A list of the most recent deficiencies for Birchwood Park Rehabilitation. 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 | 2021-09-30 | 2021-11-05 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-09-30 | 2021-11-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-09-30 | 2021-11-05 | 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 | 2021-09-30 | 2021-11-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-30 | 2021-11-05 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-09-30 | 2021-11-05 | 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 | 2021-09-30 | 2021-11-05 | 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 | 2021-09-30 | 2021-11-05 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2021-09-30 | 2021-11-05 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-09-30 | 2021-11-05 | 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 | 2021-09-30 | 2021-11-05 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2021-09-30 | 2021-11-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-09-30 | 2021-11-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-30 | 2021-11-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-09-30 | 2021-11-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-30 | 2021-11-05 | N |
| Report COVID19 data to residents and families. | Health | 2021-09-30 | 2021-11-05 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-30 | 2021-11-05 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-09-30 | 2021-11-05 | 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 | 2021-09-30 | 2021-11-05 | Y |
| 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 | 2021-09-30 | 2021-11-05 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-09-30 | 2021-11-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-30 | 2021-11-05 | Y |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-09-30 | 2021-11-05 | 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 | 2021-09-30 | 2021-11-05 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2021-09-30 | 2021-11-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-30 | 2021-11-05 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-09-30 | 2021-11-05 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-09-30 | 2021-11-05 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-09-30 | 2021-11-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-30 | 2021-11-05 | 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 | 2020-03-05 | 2020-04-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-03-05 | 2020-04-10 | 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 | 2020-03-05 | 2020-04-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-03-05 | 2020-04-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-03-05 | 2020-04-10 | N |
| Respond appropriately to all alleged violations. | Health | 2020-03-05 | 2020-04-10 | 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 | 2020-03-05 | 2020-04-10 | 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 | 2020-03-05 | 2020-04-10 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-03-05 | 2020-04-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-05 | 2020-04-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-05 | 2020-04-10 | 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 | 2020-03-05 | 2020-04-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-05 | 2020-04-10 | 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 | 2020-03-05 | 2020-04-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-03-05 | 2020-04-10 | 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 | 2020-03-05 | 2020-04-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-03-05 | 2020-04-10 | 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 | 2020-03-05 | 2020-04-10 | 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 | 2020-03-05 | 2020-04-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-03-05 | 2020-04-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-05 | 2020-04-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-03-05 | 2020-04-10 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-03-05 | 2020-04-10 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2020-03-05 | 2020-04-10 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-03-05 | 2020-04-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-03-05 | 2020-04-10 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-03-05 | 2020-04-10 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-03-05 | 2020-04-10 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-03-05 | 2020-04-10 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2020-03-05 | 2020-04-10 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-03-05 | 2020-04-10 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-03-05 | 2020-04-10 | N |
| Establish methods for sharing information. | Fire Safety | 2020-03-05 | 2020-04-10 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2020-03-05 | 2020-04-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-03-05 | 2020-04-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-03-05 | 2020-04-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-03-05 | 2020-04-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-03-11 | 2020-03-25 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-04-23 | 2019-08-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-05 | 2019-07-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-05 | 2019-07-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-05 | 2019-05-17 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-04-05 | 2019-05-17 | 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 | 2019-04-05 | 2019-05-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-05 | 2019-05-17 | 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 | 2019-04-05 | 2019-05-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-05 | 2019-05-17 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-04-05 | 2019-05-17 | 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 | 2019-04-05 | 2019-05-17 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-04-05 | 2019-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-05 | 2019-05-17 | N |
| Dispose of garbage and refuse properly. | Health | 2019-04-05 | 2019-05-17 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2019-04-05 | 2019-05-17 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-04-05 | 2019-05-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-04-05 | 2019-05-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-04-05 | 2019-05-17 | 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 | 2019-04-23 | 2019-05-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-04-23 | 2019-05-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-04-23 | 2019-05-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-04-05 | 2019-04-05 | N |
