Deficiency Records for Birchwood Health and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Birchwood Health and Rehabilitation 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? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-08-17 | 2023-11-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-17 | 2023-11-12 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-08-17 | 2023-11-12 | Y |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-08-17 | 2023-09-17 | 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 | 2023-08-17 | 2023-09-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-17 | 2023-09-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-17 | 2023-09-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-17 | 2023-09-17 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-08-15 | 2023-09-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-08-15 | 2023-09-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-15 | 2023-09-17 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-08-15 | 2023-08-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-15 | 2023-08-17 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-15 | 2023-08-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-15 | 2023-08-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-17 | 2022-09-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-17 | 2022-09-16 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-17 | 2022-09-16 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-10-21 | 2021-11-13 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2021-10-25 | 2021-11-13 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-10-25 | 2021-11-13 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2021-10-25 | 2021-11-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-25 | 2021-11-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-25 | 2021-11-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-25 | 2021-11-13 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-25 | 2021-11-13 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-10-25 | 2021-11-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-10-25 | 2021-11-13 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-25 | 2021-11-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-25 | 2021-11-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-30 | 2021-10-31 | Y |
| 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 | 2021-09-30 | 2021-10-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-30 | 2021-10-31 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-01-09 | 2020-02-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-01-09 | 2020-02-09 | N |
