Deficiency Records for Birch Creek Post Acute and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Birch Creek Post Acute and 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? |
|---|---|---|---|---|
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-26 | 2023-06-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-26 | 2023-06-06 | 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 | 2023-04-26 | 2023-06-06 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-04-26 | 2023-06-06 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-26 | 2023-06-06 | 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 | 2023-04-26 | 2023-06-06 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-04-26 | 2023-06-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-26 | 2023-06-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-26 | 2023-06-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-26 | 2023-06-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-26 | 2023-06-06 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-04-26 | 2023-06-06 | 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 | 2023-04-26 | 2023-06-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-26 | 2023-06-06 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-04-26 | 2023-06-06 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-27 | 2023-05-31 | 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 | 2023-04-27 | 2023-05-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-27 | 2023-05-31 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-02-03 | 2023-02-28 | Y |
| 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 | 2021-08-27 | 2021-09-29 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-08-27 | 2021-09-29 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-27 | 2021-09-29 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-27 | 2021-09-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-08-27 | 2021-09-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-08-27 | 2021-09-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-08-27 | 2021-09-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-08-27 | 2021-09-29 | 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 | 2021-08-27 | 2021-09-29 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-27 | 2021-09-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-08-27 | 2021-09-29 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-08-27 | 2021-09-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-27 | 2021-09-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-08-27 | 2021-09-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-08-27 | 2021-09-29 | N |
| Post nurse staffing information every day. | Health | 2021-08-27 | 2021-09-29 | 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 | 2021-08-27 | 2021-09-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-27 | 2021-09-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-27 | 2021-09-29 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-27 | 2021-09-29 | Y |
| Meet other general requirements. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-08-17 | 2021-09-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-05-20 | 2021-06-15 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-03-15 | 2019-04-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-03-15 | 2019-04-24 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-03-15 | 2019-04-24 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-03-15 | 2019-04-24 | 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 | 2019-03-15 | 2019-04-24 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-15 | 2019-04-24 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-03-15 | 2019-04-24 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-15 | 2019-04-24 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-03-15 | 2019-04-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-03-15 | 2019-04-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-03-15 | 2019-04-24 | 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 | 2019-03-15 | 2019-04-24 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-03-15 | 2019-04-24 | 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 | 2019-03-15 | 2019-04-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-15 | 2019-04-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-15 | 2019-04-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-03-12 | 2019-04-11 | N |
