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? |
|---|---|---|---|---|
| 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 |
| Honor the resident's right to manage his or her financial affairs. | Health | 2019-01-16 | 2019-02-09 | 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 | 2019-01-16 | 2019-02-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-16 | 2019-02-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-01-16 | 2019-02-09 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-01-16 | 2019-02-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-16 | 2019-02-09 | N |
