CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Birchwood Park Rehabilitation
View the most recent health deficiencies and inspection results for Birchwood Park Rehabilitation. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Birchwood Park Rehabilitation. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-12-19 | 2025-05-14 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-12-19 | 2025-05-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-12-19 | 2025-05-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-12-19 | 2025-05-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-12-19 | 2025-05-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-04-04 | 2025-05-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2025-04-04 | 2025-05-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2025-04-04 | 2025-05-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2025-04-04 | 2025-05-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2025-04-04 | 2025-05-14 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2025-04-04 | 2025-05-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-12-19 | 2025-05-14 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-12-19 | 2025-05-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-12-19 | 2025-05-14 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2024-12-19 | 2025-05-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-12-19 | 2025-05-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-12-19 | 2025-05-14 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-12-19 | 2025-05-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-12-19 | 2025-05-14 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-12-19 | 2025-05-14 | 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 | 2024-12-19 | 2025-05-14 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2024-12-19 | 2025-05-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-12-19 | 2025-05-14 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-12-19 | 2025-02-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-12-19 | 2025-02-20 | N |
| Meet other general requirements. | Fire Safety | 2024-12-19 | 2025-02-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-12-19 | 2025-02-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-12-19 | 2025-02-20 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-12-19 | 2025-02-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-12-19 | 2025-02-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-12-19 | 2025-02-15 | Y |
| Provide training in compliance and ethics. | Health | 2024-12-19 | 2025-02-15 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2024-12-19 | 2025-02-15 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-12-19 | 2025-02-15 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-12-19 | 2025-02-15 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2024-12-19 | 2025-02-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-12-19 | 2025-02-15 | Y |
| Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). | Health | 2024-12-19 | 2025-02-15 | Y |
| 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 | 2024-12-19 | 2025-02-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-12-19 | 2025-02-15 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2024-12-19 | 2025-02-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-12-19 | 2025-02-15 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-12-19 | 2025-02-15 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-12-19 | 2025-02-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-12-19 | 2025-02-15 | Y |
| Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents. | Health | 2024-12-19 | 2025-02-15 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-12-19 | 2025-02-15 | N |
| Protect a residents' right to refuse some types of non-requested transfers within the nursing home. | Health | 2024-12-19 | 2025-02-15 | N |
| Not prohibit or in any way discourage a resident from communicating with federal, state, or local officials. | Health | 2024-12-19 | 2025-02-15 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-12-19 | 2025-02-15 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-12-19 | 2025-02-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-12-19 | 2025-02-15 | N |
| Provide activities to meet all resident's needs. | Health | 2024-12-19 | 2025-02-15 | N |
| Ensure the activities program is directed by a qualified professional. | Health | 2024-12-19 | 2025-02-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-12-19 | 2025-02-15 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-12-19 | 2025-02-15 | 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 | 2024-12-19 | 2025-02-15 | 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 | 2024-12-19 | 2025-02-15 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-12-19 | 2025-02-15 | N |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2024-12-19 | 2025-02-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-12-19 | 2025-02-15 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2024-12-19 | 2025-02-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-12-19 | 2025-02-15 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-12-19 | 2025-02-15 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-12-19 | 2025-02-15 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-12-19 | 2025-02-15 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-04-15 | 2024-05-30 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-04-15 | 2024-04-02 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-03 | 2023-11-28 | Y |
| 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 |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-09-30 | 2021-11-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-30 | 2021-11-05 | N |
| Assist a resident in gaining access to vision and hearing services. | 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 |
| 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 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-09-30 | 2021-11-05 | N |
| 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 | 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 (including nights and weekends) and emergencies. | 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 |
| 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 | 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 |
| Perform COVID19 testing on residents and staff. | 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 |
| 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 | N |
| 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 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-30 | 2021-11-05 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-09-30 | 2021-11-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-30 | 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 |
| 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 | 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 |
| Respond appropriately to all alleged violations. | 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 |
| 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 |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 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 |
| 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 |
| 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 |
| 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 |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-03-05 | 2020-03-25 | N |