Birchwood Care Center

In the surveyor’s words

From the most serious findings on record at Birchwood Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 27, 2026

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, personnel file review, and policy review, the facility failed to ensure a resident was safely transferred to a wheelchair. This resulted in Actual Harm on 04/15/26 when Certified Nurse Aide (CNA) #174 transferred Resident #70 to a wheelchair without utilizing a mechanical lift and additional staff assistance. Resident #70 was sent to the hospital and received treatment for a displaced comminuted right femur fracture (happens when a severe impact breaks a bone into three or more pieces) and a left tibia and fibula fracture. This affected one (Resident #70) of three residents reviewed for accidents. The facility census was 67. […]

• No harm, potential for more than minimal, widespreadF812Feb 14, 2022

  Based on observations, review of personnel files, and staff interview, the facility failed to properly handle food items while passing lunch trays to residents. The facility identified 67 residents that received food from the kitchen. The facility census was 69. Findings included: Observation on 02/07/22 at 12:50 P.M. of Housekeeper #74 revealed she was passing the lunch tray to Resident #15. Housekeeper #74 was noted opening the lid of the lunch tray and grabbing the sandwich from the tray with her bare hands. The housekeeper proceeded to cut the sandwich in half and put it back on the tray of Resident #15. Interview on 02/07/22 at 12:52 P.M. with Housekeeper #74 confirmed that she did grab the sandwich of Resident #15 with her bare hands and cut it in half. […]

• No harm, potential for more than minimal, isolatedF625Feb 14, 2022

  Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were provided with a bed hold notice upon transferring to the hospital. This affected two (#13 and #52) of two residents reviewed for hospitalization . The facility census was 69. Findings include: 1. Review of Resident #52's medical record revealed the resident was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/07/22, revealed Resident #52 was severely cognitively impaired. Review of Resident #52's progress note dated 12/23/21 revealed Resident #52 had complaints of sharp sudden chest pains. Emergency medical services were called. […]

• No harm, potential for more than minimal, isolatedF690Feb 14, 2022

  Based on observation, record review, resident and staff interviews, review of the facility's policy, and review of the guidance from www.medlineplus.gov, the facility failed to provide routine catheter care. This affected one (Resident #39) of three residents reviewed for catheter care. The facility identified five residents with an indwelling or external catheter. The facility census was 69. Findings include: Review of the medical record for Resident #39 revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the plan of care dated 12/06/21 revealed Resident #39 had an indwelling catheter related to the history of hydronephrosis due to obstruction. […]

• No harm, potential for more than minimal, isolatedF755Feb 14, 2022

  Based on medical record review and staff interview, the facility failed to ensure the resident's blood pressure was obtained per physician orders and related to use of a as needed blood pressure medication. This affected two (#12 and #32) of five residents reviewed for unnecessary medications. The facility census was 69. Findings include: 1. Review of the medical record for Resident #12 revealed an admitted [DATE]. Diagnoses included essential (primary) hypertension, [CONDITION(S)], acute on chronic systolic heart failure. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 11/12/21, revealed Resident #12 had intact cognition. […]