Charlwell House Health and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for two Residents (#38, #19), out of a total sample of 19 residents. Specifically, the facility failed, for Residents #38 and #19, to ensure pain medication was administered in accordance with the pain scale indicated in the Physician's order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (#27) received treatment to pressure areas on the bilateral heels in accordance with professional standards to promote healing, out of a total sample of 19 residents. Specifically, for Resident #27, the facility failed to assess (including wound description, shape, measurements and condition), document and provide treatments as indicated to pressure ulcers on the bilateral heels.

Inspectors wroteBased on observation and interview, the facility failed to ensure that medications in the refrigerator were stored under the proper temperature for 2 out of 2 medication rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed: 1. For Resident #57, to follow infection control standards while completing a dressing change; and 2. To maintain an infection prevention and control program which included a complete and accurate system of surveillance to identify any trends or potential infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified of changes to a wound for one Resident (#27), out of a total sample of 19 residents. Specifically, for Resident #27, the facility failed to notify the physician of changes to a wound on the right lower extremity from a superficial wound (minor injury that affects only the outermost layer of skin) to a wound with slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) in the wound bed.

Inspectors wroteBased on record review and interview, the facility failed to ensure nursing staff provided the resident and/or representative with a summary of the baseline care plan for one Resident (#126), out of a total sample of 19 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement and individualize a comprehensive care plan for one Resident (#58), out of a total sample of 19 residents. Specifically, the facility failed to ensure a comprehensive care was developed and implemented related to Resident #58's smoking status and preferences.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#66), out of a total sample of 19 residents. Specifically, the facility failed to ensure nail care was performed for Resident #66.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one Resident (#27) received treatment of a wound in accordance with professional standards for quality care, out of a total sample of 19 residents. Specifically, for Resident #27, the facility failed to provide wound treatments as ordered and failed to assess (including wound description, shape, measurements and condition) a wound to the right lower extremity for changes and identify that the wound changed from a superficial wound (minor injury that affects only the outermost layer of skin) to a wound with slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) in the wound bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to schedule a podiatry appointment and failed to ensure good foot health was maintained for one Resident (#27), out of a total sample of 19 residents. Specifically, for Resident #27, the facility failed to schedule an appointment with a community podiatrist per physician's order and failed to provide diabetic foot care in accordance with hospital recommendations and professional standards for the Resident who was at risk for decline in his/her foot health related to a history of diabetes and bilateral amputations.

Inspectors wroteBased on record review and interview, the facility failed to ensure the monthly drug regimen review identified irregularities for one Resident (#34), out of 19 sampled residents. Specifically, the Pharmacist failed to identify and report irregularities (use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) related to the duration of an antibiotic medication (Flagyl) resulting in the Resident receiving an additional 37 doses.

Inspectors wroteBased on record review and interview, the facility failed to ensure the drug regimen for one Resident (#34), out of 19 sampled residents, was free of unnecessary drugs. Specifically, the facility failed to ensure an antibiotic medication (Flagyl) was not given in excessive duration resulting in the Resident receiving an additional 37 doses.

Inspectors wroteBased on record review and interviews, for one Resident (#69), of 19 sampled residents, the facility failed to provide specialized rehabilitative services, specifically physical and occupational therapy, as ordered.

Inspectors wroteBased on records reviewed and interviews for three of three sampled residents (Resident #1, #2, and #3), the Facility failed to ensure they maintained complete and accurate medical records, related to Certified Nurse Aide (CNA) Activity of Daily Living (ADL) Flow Sheets, when daily documentation by CNA's were not consistently completed, with ADL Flow Sheets often left completely blank. Findings Include: Review of the Facility's Policy tilted Charting and Documentation, dated as last revised July 2017, indicated all services provided to the resident, progress towards care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The Policy further indicated documentation in the medical record will be complete and accurate. [...]

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to follow professional standards for two Residents (#24 and #219), out of a total sample of 20 residents. Specifically, the facility failed: 1. For Resident #24, to reconcile the Resident's medications from the hospital discharge summary to restart Plavix (Clopidogrel- antiplatelet medication that prevents blood clots from forming) on 10/18/23, resulting in the Resident missing 65 doses of Plavix from 10/18/23 to 12/18/23; and 2. For Resident #219, to ensure the Resident's transparent semi-permeable membrane (TSM) dressing to the left upper extremity midline catheter was changed in accordance with the physician's order following readmission, and in accordance with the facility policy.

