Birch Creek Post Acute & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Birch Creek Post Acute & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF880Aug 27, 2021

  Based on observation, interview and record review, the facility failed to implement key components of an effective infection prevention and control program by failing to use personal protective equipment (PPE) while entering the rooms of residents on transmission-based precautions (TBP) and failing to disinfect shared resident equipment between use by residents on TBP in one of four halls (400 Hall) reviewed for infection control. Additionally, the facility failed to ensure infection control practices were followed for two of two residents (Residents 58 and 145) reviewed for urinary catheters. These failures placed residents and staff at risk of potential exposure to COVID-19, increased the likelihood of serious harm or death, increased chance of infection and a diminished quality of life. […]

• Actual harm, isolatedF689Mar 26, 2026

  Based on interview and record review the facility failed to provide adequate supervision, identify fall trends and implement progressive resident centered interventions for 1 of 3 residents (Resident 6) reviewed for falls. Resident 6, who had 5 falls since [DATE] and a decline in their strength/condition, experienced harm when they fell and broke their ankle that required transfer to the emergency department for evaluation and treatment. This failure placed residents at risk of repeated falls and injuries.Findings included.Review of the facility Falls and Fall Risk Management policy, dated [DATE], showed staff would identify interventions related to residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.Review of… […]

• Actual harm, isolatedF690Mar 26, 2026

  Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for urinary catheters (a flexible tube inserted into the bladder through the urethra to drain urine) were assessed for complications associated with indwelling urinary catheters. Failure of the facility to coordinate with urology and monitor for urinary retention following catheter removal, resulted in harm to Resident 1 when they experienced prolonged pain and discomfort as evidenced by crying out and a change in level of consciousness. […]

• Actual harm, isolatedF684Mar 22, 2024

  Based on interview and record review, the facility failed to take timely action for 1 of 3 who experienced a significant change in their baseline condition. Resident 1 experienced harm when the serious changes in cognition, blood pressure and temperature were not addressed timely, and they had to eventually be hospitalized . Findings included . The facility's Fall Management Guideline, dated 05/10/2023, documented facility staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling, and to try to minimize complications from falling. […]

• Actual harm, isolatedF689Aug 27, 2021

  Based on observation, interview and record review, the facility failed to ensure it was free from accident hazards for two of six residents (Residents 38 and 443) reviewed for accidents. Failure to identify/address all risk factors and ensure care planned interventions implemented to provide supervision and assistance were consistently provided resulted in harm when Resident 38 had multiple falls that resulted in fractures to the right foot and Resident 443 experienced a right hip/femur fracture after falling on 08/08/2021. These failures placed residents at risk for unmet needs, avoidable injuries, and diminished quality of life. […]