Deficiency Records for Charlwell House Health and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Charlwell House Health and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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 services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-01 | 2022-12-30 | 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 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-01 | 2022-12-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 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 |
| 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 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 |
| 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 |
| 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 |
| 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 |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-01 | 2022-11-11 | 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 |
| 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 |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | 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 |
| 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 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 |
| Report COVID19 data to residents and families. | Health | 2022-09-01 | 2022-10-21 | N |
| Keep all essential equipment working safely. | 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 |
| 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 |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-09-12 | 2022-09-23 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-09-12 | 2022-09-23 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-09-12 | 2022-09-23 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-09-12 | 2022-09-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-12 | 2022-09-23 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-12 | 2022-09-23 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-01-27 | 2022-02-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-19 | 2021-11-10 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-07-06 | 2021-10-15 | 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 | 2021-07-06 | 2021-10-15 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-07-06 | 2021-10-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-07-06 | 2021-10-15 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-07-06 | 2021-10-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-06 | 2021-10-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-06-17 | 2021-10-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-06-17 | 2021-10-15 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-06-17 | 2021-10-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-06-17 | 2021-10-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-06-17 | 2021-10-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-06-17 | 2021-10-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-06-17 | 2021-10-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-06-17 | 2021-10-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-06 | 2021-09-17 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-07-06 | 2021-09-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-06 | 2021-09-17 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-06 | 2021-09-17 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-07-06 | 2021-09-17 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-07-06 | 2021-09-17 | 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 | 2021-07-06 | 2021-09-17 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-07-06 | 2021-09-17 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-06 | 2021-09-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-06 | 2021-09-17 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-06 | 2021-09-17 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2021-07-06 | 2021-09-17 | N |
| Provide activities to meet all resident's needs. | Health | 2021-07-06 | 2021-09-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-06 | 2021-09-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-06 | 2021-09-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-07-06 | 2021-09-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-06 | 2021-09-17 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-07-06 | 2021-09-17 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-06 | 2021-09-17 | 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 | 2021-07-06 | 2021-09-17 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-07-06 | 2021-09-17 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-07-06 | 2021-09-17 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-07-06 | 2021-09-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-07-06 | 2021-09-17 | 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 and emergencies. | Health | 2021-07-06 | 2021-09-17 | 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 | 2021-07-06 | 2021-09-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-07-06 | 2021-09-17 | N |
| Keep all essential equipment working safely. | Health | 2021-07-06 | 2021-09-17 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2021-07-06 | 2021-09-17 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2021-07-06 | 2021-09-17 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-07-06 | 2021-09-17 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-07-06 | 2021-09-17 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-06-17 | 2021-09-17 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-06-17 | 2021-09-17 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-06-17 | 2021-09-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2021-06-17 | 2021-09-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-06-17 | 2021-09-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-06-17 | 2021-09-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-06-17 | 2021-09-17 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-06-17 | 2021-09-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-17 | 2021-09-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-06-17 | 2021-09-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-06 | 2021-08-28 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-07-06 | 2021-08-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-06 | 2021-08-28 | N |
| Dispose of garbage and refuse properly. | Health | 2021-07-06 | 2021-08-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-12 | 2021-08-10 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-06-17 | 2021-08-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-06-17 | 2021-08-09 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-06-17 | 2021-08-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-06 | 2021-07-15 | N |
| Report COVID19 data to residents and families. | Health | 2021-06-02 | 2021-06-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-12 | 2021-05-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-22 | 2021-05-21 | Y |
| 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 | 2021-04-22 | 2021-05-21 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-04-22 | 2021-05-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-22 | 2021-05-21 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-08-15 | 2019-09-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-08-15 | 2019-09-10 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-15 | 2019-09-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-15 | 2019-09-10 | N |
