Charlwell House Health and Rehabilitation Center

Charlwell House

MI Elder Abuse Free Legal ConsultationDid someone you love suffer elder abuse or neglect at Charlwell House? Our lawyers can help.

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation.

Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

About Charlwell House

Charlwell House is a for profit, 124-bed Medicare/Medicaid certified skilled nursing facility that provides services to the residents of Westwood, Dedham, Canton, Walpole, Sharon, Medfield, Needham, Stoughton, Milton, Norfolk, Randolph, Wellesley, Foxborough, Natick, Newton, and the other towns in and surrounding Bristol County, Massachusetts.

Charlwell House
305 Walpole St
Norwood, MA 02062

Phone: (781) 762-7700

CMS Star Quality Rating

Charlwell HouseThe Centers for Medicare and Medicaid (CMS) rates all nursing homes that accept medicare or medicaid benefits. CMS created a 5 Star Quality Rating System—1 star is the lowest rating and 5 stars is the highest—that look at three areas.

As of 2018, Charlwell House in Norwood, Massachusetts received a rating of 4 out of 5 stars.

Performance Area Rating
Overall Rating 4 out of 5 (Above Average)
State Health Inspections 3 out of 5 (Average)
Staffing 4 out of 5 (Above Average)
Quality Measures 3 out of 5 (Average)

Fines Against Charlwell House

The Federal Government has not fined Charlwell House in the last 3 years.

Fines and Penalties

Our Nursing Home Accident Lawyers inspected government records and discovered Charlwell House committed the following offenses:

Failed to keep each resident free from physical restraints, unless needed for medical treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to assess the use of a self-releasing seatbelt as a restraint for 1 resident, (#16), out of a total of 23 sampled residents.

Findings include:

Resident #16 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. During initial tour on 4/18/17 at 8:37 A.M., Resident #16 was observed seated in his/her wheelchair with a seatbelt around his/her waist. At 8:40 A.M., Nurse #1 said that Resident #16 is able to release the seatbelt himself/herself and that Nurse #1 toilets the resident at 11:00 A. M., and that is when he/she is able to demonstrate that he/she is able to self release. Nurse #1 said that Resident #16 has the belt as he/she often stands up unassisted and is a fall risk.

Review of the facility’s restraint policy dated 8/2016 indicated the following: Procedure: Assess resident’s need for restraint use, obtain consent for restraint use, obtain physician’s orders [REDACTED]. Documentation: Date and time restraint is to be applied, fall risk assessment, assessment for restraint use, consent for restraint use, date and time of episode of behavior that led to the use of the restraint, type of restraint use, frequency of checking the resident, frequency and length of time the restraint is released, condition of the part restrained, condition of the resident while restrained, effectiveness of the restraint, repositioning, exercise and toileting of the resident, other measures used to control behavior.

During Review of Resident #16’s clinical record, there was no evidence or documentation that a physician’s orders [REDACTED]. The only documentation in Resident #16’s clinical record that indicated he/she was utilizing a seatbelt was in his/her Falls Risk Careplan dated 9/20/16. The intervention of the self release belt in wheelchair did not indicate a start date, the reason why the seat belt was being utilized, or identify a means of monitoring the use of the device.

During interview with Unit Manager #1 and Nurse #1 on 4/21/17 at 8:47 A.M., they said that Resident #16 had been using the seatbelt since 11/2016 or 12/2016 but could not remember for sure. During interview with the Rehab Director on 4/21/17 at 9:55 A.M., she said that should a resident be assessed to determine if a device is either a restraint or a device used for positioning, mobility, or safety, the expectation is that a referral would be made to the rehab department to assess the resident and the device. She said that since she had started working at the facility in 11/2016 no one from the rehab department had been asked to perform an assessment on any resident, including Resident #16, utilizing a seatbelt to determine if the seatbelt was a restraint or not.

Surveyor #3 observed two attempts by Nurse #1 to ask Resident #16 to release his/her seatbelt on 4/21/17 at 8:55 A.M., and at 10:30 A.M. During both attempts, Nurse #1 asked the Resident multiple times to release his/her belt and placed his/her hands on the belt itself. Nurse #1 reported that this is not Resident #16’s usual baseline and that he/she was very lethargic.

During interview with CNA #1 on 4/21/17 at 9:00 A.M., she said that the resident can release the belt, but not when he/she is sleepy. On 4/21/17 at 11:55 A.M., the Director of Nursing, (DON), and Administrator met with the Survey team. During this interview, the DON said that the facility did not consider the use of a seatbelt of Resident #16 as a restraint as he/she could self release it.

