Birchwood Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Jun 12, 2026

  Based on interview and document review, the facility failed to verify and obtain on admission a resident's need for bipap (bilevel positive airway pressure machine which delivers pressurized air through a mask over the nose or mouth to provide improvement in breathing) equipment and failed to notify the provider after prescribed breathing interventions were ineffective for 1 of 1 resident (R90) reviewed for hospitalization. This resulted in an Immediate Jeopardy situation when R90 continued to have respiratory decompensation leading to the need for transfer to the emergency room, intubation, and admission to the intensive care unit. The IJ began on 6/4/26, when R90 was hospitalized , intubated, and admitted to the intensive care unit. […]

• Immediate jeopardy, isolatedF689Nov 13, 2025

  Based on interview, observation, and document review the facility failed to provide adequate supervision resulting in the likelihood of serious harm, injury, impairment, or death for 1 of 3 residents (R1) who was assessed to be at risk for elopement, had exit seeking behavior, and wore a WanderGuard (security device that prevents residents at risk of wandering from a designated area). The facility's failure resulted in an immediate jeopardy when R1 exited the building without staff knowledge and was returned to the facility by a community member (CM)-A.The immediate jeopardy began on [DATE] when R1 exited the facility chapel door at 6:25 p.m. The facility was made aware of R1 missing after CM-A arrived at the facility at 6:44 p.m., with R1 who was found two blocks away. […]

• Immediate jeopardy, isolatedF600Jun 7, 2023

  Based on interview, and document review, the facility failed to provide adequate supervision and interventions to prevent ongoing sexual abuse of 1 of 3 residents (R1) reviewed for abuse. This resulted in an immediate jeopardy (IJ) for R1 who received unwanted sexual touching by R3 without facility intervention. The IJ began on 5/20/23 at 2:16 p.m., when R3 was observed kissing R1's hand and touching R1's chest (breasts) and neck. The administrator and director of nursing (DON) were notified of the IJ on 6/6/23 at 12:33 p.m. The IJ was removed on 6/7/23 at 11:58 a.m. but noncompliance remained at the lower scope and severity level of a D which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. […]

• Actual harm, isolatedF686Feb 9, 2024

  Based on observation, interview, and document review, the facility failed to perform timely and accurate comprehensive skin assessments, follow prescribed wound care orders and implement interventions to promote healing for 2 of 3 residents (R2, and R51) who were admitted to the facility without pressure ulcers. This resulted in harm for R2 and R51 when R2 developed a pressure ulcer and the pressure ulcer worsened and R51 developed an unstageable pressure ulcer. Findings include: A stage one pressure injury is intact skin with a localized area of redness that is non-blanchable (does not turn white when pressed). A stage two pressure ulcer is partial thickness loss of the skin with exposed dermis, presenting as a shallow open ulcer. […]

• Actual harm, isolatedF689Jan 10, 2024

  Based on interview and record review, the facility failed to reduce the risk of accidents to prevent falls for one of one resident (R1) reviewed for falls with injuries. The facility failed to assess and add interventions following a positive Covid diagnosis with symptoms increasing the potential R1's risk for falls and did not comprehensively analyze and update the care plan with appropriate interventions following a fall that resulted in new fractures. Findings include: R1's progress noted dated 11/21/23 indicated R1 was admitted to the facility from a hospital 11/21/23 with a primary diagnosis of a spinal surgery following a fracture in his back in the 11th and 12th lumbar vertebra that resulted from a fall at home. […]