Birchaven Retirement Village

In the surveyor’s words

From the most serious findings on record at Birchaven Retirement Village, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF803Jan 9, 2025

  Based on observation, staff interview, review of the menu and review of the dietary spreadsheet, the facility failed to ensure food was served per the facility menu and spreadsheet. This had the potential to affect 29 (#2, #6, #7, #11, #12, #14, #16, #17, #20, #25, #28, #29, #33, #36, #37, #41, #42, #43, #44, #52, #62, #63, #65, #66, #72, #74, #75, #76, and #149) residents who resided on the Cedar and Dogwood units. The facility census was 90. Findings include: Review of the weekly menu revealed the meal for lunch on 01/08/24 was a fried bologna sandwich and a relish plate with ranch dressing and scalloped corn or broccoli cheddar soup with an Italian beef sub. Review of the menu spreadsheet for lunch on 01/08/24 revealed broccoli cheddar soup would be served as a six-ounce portion. […]

• No harm, potential for more than minimal, patternF812Jan 9, 2025

  Based on observation and staff interview, the facility failed to ensure food items stored in unit refrigerators were labeled and dated and further failed to ensure unit refrigerators did not contain expired food items. This had the potential to affect 45 (#1, #2, #5, #6, #7, #8, #9, #11, #12, #14, #16, #17, #19, #20, #22, #23, #25, #28, #29, #33, #36, #37, #41, #42, #43, #44, #45, #47, #48, #51, #52, #54, #55,#59, #61, #62, #63, #65, #66, #72, #74, #75, #76, #148, and #149) who resided on the Birch, Cedar, and Dogwood units. The facility census was 90. Findings include: 1. Observation on [DATE] at 11:25 A.M. of the unit refrigerator located on the Birch-hall revealed there was an unlabeled pack of two small sandwiches which stated to use by [DATE]. An interview on [DATE] at 11:28 A.M. […]

• No harm, potential for more than minimal, patternF880Jan 9, 2025

  Based on observations, resident interview, staff interview, review of facility Transmission Based Precautions (TBP) and Enhanced Barrier Precautions (EBP) postings, and review of facility policy, the facility failed to ensure proper infection control practices were implemented related to Coronavirus Disease 2019 (COVID-19) and EBP. This affected six residents (#25, #14, #28, #72, #49, and #82) of eight residents reviewed for TBP and EBP. The facility census was 90. Findings include: 1. Review of Resident #25's medical record revealed an admitted [DATE]. Diagnoses included cognitive communication deficit, type II diabetes, dysphagia, end stage renal disease, dependence on renal dialysis, peripheral vascular disease, and heart failure. […]

• No harm, potential for more than minimal, patternF887Jan 9, 2025

  Based on record review and staff interview, the facility failed to ensure residents received education and provided consent for COVID-19 vaccinations prior to administration or refusal. This affected five resident (#28, #46, #82, #149, and #201) of five residents reviewed for COVID-19 vaccination. The facility census was 90. Findings include: 1. Review of the medical record of Resident #28 revealed an admitted [DATE]. Diagnoses included rhabdomyolysis, type II diabetes mellitus, obesity, cerebral infarction, and chronic obstructive pulmonary disease. Review of the medical record revealed no form to indicate Resident #28 was given any information on COVID-19 vaccination nor any consent or refusal of the vaccine. 2. Review of the medical record of Resident #46 revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, patternF584Nov 8, 2021

  Based on observation and staff interview, the facility failed to ensure building temperatures were maintained at a comfortable level. This had the potential to affect all 17 residents (#11, #12, #13, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, and #33) who resided on the Cedar Hall. The facility census was 83. Findings include: Observation on 11/07/21 at 8:39 A.M. of the Cedar Hall found the unit felt colder than the adjacent Dogwood Hall. Review of the heating and cooling unit thermometer located in the common area at the end of the hallway revealed the temperature was 66 degrees Fahrenheit (F) in the common area. Interview on 11/07/21 at 8:40 A.M. with Registered Nurse (RN) #301 verified the thermostat was set to 66 degrees F and was on the cool setting. […]