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Deficiency Records for Birchwood Rehabilitation and Healthcare Center
A list of the most recent deficiencies for Birchwood Rehabilitation and Healthcare Center. 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 Rehabilitation and Healthcare Center. 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? |
|---|---|---|---|---|
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-06-13 | 2024-07-22 | 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 | 2024-06-13 | 2024-07-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-06-13 | 2024-07-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-06-13 | 2024-07-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-06-13 | 2024-07-22 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-06-13 | 2024-07-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-05-17 | 2024-06-25 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-17 | 2024-06-25 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-05-17 | 2024-06-25 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-06-07 | 2024-06-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-06-07 | 2024-06-25 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-06-07 | 2024-06-25 | 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 | 2024-06-07 | 2024-06-25 | 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 | 2024-06-07 | 2024-06-25 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-03-28 | 2024-05-17 | Y |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2024-03-28 | 2024-05-17 | 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 | 2024-03-28 | 2024-05-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-28 | 2024-05-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-28 | 2024-05-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-03-28 | 2024-05-17 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-08-08 | 2023-09-06 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-08-08 | 2023-09-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-08 | 2023-09-06 | Y |
| 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 | 2023-08-08 | 2023-09-06 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-05-05 | 2023-06-08 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-05-05 | 2023-06-08 | N |
| 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 | 2023-05-05 | 2023-06-08 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-05-05 | 2023-06-08 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-05-05 | 2023-06-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-05 | 2023-06-08 | N |
| 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. | Health | 2023-05-05 | 2023-06-08 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-05-05 | 2023-06-08 | Y |
| 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 | 2023-05-17 | 2023-06-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-05-17 | 2023-06-01 | 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 | 2023-03-28 | 2023-05-05 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-03-28 | 2023-05-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-28 | 2023-05-05 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-03-28 | 2023-05-05 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2023-03-28 | 2023-05-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-10 | 2022-12-12 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-10 | 2022-12-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2022-12-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-10 | 2022-08-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-06-10 | 2022-08-01 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-06-10 | 2022-08-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-06-10 | 2022-08-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-06-10 | 2022-08-01 | 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 | 2022-06-10 | 2022-08-01 | 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 | 2022-06-10 | 2022-08-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-10 | 2022-08-01 | N |
| Report COVID19 data to residents and families. | Health | 2022-06-10 | 2022-08-01 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-10 | 2022-08-01 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-06-10 | 2022-08-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-10 | 2022-08-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-10 | 2022-08-01 | Y |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-06-06 | 2022-07-05 | 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 | 2022-06-06 | 2022-07-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-06 | 2022-07-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-06 | 2022-07-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-06-06 | 2022-07-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-23 | 2022-04-05 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-23 | 2022-04-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-15 | 2022-01-18 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-06-08 | Not Fixed | Y |
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