Deficiency Records for Birch Healthcare Center
Updated as of January 01, 2023
This is not the most recent data for Birch Healthcare Center. For the most recent information, click here.
A list of the most recent deficiencies for Birch 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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-16 | 2022-10-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-16 | 2022-10-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-16 | 2022-10-01 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-16 | 2022-10-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-16 | 2022-10-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-16 | 2022-10-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-16 | 2022-10-01 | 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 | 2022-07-07 | 2022-08-22 | 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 | 2022-07-07 | 2022-08-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-07 | 2022-08-22 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-07-07 | 2022-08-22 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-07-07 | 2022-08-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-07 | 2022-08-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-07 | 2022-08-22 | N |
| Post nurse staffing information every day. | Health | 2022-07-08 | 2022-08-15 | 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 | 2022-07-08 | 2022-08-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-08 | 2022-08-14 | 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 | 2022-07-08 | 2022-08-14 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-07-08 | 2022-08-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-08 | 2022-08-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-08 | 2022-08-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-07-08 | 2022-08-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-08 | 2022-08-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-08 | 2022-08-12 | 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 | 2021-12-13 | 2022-02-22 | 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 | 2021-12-13 | 2022-02-22 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-12-13 | 2022-02-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-12-13 | 2022-02-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-13 | 2022-02-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-12-13 | 2022-02-22 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-12-16 | 2022-01-31 | 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 | 2021-12-16 | 2022-01-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-16 | 2022-01-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-16 | 2022-01-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-16 | 2022-01-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-16 | 2022-01-31 | 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 | 2021-12-16 | 2022-01-31 | 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 | 2021-12-16 | 2022-01-31 | N |
| 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 | 2021-12-16 | 2022-01-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-16 | 2022-01-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-16 | 2022-01-31 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-12-16 | 2022-01-31 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-12-16 | 2022-01-04 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2021-06-07 | 2021-07-19 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-06-07 | 2021-07-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-07 | 2021-07-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-06-07 | 2021-07-19 | Y |
| Report COVID19 data to residents and families. | Health | 2021-06-07 | 2021-07-19 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-04-13 | 2021-05-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-04-13 | 2021-05-04 | 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 | 2021-02-04 | 2021-04-08 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-02-04 | 2021-04-08 | 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 | 2021-02-04 | 2021-04-08 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-02-04 | 2021-04-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-02-04 | 2021-04-08 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-02-04 | 2021-04-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-02-04 | 2021-04-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-02-04 | 2021-04-08 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-02-08 | 2021-03-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-02-08 | 2021-03-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-02-08 | 2021-03-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-02-08 | 2021-03-15 | 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 | 2021-02-08 | 2021-03-15 | 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 | 2021-02-08 | 2021-03-15 | 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 | 2021-02-08 | 2021-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-02-08 | 2021-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-08 | 2021-03-15 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-02-08 | 2021-03-15 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2021-02-08 | 2021-03-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-08-17 | 2020-09-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-08-17 | 2020-09-16 | 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 | 2020-06-01 | 2020-06-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-06-01 | 2020-06-23 | N |
