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Deficiency Records for Charlwell House Health and Rehabilitation

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.

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?
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
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2024-04-30 2024-05-16 N
Conduct testing and exercise requirements. Fire Safety 2024-04-30 2024-05-16 N
Implement emergency and standby power systems. Fire Safety 2024-04-30 2024-05-16 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2024-04-30 2024-05-16 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2024-04-30 2024-05-16 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-04-30 2024-05-16 N
Give the resident's representative the ability to exercise the resident's rights. Health 2024-04-16 2024-05-15 N
Ensure services provided by the nursing facility meet professional standards of quality. 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
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
Provide safe and appropriate respiratory care for a resident when needed. 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
Develop and implement policies and procedures for flu and pneumonia vaccinations. 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
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
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
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

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