Inspectors wroteBased on record review and interviews, the facility failed to obtain the recommended eye care services in a timely manner to maintain the highest psychosocial well-being of one Resident (#42), out of a total sample of 20 residents. Specifically, the facility failed to ensure follow-up appointments were scheduled for an eye specialist for cataract surgery (indicated when clouding of the normally clear lens of the eye impairs vision and interferes with usual day-to-day activities), after the initial appointment was canceled due to lack of transportation resulting in a four-month delay.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure that drugs and biologicals were labeled and stored in accordance with current accepted professional standards. Specifically, the facility failed to ensure medications were properly labeled with a shortened expiration date upon opening and the resident's name was on the medication in two of four medication carts in use by the facility.

Inspectors wroteBased on record review, interview, and policy review, the facility failed, for five of five sampled Residents (#219, #33, #8, #13, and #53), to ensure residents were offered the pneumonia vaccine, unless the immunization was medically contraindicated or the resident had already been immunized.

Inspectors wroteBased on observation, interview, and documentation review, the facility failed to implement an effective pest control program, as evidenced by sanitation concerns, mice sightings, and mice droppings on two of two open resident units (A and B), on one closed resident unit (C), and the laundry room.

Inspectors wroteBased on interview and record review, the facility failed to ensure a [NAME] Treatment Plan (court approved treatment plan for the administration of antipsychotic medications) was obtained prior to the administration of an antipsychotic medication for one Resident (#8), in a total sample of 20 residents.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure that for one Resident (#60), out of a total sample of 20 residents, that care and treatment to the Resident's urinary drainage device was provided in accordance with the facility policy. Specifically, the facility failed to ensure that the Resident's suprapubic catheter bag was positioned in a method to avoid potential contamination.

Inspectors wroteBased on record review, observation, and staff interview, the facility failed to ensure that for one Resident (#40), out of 17 sampled residents, that oxygen delivery equipment was replaced in accordance with the physician's order.

Inspectors wroteBased on observation, interview, and record review, the Administration failed to 1. Initiate an appropriate response to an outbreak of COVID-19 when a staff member tested positive for COVID-19 on [DATE]; and 2. Implement the facility's infection prevention and control program, including testing of staff and residents, and cohorting and quarantine measures to protect vulnerable residents during a COVID-19 outbreak. The facility's COVID-19 outbreak began on [DATE]. As of [DATE], the facility identified 5 staff members and 18 residents had tested positive for COVID-19. Five of the positive residents were sent to the hospital and one unvaccinated resident died at the facility after being exposed to their COVID-19 positive roommate. It was determined the Immediate Jeopardy began on [DATE] and was identified on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections, including COVID-19. Specifically, the facility failed to 1. Identify and respond to an outbreak of COVID-19 on [DATE]; 2. Ensure staff implemented infection prevention and control practices including: a. Cohorting residents during an outbreak, including those who were not up to date with the COVID-19 vaccine, and b. Utilizing the appropriate personal protective equipment (PPE) between the care of COVID-19 positive residents and COVID-19 negative residents, including those residents who were not up to date with the COVID-19 vaccine; and 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to conduct COVID-19 testing in accordance to 1. Initiating outbreak testing when a staff member tested positive on [DATE]; 2. Initiating testing for Resident #67 who was exposed to COVID-19 and presented with symptoms; 3. Determining if contact tracing or group level testing should be conducted, including following guidelines from the local health authority; 4. Following community transmission levels for routine testing of staff; and 5. Following infection control practices while testing staff. The facility's COVID-19 outbreak began on [DATE]. As of [DATE], the facility identified 5 staff members and 18 residents had tested positive for COVID-19. Five of the positive residents were sent to the hospital and one unvaccinated resident died at the facility after being exposed to their COVID-19 positive roommate. [...]

Inspectors wroteBased on record review, interview, and observation, the facility failed for one Resident (#78), out of a total of 22 sampled residents, to a. Initiate treatment to the Resident's mid coccyx to promote wound healing, and b. Ensure the Resident was evaluated by the wound practitioner for multiple pressure ulcers (stage 2 and 3).

Inspectors wroteBased on interview, record review, review of employee education files, and policy review, the facility failed to: 1. Ensure 5 out of 5 staff nurses had completed training and competencies for specialized respiratory care, specifically tracheostomy care; and 2. For Resident #401, provide competent nursing care for a Resident with a tracheostomy.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure the main kitchen and 3 of 3 kitchenettes were clean and sanitary to ensure safe food storage and service and to prevent the potential spread of foodborne illness to residents who are at high risk.

Inspectors wroteBased on review of the Facility Assessment and interviews, the facility failed to conduct and document a facility wide assessment that accurately reflected the resources necessary to care for its residents. Specifically, the facility failed to: 1. Complete a Facility Assessment which accurately reflected the average daily census; 2. Identify the utilization of agency/temporary staff; 3. Conduct staff training and competencies of nursing staff; 4. Ensure that the Facility Assessment identified the facility would accept residents with specialized respiratory care, specifically for the care and treatment of a tracheostomy and have competent staff to provide the care; 5. Include contracts, memorandums of understanding, or other agreements with third parties that provide services or equipment to the facility during both normal operations and emergencies; and 6. [...]

