Birch Hill Health Services

In the surveyor’s words

From the most serious findings on record at Birch Hill Health Services, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880Aug 30, 2023

  Based on observation, record review, and staff and resident interview, the facility did not maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the transmission of communicable disease and infection for 26 residents who resided on the secure unit (A and B wings) and with the potential to affect all 34 residents residing in the facility. Appropriate testing and initiation of precautions were not completed for 2 Residents (R) (R11 and R25) upon symptom onset. Four staff observed did not don (put on), doff (remove), and wear personal protective equipment (PPE) while entering and exiting COVID-19 positive residents' rooms in accordance with Centers for Disease Control and Prevention (CDC) guidelines and the facility's policy. […]

• No harm, potential for more than minimal, patternF657Sep 25, 2024

  Based on record review and staff interview, the facility did not revise care plans in accordance with current care needs for 4 residents (R) (R38, R21, R40, and R35) of 14 sampled residents. The facility did not revise R38, R21, and R40's care plans when R38, R21, and R40 started Hospice care. R35 had a restorative program that indicated R35 should be walked to meals. The facility did not revise R35's care plan to indicate staff did not always ambulate R35 to meals but ambulated R35 at other times during the day. Findings include: 1. From 9/23/24 to 9/25/24, Surveyor reviewed R38's medical record. R38 was admitted to the facility on [DATE] and had diagnoses including encephalopathy, depression, and dementia. […]

• No harm, potential for more than minimal, patternF761Sep 25, 2024

  Based on observation, staff interview, and record review, the facility did not ensure 1 of 2 refrigerators in the medication storage room that contained vaccines and insulin maintained an appropriate temperature per the facility's policy and instructions on the facility's temperature log. In addition, the facility did not ensure medications for 7 residents (R) (R40, R33, R21, R22, R1, R194, and R3) of 19 residents in 1 of 1 medication cart were dated appropriately when opened. The medication refrigerator log for [DATE] indicated temperatures had been taken only once per day and 8 of the 22 temperatures were out of range. The refrigerator contained vaccines and insulin which required a temperature between ,d+[DATE] degrees F to preserve their integrity. […]

• No harm, potential for more than minimal, isolatedF583Jul 1, 2026

  Based on interview and record review, the facility did not ensure the security and privacy of medical information for 1 resident (R) (R7) of 3 sampled residents. R7's care plan was posted in R1's room. Family Member (FM)-C observed the care plan and informed staff. Findings include: The facility's Resident Rights document indicates: .Privacy: Residents have the right .to confidentiality concerning their personal and medical information . The facility's Health Insurance Portability and Accountability Act (HIPAA) document indicates: .HIPAA-Prohibited Activities: .Leaving resident information accessible to people who have no right to see it . On 7/1/26 at 10:26 AM and 7/2/26 at 10:54 AM, Surveyor interviewed FM-C who stated R7's care plan was posted inside the door of R1's closet. […]

• No harm, potential for more than minimal, isolatedF880Jul 1, 2026

  Based on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 1 resident (R) (R3) of 3 sampled residents. R3 was on contact precautions. Multiple staff provided care for R3 without donning the appropriate personal protective equipment (PPE). Findings include: The facility's Transmission Based (Isolation) Precautions policy, revised 3/2026, indicates: .9. Initiation of Transmission-Based Precautions (TBP) (isolation precautions): a. Nursing staff may place residents with suspected or confirmed infectious diarrhea, influenza, or symptoms consistent with a communicable disease on TBP/isolation empirically while awaiting confirmation. b. […]