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Deficiency Records for The Birch at Sutherland
A list of the most recent deficiencies for The Birch at Sutherland. 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 The Birch at Sutherland. 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? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2024-02-14 | 2024-03-29 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-02-14 | 2024-03-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-14 | 2024-03-29 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-14 | 2024-03-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-14 | 2024-03-29 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-11-16 | 2023-12-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-11-16 | 2023-12-31 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-11-16 | 2023-12-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-16 | 2023-12-31 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-11-16 | 2023-12-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-16 | 2023-12-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-16 | 2023-12-31 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-11-14 | 2023-12-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-09 | 2023-08-31 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-08-09 | 2023-08-31 | Y |
| 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. | Health | 2022-09-01 | 2022-10-16 | N |
| 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. | Health | 2022-09-01 | 2022-10-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-01 | 2022-10-16 | N |
| Dispose of garbage and refuse properly. | Health | 2022-09-01 | 2022-10-16 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-01 | 2022-10-16 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-09-01 | 2022-10-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-01 | 2022-10-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-01 | 2022-10-16 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-01 | 2022-10-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-01 | 2022-10-16 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-30 | 2022-10-16 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-08-30 | 2022-10-16 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-30 | 2022-10-16 | N |
| Meet requirements for the use and maintenance of medical gas equipment. | Fire Safety | 2022-08-30 | 2022-10-16 | N |
| 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. | Health | 2021-06-10 | 2021-07-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-10 | 2021-07-21 | 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 | 2021-06-10 | 2021-07-21 | N |
| 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. | Health | 2021-06-10 | 2021-07-21 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-06-10 | 2021-07-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-10 | 2021-07-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-06-10 | 2021-07-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-06-10 | 2021-07-21 | N |
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