Birchwood Rehabilitation & Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Aug 20, 2025

  Based on clinical record review, facility policy review, staff interviews, and observations, it was determined the facility failed to ensure the safety and supervision of two residents identified at risk for wandering and elopement. The facility allowed one resident lacking decision-making capacity and under court-appointed guardianship to leave the premises unsafely (Resident 2) and failed to prevent another resident with known wandering behaviors from exiting through malfunctioning or unsecured doors (Resident 3), resulting in serious injury for two of five residents. These failures placed five residents (Residents 1,2, 3, 4 and 5) at the facility in immediate Jeopardy in which the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death. […]

• Actual harm, isolatedF610Aug 18, 2026

  Based on review of facility policies, clinical records, hospital records, and staff interviews, the facility failed to recognize and thoroughly investigate an injury of unknown origin involving potential neglect and failed to report the results of the investigation to the State Survey agency for one of three residents reviewed (Resident 5) resulting in actual harm evidenced by significant urethral trauma.Findings include:Review of the facility's Abuse Policy, last reviewed February 9, 2026, revealed residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. […]

• Actual harm, isolatedF689Sep 17, 2025

  Based on review of clinical records, facility investigative reports, and staff interviews, it was determined the facility failed to adequately investigate resident falls and timely develop and implement effective safety interventions to prevent falls for residents with a known history of falls and unsafe behaviors. This deficient practice resulted in repeated falls for one resident (Resident 3) and a serious injury (fracture of knee) requiring hospitalization for another resident (Resident 1), affecting two of the seven sampled residents.Findings include: A review of Resident 3's clinical record revealed admission to the facility on May 7, 2025, with a diagnosis to include hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral… […]

• Actual harm, isolatedF689Oct 24, 2024

  Based on clinical record review, review of a facility investigation, and staff interview, it was determined the facility failed to implement planned interventions to prevent a fall with injury, resulting in a facial fracture for one resident (Resident 1) out of 5 reviewed. Findings include: Clinical record review revealed that Resident 1 was admitted to the facility on [DATE], with diagnosis to include critical illness myopathy (a common neuro-muscular complication of intensive care treatment associated with increased morbidity and mortality), chronic respiratory failure (a condition in which your blood doesn't have enough oxygen), and Langerhans Cell Histiocytosis (a rare disorder that can damage tissue or cause lesions to form in one or more places in the body). […]

• No harm, potential for more than minimal, widespreadF801Aug 8, 2023

  Based on staff interview and a review of employee credentials, it was determined that the facility failed to employ a full-time qualified dietary services supervisor in the absence of a full-time qualified dietitian. Findings include: Interview with the facility's Nursing Home Administrator on August 8, 2023, at approximately 3 PM, revealed that Employee 1 became the dietary supervisor on January 13, 2023. The NHA also verified that Employee 1 was not possess the regulatory required qualifications, and was not a CDM (certified dietary manager), but was in the process of completing the CDM program. […]