She said because of this the facility did not follow their Restraint Policy and no assessment, consent, or physician’s orders [REDACTED].

Surveyor #3 asked what the purpose of the use of self-releasing seatbelts in the facility are for, and the DON said that the belt is used to have the residents stay seated. She said that staff had made her aware that Resident #16 was unable to release the belt during earlier observations with the surveyor, and attributed this to the fact that the resident was lethargic that day and it was not the norm for the resident. When asked about the facility’s process of monitoring the use of devices, such as seatbelts, for residents to determine when they may become a restraint as resident’s functional abilities decline, the DON said that there is no current system in place to monitor. The facility failed to implement an appropriate process for initiating, documenting, and monitoring appropriate devices that restrain residents.

Failed to hire only people with no legal history of abusing, neglecting or mistreating residents; or report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow its policy and procedure for reporting allegations of sexual abuse for one sampled Resident (#9), out of 23 sampled residents to the State Agency as required.

Findings include:

Resident #9 was admitted to the facility in 7/2016 with the [DIAGNOSES REDACTED]. Review of nurses notes dated 3/18/17 at 6:36 A.M., indicated that Resident #9 reported, inappropriate touching during care with foul language, I’m very scared, nursing director made aware and this writer sent CNA home per DON at 5:45 A.M., one on one with positive effect nursing supervisor also made aware Resident comf. at present.

Review of Facility Abuse Prevention Policy and Procedure for Reporting that dated 4/17/17 indicated the following process: Notify the law enforcement and appropriate State Agency immediately by fax or telephone after identification of alleged/suspected incident. During interview with the Administrator and Director of Nursing, on 4/20/17 at 11:50 A.M., they acknowledged that although the facility investigated Resident #9’s allegation of abuse, they did not report it to the State Agency.

Failed to provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality.

The facility failed to provide a dignified dining experience for residents on the B and A units.

Findings include:

Review of the facility’s Dependent Eating Policy dated 8/2016 indicated the following: Never make the resident feel that the meal must be hurried, but that the procedure is pleasant. Give him/her your complete attention. Sit so you are at the same level as the resident when possible.

On 4/21/17 at 9:00 A.M., two staff CNAs were observed standing while feeding residents and speaking in a foreign language in the A unit dinning area. On 4/21/17 at 12:51 P.M., in the B Unit dining area, one CNA was observed seated next to a resident she was assisting with lunch. Another aide was standing next to him/her and both were speaking in a foreign language. Another aide appeared to be sleeping in a corner of the dining area. Her eyes were closed and her head was resting on her hand. During interview with the Administrator on 4/21/17, at 12:55 P.M., she said that although the facility has no formal policy on staff speaking in foreign languages in resident areas or in front of residents, she said that staff are expected to not speak in foreign languages in front of residents.

Failed provide care by qualified persons according to each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on chart review, interview, and observation., the facility failed to follow physician’s orders for 3 residents (#6,#7,#9), out of a total of 23 sampled residents.

Findings include:

1. For Resident #9, the facility failed to apply the soft neck collar to the Resident while out of bed. Resident #9 was admitted to the facility on ,[DATE] with the [DIAGNOSES REDACTED]. Review of Physicians Order dated 7/27/16 indicated Resident #9 was to wear Soft Neck Collar when out of bed every day and evening shift for Cervical Radiculopathy. On 4/20/17 at 8:30 A.M., Resident was observed in her room in the wheelchair having breakfast not wearing soft neck collar. At 10:30 A.M., Resident observed in her room in wheelchair talking to visitor still not wearing soft neck collar. Unit Manager (UM) was interviewed on 4/20/17 at 11:00 A.M., and said that Resident wears it for comfort only, and that he/she take it off when he/she does not want it. UM said that she will ask physician to evaluate and change the order to only as needed.

2. For Resident #7, the facility failed to follow a physician’s order to check his/her bed alarm every shift. Resident #7 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #7’s physician’s orders indicated the following: Bed Sensor Alarm, Check alarm every shift, initiated 7/21/16. Review of Resident #7’s TARs dated 1/2017, 2/2017, and 3/2017 indicated that no staff completed the bed alarm checks as ordered and the sections were completely blank. Resident #7’s TAR dated 4/2017 indicated that the only time his/her bed sensor alarm was checked was on 4/18/17. During interview with the DON and the Administrator, on 4/20/17 at 8:20 A.M., the DON said that the staff caught the error this week and began documenting the checks on 4/18/17. She attributed the error to a computer glitch