Inspectors wroteBased on interview and policy review, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) plan that describes their approach to improving the quality of life, care, and services to residents in the facility.

Inspectors wroteBased on record review and interviews, the facility failed to define, implement, and maintain a comprehensive quality assurance and performance improvement (QAPI) plan to address the full range of care and services provided by the facility, including infection control practices during the COVID-19 pandemic.

Inspectors wroteBased on policy review and interview, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee that included the required members at their meetings.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff implemented a system to ensure that all mechanical and electrical kitchen equipment was maintained in safe operating condition.

Inspectors wroteBased on observation, document review, and interview, the facility failed to maintain an effective pest control program ensuring that the facility, including the main kitchen and three of three nutrition kitchenettes were free from pests, including mice and roaches.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that the resident representative had information in advance to exercise the resident's rights for four Residents (#13, #102, #301, and #44), out of sample of 22 residents and three closed records. Specifically, the facility failed to ensure that for: 1. Resident #13, the legal guardian (a person who has been appointed by a court or otherwise has the legal authority to care for the personal and property interests of another person who is deemed incapacitated) signed consents for equipment, services, and treatment upon admission to the facility; 2. Resident #102, a valid, court approved [NAME] treatment plan was in place for the administration of antipsychotic medication and risk/benefits were identified for consent for the use of psychotropic medication; 3. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure that residents had a safe, clean, homelike environment on one unit (C Unit) out of three units in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure that individualized, comprehensive care plans were developed and consistently implemented for seven Residents (#13, #35, #49, #65, #93, and #76), out of 22 sampled residents. Specifically, the facility failed 1. For Resident #13, to develop a care plan for the use of psychotropic medications that identified target behaviors, non-pharmacological interventions, and measurable goals of treatment; 2. For Resident #35, to develop a care plan for the use of psychotropic medications that identified target behaviors, non-pharmacological interventions, and measurable goals of treatment; 3. For Resident #49, to: a. develop a care plan for the use of psychotropic medications that identified target behaviors and measurable goals of treatment; and b. implement non-pharmacological interventions for behaviors; 4. [...]

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for five Residents (#13, #28, #103, #301, and #92), out of a total sample of 22 residents. Specifically, the facility failed 1. For Resident #13, a. To ensure psychotropic medications were not administered without signed, informed consent from the legal Guardian; b. To ensure specialized compression wraps were obtained according to physician's orders; 2. For Resident #28, to ensure the Resident's pacemaker was monitored and evaluated as per the facility policy and standards of practice; 3. For Resident #103, to ensure psychotropic medications were not administered without signed, informed consent; 4. [...]

Inspectors wrote3. Review of the facility's policy titled Death of a Resident/Patient, dated 7/2016, included but was not limited to: -Assess the resident/patient for vital signs: apical pulse, respirations, blood pressure -Document the following in the Nurse's Note: -Time absence of vital signs was determined -Time and name of Physician notified -Time and name of family member notified -Name of designated funeral home and time notified -Name of funeral home representative and time body released -Status of deceased resident/patient's personal possessions and what was sent with the body (i.e., glasses, dentures, etc.) Resident #102 was admitted to the facility in June 2022 with diagnoses including a history of a stroke, hypertension, and diabetes mellitus. Review of the medical record indicated a 7/2/22 Clinical Nurse's Note indicated: Resident found at 6:15 A.M. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure staff provided residents an environment free from accident hazards on two units (Unit B and Unit C) of three units in the facility. Specifically, the facility failed to: 1. ensure the clean utility room was securely locked and hazardous items were not easily accessible to wandering residents on the Unit C; and 2. ensure medication was properly disposed of and not accessible to wandering residents on Unit B.

Inspectors wroteBased on observation, interview, document review, and policy review, the facility failed to safely provide pharmaceutical services to ensure the provision of emergency medications and accurate acquiring, receiving, and dispensing of drugs to meet the needs of its residents on one (Unit B) of three units.

Inspectors wroteBased on record review, policy review, and staff interviews, the facility failed to ensure that for nine Residents (#1, #13, #28, #35, #49, #65, #93, #103, and #301), out of a total sample of 22 residents, that each Resident's drug regimen was free of unnecessary drugs. Specifically, the facility failed to ensure that an appropriate diagnosis was identified, targeted behaviors/signs and symptoms were monitored to evaluate the effectiveness of psychotropic medication, and/or potential side effects were identified and monitored to promote or maintain the Residents' highest practicable mental, physical, and psychosocial well-being, per the facility policy.

