Deficiency Records for Birchwood Care Home
Updated as of October 01, 2022
This is not the most recent data for Birchwood Care Home. For the most recent information, click here.
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? |
|---|---|---|---|---|
| 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 |
| Provide and implement an infection prevention and control program. | Health | 2020-04-29 | 2020-05-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-27 | 2020-01-15 | Y |
| 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 | 2019-11-27 | 2020-01-15 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-11-27 | 2020-01-15 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2019-11-27 | 2020-01-15 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-11-27 | 2020-01-15 | 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 |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-11-02 | 2017-12-01 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-11-02 | 2017-12-01 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-11-02 | 2017-12-01 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-11-02 | 2017-12-01 | N |
