Deficiency Records for Birchaven Retirement Village
Updated as of October 01, 2016
This is not the most recent data for Birchaven Retirement Village. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2015-08-20 | 2015-09-30 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2015-08-20 | 2015-09-30 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2015-08-20 | 2015-09-30 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2015-08-20 | 2015-09-30 | N |
| Horizontal exits. | Fire Safety | 2015-08-18 | 2015-09-30 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2015-08-18 | 2015-09-30 | N |
| Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2015-08-18 | 2015-09-30 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2015-08-18 | 2015-09-30 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2015-08-18 | 2015-09-30 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2015-08-18 | 2015-09-30 | N |
| Properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2015-08-18 | 2015-09-30 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2015-08-20 | 2015-09-30 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2015-08-20 | 2015-09-30 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2015-08-20 | 2015-09-30 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2015-08-20 | 2015-09-30 | N |
| Horizontal exits. | Fire Safety | 2015-08-18 | 2015-09-30 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2015-08-18 | 2015-09-30 | N |
| Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2015-08-18 | 2015-09-30 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2015-08-18 | 2015-09-30 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2015-08-18 | 2015-09-30 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2015-08-18 | 2015-09-30 | N |
| Properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2015-08-18 | 2015-09-30 | 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 | 2014-05-08 | 2014-06-06 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2014-05-08 | 2014-06-06 | 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 | 2014-05-08 | 2014-06-06 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2014-05-06 | 2014-06-06 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2014-05-06 | 2014-06-06 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2014-05-06 | 2014-06-06 | 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 | 2014-05-08 | 2014-06-06 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2014-05-08 | 2014-06-06 | 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 | 2014-05-08 | 2014-06-06 | N |
| Corridor and hallway doors that block smoke. | Fire Safety | 2014-05-06 | 2014-06-06 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2014-05-06 | 2014-06-06 | N |
| Proper medical gas storage and administration areas. | Fire Safety | 2014-05-06 | 2014-06-06 | N |
| Approved construction type or materials. | Fire Safety | 2013-03-04 | 2013-04-15 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2013-03-04 | 2013-04-15 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2013-03-04 | 2013-04-15 | N |
| Approved construction type or materials. | Fire Safety | 2013-03-04 | 2013-04-15 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2013-03-04 | 2013-04-15 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2013-03-04 | 2013-04-15 | N |
