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Deficiency Records for Birch Creek Post Acute and Rehabilitation
A list of the most recent deficiencies for Birch Creek Post Acute and Rehabilitation. 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 Birch Creek Post Acute and Rehabilitation. 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? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-15 | 2024-08-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-07-10 | 2024-08-06 | 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 | 2024-07-10 | 2024-08-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-10 | 2024-08-06 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-05-23 | 2024-07-02 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-05-23 | 2024-07-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-05-23 | 2024-07-02 | 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 | 2024-05-23 | 2024-07-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-23 | 2024-07-02 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-05-23 | 2024-07-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-23 | 2024-07-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-23 | 2024-07-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-05-23 | 2024-07-02 | 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 | 2024-05-23 | 2024-07-02 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-05-23 | 2024-07-02 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-05-23 | 2024-07-02 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-05-23 | 2024-07-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-23 | 2024-07-02 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Meet other general requirements. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-21 | 2024-06-24 | N |
| Respond appropriately to all alleged violations. | Health | 2024-03-22 | 2024-04-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-03-22 | 2024-04-30 | 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 | 2023-04-26 | 2023-06-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-26 | 2023-06-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-04-26 | 2023-06-06 | 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 | 2023-04-26 | 2023-06-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-26 | 2023-06-06 | 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 | 2023-04-26 | 2023-06-06 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-04-26 | 2023-06-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-26 | 2023-06-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-26 | 2023-06-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-26 | 2023-06-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-26 | 2023-06-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-26 | 2023-06-06 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-04-26 | 2023-06-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-26 | 2023-06-06 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-04-26 | 2023-06-06 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-02-03 | 2023-02-28 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-08-27 | 2021-09-29 | 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 | 2021-08-27 | 2021-09-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-27 | 2021-09-29 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-27 | 2021-09-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-27 | 2021-09-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-08-27 | 2021-09-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-08-27 | 2021-09-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-27 | 2021-09-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-08-27 | 2021-09-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-27 | 2021-09-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-27 | 2021-09-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-27 | 2021-09-29 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-08-27 | 2021-09-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-27 | 2021-09-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-27 | 2021-09-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-27 | 2021-09-29 | N |
| Post nurse staffing information every day. | Health | 2021-08-27 | 2021-09-29 | 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 | 2021-08-27 | 2021-09-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-27 | 2021-09-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-27 | 2021-09-29 | N |
| Meet other general requirements. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
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