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Deficiency Records for Charlwell House Health and Rehabilitation

View the most recent health deficiencies and inspection results for Charlwell House Health and Rehabilitation. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Charlwell House Health and Rehabilitation. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Provide properly protected cooking facilities. Fire Safety 2025-05-30 2025-06-30 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2025-05-30 2025-06-30 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2025-05-30 2025-06-30 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2025-05-30 2025-06-30 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2025-05-30 2025-06-30 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2025-05-30 2025-06-26 N
Provide and implement an infection prevention and control program. Health 2025-05-30 2025-06-26 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2025-05-30 2025-06-26 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2025-05-30 2025-06-26 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2025-05-30 2025-06-26 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2025-05-30 2025-06-26 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2025-05-30 2025-06-26 N
Provide appropriate foot care. Health 2025-05-30 2025-06-26 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2025-05-30 2025-06-26 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2025-05-30 2025-06-26 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2025-05-30 2025-06-26 N
Provide or get specialized rehabilitative services as required for a resident. Health 2025-05-30 2025-06-26 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2025-05-30 2025-06-26 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-08-13 2024-09-10 Y
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-04-16 2024-05-16 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2024-04-16 2024-05-16 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2024-04-16 2024-05-16 N
Implement emergency and standby power systems. Fire Safety 2024-04-16 2024-05-16 N
Conduct testing and exercise requirements. Fire Safety 2024-04-16 2024-05-16 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2024-04-16 2024-05-16 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2024-04-16 2024-05-15 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2024-04-16 2024-05-15 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2024-04-16 2024-05-15 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2024-04-16 2024-05-15 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-04-16 2024-05-15 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2024-04-16 2024-05-15 N
Assist a resident in gaining access to vision and hearing services. Health 2024-04-16 2024-05-15 N
Give the resident's representative the ability to exercise the resident's rights. Health 2024-04-16 2024-05-15 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-09-01 2023-01-05 N
Ensure that residents are free from significant medication errors. Health 2022-09-01 2022-12-30 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-09-01 2022-12-08 N
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Health 2022-09-01 2022-12-05 N
Provide and implement an infection prevention and control program. Health 2022-09-01 2022-12-05 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-09-01 2022-12-05 N
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Health 2022-09-01 2022-11-11 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-09-01 2022-11-11 N
Perform COVID19 testing on residents and staff. Health 2022-09-01 2022-11-11 N
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Health 2022-09-01 2022-11-11 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2022-09-01 2022-11-11 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-09-01 2022-11-11 N
Post nurse staffing information every day. Health 2022-09-01 2022-10-21 N
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Health 2022-09-01 2022-10-21 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-09-01 2022-10-21 N
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-09-01 2022-10-21 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Health 2022-09-01 2022-10-21 N
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-09-01 2022-10-21 N
Have a plan that describes the process for conducting QAPI and QAA activities. Health 2022-09-01 2022-10-21 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2022-09-01 2022-10-21 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2022-09-01 2022-10-21 N
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Health 2022-09-01 2022-10-21 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2022-09-01 2022-10-21 N
Keep all essential equipment working safely. Health 2022-09-01 2022-10-21 N
Report COVID19 data to residents and families. Health 2022-09-01 2022-10-21 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2022-09-01 2022-10-21 N
Give the resident's representative the ability to exercise the resident's rights. Health 2022-09-01 2022-10-21 N
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2022-09-01 2022-10-21 N
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Health 2022-09-01 2022-10-21 N
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Health 2022-09-01 2022-10-21 N
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Health 2022-09-01 2022-10-21 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-09-01 2022-10-21 N
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2022-09-01 2022-10-21 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2022-09-01 2022-10-21 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-09-01 2022-10-21 N
Provide activities to meet all resident's needs. Health 2022-09-01 2022-10-21 N
Provide appropriate foot care. Health 2022-09-01 2022-10-21 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-09-01 2022-10-21 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2022-09-01 2022-10-21 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2022-09-01 2022-10-21 N
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Health 2022-09-01 2022-10-21 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-09-01 2022-09-23 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-09-01 2022-09-23 N
Provide a written emergency evacuation plan. Fire Safety 2022-09-01 2022-09-23 N
Implement emergency and standby power systems. Fire Safety 2022-09-01 2022-09-23 N
List the names and contact information of those in the facility. Fire Safety 2022-09-01 2022-09-23 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-09-01 2022-09-23 N

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