Inspectors wroteBased on observation, interview, document review, and policy review, the facility failed to ensure all medications used in the facility were safely and securely stored and labeled in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Properly label all medications stored in 3 out of 6 medication carts; 2. Maintain consistent documentation of medication refrigerator temperatures for 1 out of 3 unit medication refrigerators and report temperatures out of range; 3. Ensure staff locked 2 out of 6 medication carts when unattended; and 4. Ensure safe and locked storage of 2 out of 3 unit treatment carts when unattended.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure resident representatives/families were notified of each new COVID-19 positive staff member or resident case by 5:00 P.M. the following day.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain education documentation regarding the benefits and potential risks associated with the COVID-19 vaccine for four Residents (#32, #74, #352, and #7), out of five sampled unvaccinated residents.

Inspectors wroteBased on interviews, record review, and review of the facility assessment, the facility failed to develop, implement, and permanently maintain an effective training program for newly hired staff, to include training on prevention of abuse, neglect, exploitation, misappropriation of resident property and dementia management. Specifically, a review of employee education records indicated 7 out of 7 employees had not received education related to prohibition of abuse and dementia management.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure residents were given information necessary to make health care decisions, including the risks and benefits of a psychoactive medication and consent for its use, prior to administration, for one Resident (#103) of three closed records reviewed, out of a total sample of 22 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff treated each resident with respect and dignity including the right to use their own clothing for one Resident (#402), out of a total sample of 22 residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Physician was notified that treatments were not administered as ordered for one Resident (#58), out of a total sample of three residents. Specifically, the facility failed to notify the Physician/Nurse Practitioner that treatment orders were not transcribed accurately resulting in the Resident receiving only 20 of 42 prescribed doses of antifungal treatments.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure the resident and/or the resident's representative was provided written notice of a transfer, appeal rights, and Ombudsman contact information, as required for three Residents (#35, #49, and #22), out of a total sample of 22 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident and/or the resident's representative was provided a written notice of a bed hold transfer as required for three Residents (#35, #49, and #22), out of a total sample of 22 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that staff developed and provided to residents, a baseline care plan within 48 hours of the resident's admission, that included but was not limited to the initial goals of the resident, summary of the resident's medications and dietary instructions, and services and treatments to be administered by the facility, for two Residents (#76 and #103), out of a total sample of 22 residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to provide two Residents (#402 and #13), out of a total sample of 22 residents, an activity program that engaged the Residents and supported their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure that for one Resident (#81), out of a total sample of 22 residents, the Resident received proper care and treatment to maintain mobility and good foot health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services for one Resident (#78), out of four residents with indwelling catheters (tube inserted into the bladder to drain urine), out of a total sample of 22 residents. Specifically, the facility failed to obtain a physician's order for the Resident's Foley catheter upon admission to the facility including Foley catheter care and failed to provide Foley catheter care and ongoing assessment in order to prevent catheter-related urinary tract infections.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure that care and treatment of a tracheostomy (a surgically created opening in the windpipe to keep it open) was provided in accordance with the facility policy/protocols and professional standards of practice for one of one Resident (#401) with a tracheostomy, out of a total sample of 22 residents. Specifically, the facility failed to: a.) Obtain physician's orders to provide a person-centered care plan for care of tracheostomy and tracheostomy tube and speaking valve; b.) Implement the facility protocol for scheduled tracheostomy tube, inner cannula, tube ties/holder and mask changes, along with suctioning to prevent airway occlusion and respiratory infections; [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, for one Resident (#39), of one resident receiving dialysis, out of a total sample of 22 residents. Specifically, the facility failed to ensure ongoing communication and collaboration between the facility and the dialysis center.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure staff had the skills necessary to meet the behavioral healthcare needs of one Resident (#49), out of a sample of 22 residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one Resident (#302) remained free of significant medication errors, in a total sample of 14 residents. Specifically, Resident #302 was administered a COVID-19 bivalent booster dose without having received a primary monovalent series of the COVID-19 vaccine.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain medical records that are complete, accurate, and systemically organized within accepted professional standards of practice for one Resident (#60), out of a total sample of 22 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that services were coordinated with the Hospice provider to implement the resident's plan of care as required in the provider contract agreement for one Resident (#93), out of a total sample of 22 residents.

Inspectors wroteBased on observation and interviews, the facility failed to make the most recent survey results of the facility available in a place readily accessible to residents, family members, and legal representatives of residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure Nurse staffing information posted was accurate and included the current date, total number and actual hours worked by licensed and unlicensed staff, Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nurse Aides (CNA), and the resident census as required.