-educated and the lift was removed from service pending inspection.
Deficiencies (1)
F0689: The facility failed to ensure manufacturers' recommendations were followed for full body mechanical lift transfers, resulting in a resident falling when a sling strap detached causing serious injury and hospitalization.
Report Facts
Date of incident: Feb 6, 2024
Date of survey completion: Feb 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-A | Nursing Assistant | Involved in resident transfer and fall incident |
| NA-B | Nursing Assistant | Involved in resident transfer and fall incident |
| Director of Nursing | Director of Nursing | Investigated incident and oversaw staff re-education |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 16, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to medication self-administration, physical restraints, and infection control.
Findings
The facility failed to ensure a self-administration of medication assessment was completed for one resident, used physical restraints without proper orders or documentation for one resident, and did not follow proper glove changing procedures during wound care for another resident.
Deficiencies (3)
F 0554: The facility failed to ensure a self-administration of medication (SAM) assessment was completed for 1 of 1 resident reviewed for medication administration. The resident was left alone during nebulizer treatment without a SAM assessment.
F 0604: The facility failed to ensure residents were free from physical restraints for 1 of 1 resident reviewed. The resident had Velcro straps used as a safety device without physician orders, care plan documentation, or staff training.
F 0880: The facility failed to ensure gloves were changed during dressing change for 1 of 1 resident reviewed for skin tear. The nurse did not change gloves between removing old dressing and applying new steristrips.
Report Facts
Residents Affected: 1
Residents Affected: 1
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Registered Nurse | Named in medication self-administration deficiency observation and interview |
| RN-B | Registered Nurse | Named in physical restraint deficiency interviews and observations |
| RN-C | Registered Nurse | Named in infection control deficiency observation and interview |
| RN-D | Director of Nursing and Quality Assurance Nurse | Provided statements regarding SAM assessments, restraint policies, and infection control expectations |
| NA-B | Nursing Assistant | Provided information on training related to Velcro straps used as restraints |
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