A list of the most recent deficiencies for Birchaven Retirement Village. 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 | 2022-11-07 | 2022-12-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-07 | 2022-12-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-07 | 2022-12-09 | N |
| Post nurse staffing information every day. | Health | 2022-11-07 | 2022-12-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-07 | 2022-12-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-07 | 2022-12-09 | 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 | 2022-11-04 | 2022-12-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-04 | 2022-12-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-04 | 2022-12-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-04 | 2022-12-09 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-11-04 | 2022-12-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-04 | 2022-12-09 | N |
| 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 | 2021-11-08 | 2021-12-17 | Y |
| 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 | 2019-12-18 | 2020-02-03 | 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 | 2019-12-18 | 2020-02-03 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2019-12-18 | 2020-02-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-18 | 2020-02-03 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2019-12-18 | 2020-02-03 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-12-23 | 2020-02-03 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-12-23 | 2020-02-03 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-10-25 | 2018-12-05 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2018-10-25 | 2018-12-05 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-10-25 | 2018-12-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-25 | 2018-12-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-25 | 2018-12-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-10-25 | 2018-12-05 | 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 | 2018-10-25 | 2018-12-05 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-10-25 | 2018-12-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-25 | 2018-12-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-10-25 | 2018-12-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-25 | 2018-12-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-25 | 2018-12-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-25 | 2018-12-05 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-10-23 | 2018-12-05 | N |
