Care Citations

CHARLWELL HOUSE HEALTH AND REHABILITATION

305 WALPOLE STREET, NORWOOD, MA, 02062 · 7817627700

On the CMS record

Overall rating (CMS)
1 / 5
Health inspection rating
2 / 5
Staffing rating
4 / 5
Certified beds
124
Ownership type
For profit - Limited Liability company
Chain
BEST CARE SERVICES

Inspection findings on record (63)

Quoted exactly as CMS published them. We do not rewrite findings.

— Resident Assessment and Care Planning Deficiencies

Tag 0658 · scope/severity E · potential for more than minimal harm

Ensure services provided by the nursing facility meet professional standards of quality.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity E · potential for more than minimal harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity E · potential for more than minimal harm

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0655 · scope/severity D · potential for more than minimal harm

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity D · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0677 · scope/severity D · potential for more than minimal harm

Provide care and assistance to perform activities of daily living for any resident who is unable.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity D · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0687 · scope/severity D · potential for more than minimal harm

Provide appropriate foot care.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0756 · scope/severity D · potential for more than minimal harm

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0757 · scope/severity D · potential for more than minimal harm

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0825 · scope/severity D · potential for more than minimal harm

Provide or get specialized rehabilitative services as required for a resident.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity D · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0658 · scope/severity E · potential for more than minimal harm

Ensure services provided by the nursing facility meet professional standards of quality.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0685 · scope/severity E · potential for more than minimal harm

Assist a resident in gaining access to vision and hearing services.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0883 · scope/severity E · potential for more than minimal harm

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0925 · scope/severity E · potential for more than minimal harm

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0551 · scope/severity D · potential for more than minimal harm

Give the resident's representative the ability to exercise the resident's rights.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

Provide safe and appropriate respiratory care for a resident when needed.

Recorded as corrected on .

— Administration Deficiencies

Tag 0835 · scope/severity L · immediate jeopardy

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0880 · scope/severity L · immediate jeopardy

Provide and implement an infection prevention and control program.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0886 · scope/severity L · immediate jeopardy

Perform COVID19 testing on residents and staff.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0686 · scope/severity G · actual harm

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0726 · scope/severity F · potential for more than minimal harm

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.

Recorded as corrected on .

— Nutrition and Dietary Deficiencies

Tag 0812 · scope/severity F · potential for more than minimal harm

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Recorded as corrected on .

— Administration Deficiencies

Tag 0838 · scope/severity F · potential for more than minimal harm

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.

Recorded as corrected on .

— Administration Deficiencies

Tag 0865 · scope/severity F · potential for more than minimal harm

Have a plan that describes the process for conducting QAPI and QAA activities.

Recorded as corrected on .

— Administration Deficiencies

Tag 0867 · scope/severity F · potential for more than minimal harm

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Recorded as corrected on .

— Administration Deficiencies

Tag 0868 · scope/severity F · potential for more than minimal harm

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Recorded as corrected on .

— Environmental Deficiencies

Tag 0908 · scope/severity F · potential for more than minimal harm

Keep all essential equipment working safely.

Recorded as corrected on .

— Environmental Deficiencies

Tag 0925 · scope/severity F · potential for more than minimal harm

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0551 · scope/severity E · potential for more than minimal harm

Give the resident's representative the ability to exercise the resident's rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0584 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0656 · scope/severity E · potential for more than minimal harm

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0658 · scope/severity E · potential for more than minimal harm

Ensure services provided by the nursing facility meet professional standards of quality.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0684 · scope/severity E · potential for more than minimal harm

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0689 · scope/severity E · potential for more than minimal harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0755 · scope/severity E · potential for more than minimal harm

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0758 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0761 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0885 · scope/severity E · potential for more than minimal harm

Report COVID19 data to residents and families.

Recorded as corrected on .

— Infection Control Deficiencies

Tag 0887 · scope/severity E · potential for more than minimal harm

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.

Recorded as corrected on .

— Freedom from Abuse, Neglect, and Exploitation Deficiencies

Tag 0943 · scope/severity E · potential for more than minimal harm

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0552 · scope/severity D · potential for more than minimal harm

Ensure that residents are fully informed and understand their health status, care and treatments.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0557 · scope/severity D · potential for more than minimal harm

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0580 · scope/severity D · potential for more than minimal harm

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0623 · scope/severity D · potential for more than minimal harm

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0625 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0655 · scope/severity D · potential for more than minimal harm

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0679 · scope/severity D · potential for more than minimal harm

Provide activities to meet all resident's needs.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0687 · scope/severity D · potential for more than minimal harm

Provide appropriate foot care.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0690 · scope/severity D · potential for more than minimal harm

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0695 · scope/severity D · potential for more than minimal harm

Provide safe and appropriate respiratory care for a resident when needed.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0698 · scope/severity D · potential for more than minimal harm

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Recorded as corrected on .

— Quality of Life and Care Deficiencies

Tag 0741 · scope/severity D · potential for more than minimal harm

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Recorded as corrected on .

— Pharmacy Service Deficiencies

Tag 0760 · scope/severity D · potential for more than minimal harm

Ensure that residents are free from significant medication errors.

Recorded as corrected on .

— Resident Assessment and Care Planning Deficiencies

Tag 0842 · scope/severity D · potential for more than minimal harm

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Recorded as corrected on .

— Administration Deficiencies

Tag 0849 · scope/severity D · potential for more than minimal harm

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.

Recorded as corrected on .

— Resident Rights Deficiencies

Tag 0577 · scope/severity C · potential for minimal harm

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Recorded as corrected on .

— Nursing and Physician Services Deficiencies

Tag 0732 · scope/severity C · potential for minimal harm

Post nurse staffing information every day.

Recorded as corrected on .

Source: Centers for Medicare & Medicaid Services (CMS) · CMS Certification Number 225208