Birchwood Park Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Sep 30, 2021

  Based on observations, resident interviews and staff interviews on all four resident living areas, and review of facility documentation, the facility's staff failed to follow Centers for Disease Control and Prevention (CDC) guidance to establish an infection control program to ensure [CONDITION(S)]-CoV-2 infection control measures/practices were in place during a major [CONDITION(S)]-CoV-2 outbreak and to prevent further transmission, severe infections, hospitalization s and deaths which constituted immediate jeopardy at F880 (L) in the following specific areas: The facility failed to provide accurate documentation of their COVID-19 surveillance and data analysis including line listings of infections and vaccination status of resident and HCP; which was necessary for early detection to… […]

• Immediate jeopardy, widespreadF886Sep 30, 2021

  Based on observations, resident interviews, staff interviews and review of facility documentation, the facility's staff failed to adhere to the following Centers for Disease Control and Prevention (CDC) guidance to have an established and effective COVID-19 testing program in place during a major [CONDITION(S)]-CoV-2 outbreak and to prevent further transmission, severe infections, hospitalization s and deaths which constituted Immediate Jeapardy at a scope and severity level of 4 widespread (L): The facility failed to ascertain the vaccination status of all Healthcare Personnel (HCP) to determine who was unvaccinated and required expanded screening testing and the facility failed to conduct unvaccinated HCP testing for [CONDITION(S)]-CoV-2 infection based on the level of community… […]

• Actual harm, isolatedF603Dec 19, 2024

  Based on observations, Resident interview, facility staff interviews, clinical record review, and facility documentation review, the facility staff involuntarily secluded one (1) Resident (Resident #226) in a survey sample of 74 Residents, resulting in psychosocial harm. The findings included: For Resident #226, who refused a transfer to the locked memory care unit (for residents with dementia and behaviors), the facility staff failed to honor the resident's request. The staff moved him against his will, into the secured unit with no access codes to afford him independent egress. The resident did not meet the criteria for the move as no criteria was ever derived in the facility by way of policy or procedure, which resulted in a move for staff convenience. […]

• Actual harm, isolatedF684Dec 19, 2024

  Based on interview clinical record review and facility documentation the facility staff failed to ensure residents receive treatment and care in accordance with professional standards of practice for one (1) Resident (#376) in a survey sample of 74 Residents, which resulted in harm. The findings included: For Resident # 376 the facility staff failed to ensure follow up on lab work which led to the resident having to be hospitalized for a blood glucose of over 900, this is harm. […]

• Actual harm, isolatedF686Dec 19, 2024

  Based on observation, staff interview, facility documentation review, and clinical record review the facility staff failed to prevent, assess, identify timely, and treat avoidable pressure ulcers resulting in harm for two Residents, (Resident #117, and Resident #379) in a survey sample of 74 Residents. The findings included: 1. For Resident #117, the facility staff did not assess, nor identify an avoidable sacral pressure ulcer prior to it becoming a stage 3 full thickness ulcer with 80 % slough (dead stringy yellow tissue) in the wound bed, first identified during survey on [DATE]. The Resident was also suffering from significant weight loss, malnutrition, and meals were not provided, which would impact his skin and ability to heal. […]