Birchwood Care Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 28, 2023

  Based on interview and document review, the facility failed to reassess and implement appropriate interventions in place for 2 of 2 residents (R1, R2) with a history of elopement. This resulted in an immediate jeopardy (IJ), substandard quality of care, when R1 and R2 left the facility property unsupervised and without staff awareness. The IJ began on 2/12/23, when the facility noted R1 and R2 had left the facility unsupervised. Further, R1 and R2 were not comprehensively reassessed with appropriate interventions developed to provide adequate safety after previous exit seeking behaviors. On 2/22/23, at 5:20 p.m. the director of nursing was notified of the IJ for R1 and R2. […]

• Actual harm, isolatedF760Jul 3, 2024

  Based on interview and document review, the facility failed to ensure one of three residents (R2) reviewed was free from significant medication errors. This resulted in actual harm for R2 when he became heavily sedated by a psychotropic medication and required treatment in the hospital. Findings include: Minimum Data Set (MDS) admission assessment dated [DATE] indicated R1 admitted to the facility on [DATE]. R1's Brief Interview for Mental Status (BIMS) had a score of 15, indicating she was cognitively intact. R1's relevant diagnoses included schizoid personality disorder, borderline intellectual functioning, and unspecified urinary incontinence. R1's medication order, dated 6/9/22, indicated R1 received clozapine 600 milligrams (mg) by mouth at 8:00 p.m. nightly for schizophrenia. […]

• No harm, potential for more than minimal, widespreadF812Mar 20, 2025

  Based on observation, interview, and document review, the facility failed to ensure food items were properly stored, labeled, and dated to reduce the risk of physical cross-contamination and potential foodborne illness. This had the potential to affect all 59 residents, staff, and visitors who consumed food from the kitchen. Findings include: On 3/17/25 at 12:11 p.m., an initial kitchen tour was completed with dietary aid (DA)-A. In the walking refrigerator a sheet pan cart with several unwrapped and undated trays contained the following items: * Three trays with about 20 cheese and eggs English muffin sandwiches with a piece of parchment paper on top * Two trays with tater tots with a piece of parchment paper on top * Two trays with apple bran bowls, each containing about 35 bowls with a… […]

• No harm, potential for more than minimal, widespreadF865May 3, 2024

  Based on interview and document review, the facility failed to conduct ongoing quality assessment and assurance activities, develop, and implement appropriate plans of action to correct repeated quality deficiencies identified during the survey the facility was aware of or should have been aware of which had the potential to adversely affect all 60 residents which resided in the facility. Findings include: The facility's QAPI meeting minutes for the past 12 months were requested, however not received. Documentation and evidence of the facility's ongoing performance improvement projects (PIPs) was requested, however not received. Documentation and evidence of a recent performance improvement plan (PIP) was requested, however was not received. […]

• No harm, potential for more than minimal, widespreadF867May 3, 2024

  Based on document review and interview, the facility failed to maintain a Quality Assurance and Performance Improvement (QAPI) committee that was effective in identifying and responding to quality deficiencies, and developing procedures for feedback, data collection and monitoring systems. In addition, the facility failed to provide evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas. This deficient practice had the potential to affect all 60 residents currently residing in the facility. Findings include: Quality tracking data was requested from the facility but was not provided. […]