Charlwell House Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Charlwell House Health and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Sep 1, 2022

  Based 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. […]

• Immediate jeopardy, widespreadF880Sep 1, 2022

  Based 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. […]

• Immediate jeopardy, widespreadF886Sep 1, 2022

  Based 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. […]

• Immediate jeopardy, patternF689Jul 6, 2021

  Based on observation, record review, and interviews, the facility failed to: 1) provide adequate supervision for 10 Residents (#3, #6, #2, #41, #28, #18, #29, #48, #54 and #5) who have been assessed as being at risk for elopement. Specifically the facility failed: -To provide adequate supervision for residents who have been assessed as being at risk for elopement as its electronic system for monitoring residents with wandering behavior to prevent their elopement from a secure unit was not working, and the Facility had not initiated repairs or alternative methods of monitoring for elopement at the time of survey to ensure the resident's safety. […]

• Immediate jeopardy, isolatedF658Apr 22, 2021

  Based on records reviewed and interviews for two of three sampled residents (Resident #3 and Resident #2), the Facility failed to ensure nursing staff provided care and services that met professional standards of practice. -On [DATE], Resident #3, who experienced an acute change in condition, which included nausea, vomiting, decreased oxygen saturation levels with the need to increase his/her oxygen liter flow from 2 liters to 4 liters, and had increased lethargy, that despite being instructed by the Physician to have Resident #3 transported emergently to the Hospital Emergency Department (ED) for evaluation, Nurse #2 called for a non-medical chair van service to transport Resident #3 to the ED, and while being transported, Resident #3 vomited, became unresponsive, and died in the chair… […]