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Deficiency Records for Birchwood Care Home
A list of the most recent deficiencies for Birchwood Care Home. 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 Birchwood Care Home. 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? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-01 | 2024-07-26 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-05-01 | 2024-07-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-01 | 2024-07-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-05-01 | 2024-07-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-01 | 2024-07-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-06-18 | 2024-07-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-07-03 | 2024-07-03 | Y |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2024-05-03 | 2024-06-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-05-03 | 2024-06-20 | 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 | 2024-05-03 | 2024-06-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-03 | 2024-06-20 | N |
| Respond appropriately to all alleged violations. | Health | 2024-05-03 | 2024-06-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-03 | 2024-06-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-03 | 2024-06-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-03 | 2024-06-20 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-05-03 | 2024-06-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-05-03 | 2024-06-20 | 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 | 2024-05-03 | 2024-06-20 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-05-03 | 2024-06-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-05-03 | 2024-06-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-05-03 | 2024-06-20 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-05-03 | 2024-06-20 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-05-03 | 2024-06-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-05-03 | 2024-06-20 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| Develop a communication plan. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-03 | 2024-06-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-05-01 | 2024-06-20 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2024-05-01 | 2024-06-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-05-01 | 2024-06-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-05-01 | 2024-06-05 | 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 | 2024-05-01 | 2024-05-23 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-03-22 | 2024-05-17 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2024-05-01 | 2024-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-15 | 2024-04-20 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2024-03-15 | 2024-04-20 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-03-22 | 2024-04-19 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2024-03-22 | 2024-04-17 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-07 | 2023-08-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-07 | 2023-08-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-06-07 | 2023-08-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-07 | 2023-08-15 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-06-07 | 2023-08-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-07 | 2023-08-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-07 | 2023-08-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-07 | 2023-08-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-08 | 2023-08-08 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-06-08 | 2023-08-08 | Y |
| Establish emergency prep training and testing. | Fire Safety | 2023-06-08 | 2023-08-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-28 | 2023-03-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-26 | 2023-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-20 | 2022-11-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-10 | 2022-10-27 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-10-10 | 2022-10-27 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-10-10 | 2022-10-27 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-10-10 | 2022-10-27 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-10-10 | 2022-10-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-09 | 2022-06-30 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-03-02 | 2022-04-08 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-02 | 2022-04-08 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-03-02 | 2022-04-08 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-03-02 | 2022-04-08 | 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 | 2022-03-02 | 2022-04-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-02 | 2022-04-08 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2022-03-02 | 2022-04-08 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-03-01 | 2022-03-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-01 | 2022-03-22 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-03-01 | 2022-03-22 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-03-01 | 2022-03-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-03-01 | 2022-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-01 | 2022-03-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-01 | 2022-03-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-15 | 2021-12-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-15 | 2021-12-21 | Y |
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