Birchwood Terrace Rehab & Healthcare

In the surveyor’s words

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

• Immediate jeopardy, widespreadF880Sep 3, 2024

  Based on observations, interviews and record review the facility failed to implement an infection prevention and control program that follows the accepted national standards regarding preventing, identifying and controlling communicable diseases. Specifically, the facility failed to follow the CDC (Centers of Disease Control) and state health department recommendations for outbreak management, related to testing and other mitigation strategies including containment and personal protective equipment (PPE) use. The deficient practices associated with the lack of infection control measures led to the determination that the residents in the facility were in immediate jeopardy of serious harm and/or death. […]

• No harm, potential for more than minimal, widespreadF812Aug 20, 2025

  Based on observations, interviews, and policy reviews, the facility failed to store food in accordance with professional standards for food service safety. This deficiency has the potential to impact all residents in the facility. Findings include:Per the initial tour of the kitchen on 8/18/25 at 10:05 AM, revealed in the freezer room, three uncovered boxes that contained frozen vegetables. All three boxes were open to air. There were no expiration dates on the items. Per interview, the Assistant Dietary Manager confirmed items should be covered in the storage area.Per review of a facility policy Food Safety Requirements (Revised 2/2024), Practices to maintain safe refrigeration storage include . […]

• No harm, potential for more than minimal, widespreadF689Sep 3, 2024

  Based on observation, interview, and record review, the facility failed to ensure that resident environments were free of accident hazards related to providing safe water temperatures of less than 120 degrees Fahrenheit (F). Findings include: 1. Per observation on the Special Care Unit ((SCU) a unit that Residents with diagnoses of dementia or other cognitive impairments reside) on 8/25/24 at 4:30 PM, the hot water was assessed from a faucet in the bathroom of room [ROOM NUMBER]. The water was too hot to hold a hand under. Using a thermometer calibrated at 32.2 degrees F, the temperature of the water was 125.8 degrees F. The bathroom sink in room [ROOM NUMBER] was then checked and the temperature was 127.3. […]

• No harm, potential for more than minimal, patternF689Sep 16, 2026

  Based on observation, record review, and interview, the facility failed to ensure that resident environments were free of accident hazards related to safe handwashing water temperatures for 2 of 3 units (Units A and B). Findings include:During observations of residents' bathrooms on the memory care unit on 9/14/26 at 2:05 PM, the water temperature in the bathroom sink in room [ROOM NUMBER] was so hot that 2 surveyors could not keep their hands under the water for more than 5 seconds. After this discovery, surveyors randomly verified other bathroom sinks in residents' rooms throughout the facility and noted excessive water temperatures above 120 degrees Fahrenheit (F) on 2 of the 3 units observed. […]

• No harm, potential for more than minimal, patternF550Aug 20, 2025

  Based on observation and interview, the facility failed to provide dignity and respect to residents who require feeding assistance for 8 of 8 sampled residents. Findings include:Observation on 8/18/25 at 12:20 PM revealed four staff members feeding eight residents. Each staff was feeding 2 residents at a time. Per interview on 8/18/25 at approximately 12:40 PM, an LNA (Licensed Nursing Assistant) regarding residents requiring assistance stated, we usually do have two staff members feeding the 'feeders' because we don't have enough staff for each 'feeder' to have their own staff member to feed them. […]