Birchwood Nursing and Rehabilitation

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF868Aug 13, 2026

  Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum of the director of nursing services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one of who must be the Administrator, owner, or board member or other individual in a leadership role, and the infection preventionist for 4 of 4 quarterly meetings (09/12/25, 12/11/25, 03/12/26, and 06/11/26) reviewed for Quality Assessment Assurance committee. The facility did not ensure the Administrator attended Quality Assurance and Performance Improvement meetings on 09/12/25, 12/11/25, 03/12/26, and 06/11/26. […]

• No harm, potential for more than minimal, patternF880Aug 13, 2026

  Based on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 5 of 5 residents (Resident #3, #6, #18, #33 and #42) reviewed for infection control.The facility failed to follow their infection control policy for Residents #3, #6, #18, #33 and #42 who were on Enhanced Barrier Precautions (EBP) by not posting signage at the entrance of their rooms. This deficient practice could place residents at-risk for infection due to improper care practices. […]

• No harm, potential for more than minimal, patternF584May 8, 2024

  Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 1 shower rooms on the secured unit and 1 of 2 dining rooms (main building) reviewed for physical environment. 1. The facility did not ensure the dining room did not have cobwebs and crane flies on the ceiling and walls. 2. The facility failed to ensure the shower in the secure unit did not have pink and black grime on the walls. These failures could place the residents at risk for decreased quality of life and infection due to unsanitary conditions. The findings included: 1. […]

• No harm, potential for more than minimal, patternF698Apr 12, 2023

  46892 Based on observations, interviews, and record review the facility failed to ensure residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 2 of 2 residents (Resident # 9 and Resident #15) reviewed for dialysis. The facility failed to have a physician's order for dialysis for Resident #9. The facility failed to ensure nursing staff monitored Resident #15's central venous catheter used for dialysis (a long, flexible tube inserted into a vein in your neck, chest, arm, or groin and leads to a large vein that empties into your heart and is used as a dialysis access) for signs and symptoms of infection and for the dressing to be intact. […]

• No harm, potential for more than minimal, isolatedF645Aug 13, 2026

  Based on interviews and record reviews the facility failed to ensure residents were not admitted to the facility, unless the State mental health authority had determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission that, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility[KS4.1] for 1 Resident (Resident #3) of 5 residents reviewed for PASARR Screening. The facility failed to ensure Resident #3 had a complete and accurate PASARR screening prior to admission. This failure could place residents at risk of being misplaced or not receiving services available to them. […]