3. For Resident #6, the facility failed to administer medications as ordered by the Resident #6 was admitted to the facility in (YEAR) with [DIAGNOSES REDACTED]. Review of Resident #6’s physician’s orders indicated the following: [MEDICATION NAME]-[MEDICATION NAME] 25-100 MG; give 2 tablets two times a day for [MEDICAL CONDITION]

Pramipexole [MEDICATION NAME] tablet .125 mg give 1 tablet two times a day for [MEDICAL CONDITION] Pramipexole [MEDICATION NAME] tablet .25 mg give 2 tablet two times a day for [MEDICAL CONDITION] Creon Capsule Delayed Release 6000 unit give 1 capsule three times a day for Pancreas Comatin Tablet 200 MG by mouth five times a day for [MEDICAL CONDITION] Review of Resident #6’s MAR indicated [REDACTED].

Failed to make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow their falls protocol and complete an investigation for 1 sampled resident, (#16), out of a total of 23 sampled residents.

Findings include:

Resident #16 was admitted to the facility in 8/2016 with [DIAGNOSES REDACTED]. Review of Resident #16’s clinical record indicated that on 11/25/16 he/she had fallen in his/her room at 3:40 A.M., without injury. The note indicated that the resident’s care proxy and physician were notified of the fall. Review of the facility’s Fall Policy, dated 3/1/16, indicated that an investigation, incident report, and updates to careplans are to be completed after a fall to prevent further falls from taking place. On 4/21/17 at 10:00 A.M., the Director of Nursing said that she was not made aware that the resident had fallen and no incident report or investigation had been done per facility policy.

Failed to store, cook, and serve food in a safe and clean way

Based on observation and interview, the facility failed to maintain sanitary practices allowing cross contamination during the tray line service.

Findings include:

On 4/20/17 between 7:35 A.M. and 7:46 A.M., Surveyor #3 made direct observations of the tray line service for the breakfast meal. Cook #1 was observed wearing gloves and touching food items such as pancakes, sausages and orange slices and placing the items on plates. Cook #1 was then observed removing the covers from the heated plate truck with her gloved hands and returned to the tray line and continued to pick up food items without washing her hands and changing gloves. Cook #1 was observed repeating this three times throughout the tray line service. Surveyor #3 observed the the covers of the heated plate truck which appeared soiled and spattered with food particles.

At 7:46 A.M., the Food Service Director said that the covers from the heated plate truck were wiped down daily and are cleaned weekly. He said he understood the concerns with cross contamination and that Cook #1 should have used utensils to serve food items instead of gloved hands.

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Based on observation, the facility failed to appropriately secure medications on 1 of 4 units.

Findings include:

During rounds on the B unit at 8:42 A.M., on 4/19/17, Surveyor #3 observed a medcart unattended and 3 tablets of levaquin, (an antibiotic used to treat infections), on top of the cart with no staff in the immediate area. When the med nurse returned to the cart, she said that the tablets should not have been left on top of the medcart unattended and medication should be secured.

Charlwell House, Nursing Home Neglect and Elder Abuse Lawyers

If someone you love has suffered neglect or elder abuse by a senior caregiver, nursing home, or other care facility, our lawyers may be able to help. Regardless of whether or not criminal charges are filed against an alleged abuser, you may still be able to pursue compensation in a civil claim. Compensation in elder abuse cases may be awarded if someone in the care of another suffers harm due to intentional or negligent actions (including failure to take action).

Abuse of the elderly is not acceptable and we fight hard in these types of cases. If you suspect a nursing home or caregiver has caused harm to your loved one in someone elses’ care, contact our law firm today for a free legal consultation. Talking to us does not obligate you to anything, but we may be able to tell you if you have a claim and the value of your case. If we accept your case, you pay no fee unless we recover for you.

Oftentimes, victims of abuse either cannot or will not speak up for themselves out of fear. If you notice any warning signs or symptoms of neglect of abuse an an elderly person, it is important you contact an elder abuse lawyer immediately. Not only are there statute of limitations on filing a claim, but the sooner we start helping you, the easier it will be to collect evidence and talk to any witnesses before important details are lost, hidden, or forgotten.

Boston Personal Injury Lawyers for Elder Abuse Cases

We offer a free, no-obligation legal consultation to help you understand your rights and the value of your case. Our personal injury law firm takes cases involving elder abuse and neglect. We offer legal service to clients in Massachusetts, Rhode Island and New Hampshire.


Sources:

Medicare Nursing Home Profiles and Reports – Charlwell House

Inspection Report for Charlwell House – 04/21/2017

Page Last Updated: October 14, 2018