Birchwood Health and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, patternF689Aug 17, 2022

  Based on observation, record review, and staff interviews, the facility failed to ensure adequate supervision to prevent avoidable accidents for 1 (Resident #9) of 3 residents reviewed who were identified to be at risk for falls. The failure to provide appropriate supervision resulted in Resident #9 sustaining multiple falls with injury, requiring the resident's transfer to a higher level of care. The findings included: Review of the clinical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including dementia. The Admission Minimum Data Set (MDS) assessment with a target date of 7/15/21 noted the resident had a diagnosis of dementia and required moderate physical assistance of one person for ambulation. […]

• Actual harm, isolatedF686Aug 17, 2023

  Based on observation, record review, resident representative and staff interview, the facility failed to assess, and implement individualized, appropriate interventions to prevent the development and worsening of pressure ulcers for 1 (Resident #28) of 2 sampled residents with in-house acquired pressure ulcers. The findings included: The facility's policy and procedure for Prevention of skin impairments revised in April 2020 noted, The purpose of this procedure is to provide information regarding identification of skin impairments and interventions for specific risk factors . Risk assessment. Assess the resident on admission for existing skin impairments. Repeat the assessment weekly and upon any changes in condition . Nutrition . Conduct nutritional screenings for residents at risk. […]

• No harm, potential for more than minimal, widespreadF812Aug 17, 2023

  Based on observations, staff interviews, and facility policy and record review, the facility failed to store food in a manner to prevent possible contamination from dirty ceiling tiles and air vents and to monitor refrigeration logs and three compartment sink sanitizer check logs. The findings included: The Kitchen Operations Sanitization Policy revised July 2023 provided by the facility states the food service area shall be maintained in a clean and sanitary manner. Number 16 of the policy state kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime . […]

• No harm, potential for more than minimal, patternF725May 4, 2026

  Based on observation, review of the grievance log, review of facility's policy and procedure, residents and staff interviews, the facility failed to ensure sufficient nursing staffing to meet the needs of 10 (Residents #1, #2, #3, #4,#5, #6, #7, #8, #9 and #10) of 10 dependents residents reviewed.The findings included:Review of the facility's policy and procedure titled, Standards and Guidelines: Call lights issued 03/2018 and revised 01/2024 revealed, Resident will have a call light to summon facility personnel to ensure the resident's needs will be met. Guideline: Resident's call light is to be within reach and answered promptly by facility personnel . Answer call light promptly. All facility personnel are expected to respond to call lights . […]

• No harm, potential for more than minimal, patternF761Feb 12, 2026

  Based on observation, interview and facility policy the facility failed to ensure the safe storage of medications for 3 (Residents #1, #2, and #3) of 3 residents observed with unsecured medications at bedside.The findings included:On 2/11/26 at 10:08 a.m., during the initial tour of the facility, and on 2/12/26 at 9:10 a.m., observation of Resident #1's room revealed a bottle of Melatonin 10 mg (milligrams) gummies and a bottle of (brand name) eye vitamins soft gels stored unlocked on the resident's nightstand. Photographic evidence obtainedOn 2/12/26 at 9:26 a.m., in an interview Licensed Practical Nurse (LPN) Staff B said the medications should not be on the resident's nightstand. She said medications should be locked in the medication cart at all times.On 2/11/25 at 9:05 a.m. […]